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Questions and Answers can be found in the ChiroCode KnowledgeBase.
I want to be able to collect from a patient if Medicare does not pay. Medicare seems to deny care at random. Should I have the patient sign an ABN for every adjustment, just in case?
The ABN must be signed in order for you to be able to collect for covered services (that is 98940-98942 or CMT) that Medicare determines are not reasonable or necessary. In the Medicare Learning Network ABN Booklet (ICN 006266), it states on page five that we are prohibited from issuing ABNs on a routine basis (that is, where there is no reasonable basis to expect that Medicare may not cover the item or service). Simply stating that Medicare could deny anything anytime is not a "reasonable basis". A "reasonable basis"' would be that you know Medicare's guidelines and you suspect that the questionable service does not meet them. By using the AT modifier with a CMT code, you are telling Medicare that you believe that the service is payable (i.e. medically necessary). Instead of assuming that Medicare denies at random, for no apparent reason, providers should get familiar with what Medicare considers to be medically necessary, and bill according to their guidelines. They should then use the AT, expect to get paid, and appeal if denied. If they don't meet the criteria according to the Medicare Benefit Policy Manual, chapter 15, and their Medicare Contractor's LCD, they should consider it maintenance, and issue an ABN. See pages C18 thru C22 in the 2014 DeskBook for specifics.
What if my Medicare patient refuses to fill out the outcome assessment questionnaire?
Note it in your documentation and inform the patient that Medicare requires that you demonstrate functional improvement in order for them to determine if the care is medically necessary. In other words, they may have to pay for the care out of pocket if they don’t want to follow Medicare’s protocols.
Thanks to Ron Short, DC, MCS-P, CPC for providing this answer. He can be found at http://www.chiromedicare.net.
Our Medicare contractor is auditing claims with 98942. Do you have any suggestions for a template for documentation to warrant the use of 98942?
Using the code 98942 indicates that you determined that it was medically necessary to adjust all 5 of the spinal regions. You documentation needs to reflect that fact, including that the patient had complaints in all five regions. The 98942 is a favorite target of auditors because many providers adjust full spine without establishing medical necessity for all five regions. Essentially, each area must have a patient complaint, relevant objective findings, a clear plan for resolution, and demonstrable progress.
What percentage of improvement is REQUIRED using outcome questionnaires for Medicare to support treatment and how often do we need to do Outcome Assessment questionnaires; every 2 weeks or every 4 weeks?
I electronically sign my records; but if I find a mistake, I re-enter the SOAP notes for the same date and add the correction because once the records are electronically signed, you cannot change them; Is that OK for Medicare purposes to duplicate the SOAP notes twice to fix the error ?
I had a PI case that was paid but discounted up until the last bill. The last bill was for an adjustment, manual therapy and acupuncture and was all denied based on an IMR denial. Should this be considered as final and written off or is it something that I can contest?
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