Filing Step by Step -- Medicare
Step 1. Know if you are a "participating" or "non-participating" provider.
A. participating=contractually accepts assignment on all Medicare patients
B. non-participating=may accept assignment,or not, on Medicare patients
Step 2. Know if Medicare is primary or secondary, (these instructions are for primary). If Medicare is secondary, and you bill your normal charges to the primary payer and accept that amount as payment in full (collecting nothing from the patient, i.e., PIP), then you bill nothing to Medicare. If you plan on collecting money from the patient, (co-payments and/or deductibles), then you use your Medicare fee--for the Medicare covered service--and bill to Medicare after the primary has paid.
Step 3. Know the amount that you may legally charge for the level of CMT code used.
A. participating=allowable=par amount*
B. non-participating, no assignment=limiting charge=limiting amount*
C. non-participating, assignment=non-par allowable= non-par amount*
*minus any “fines” from PQRS and/or EHR reporting
Step 4. Know the patient's Medicare identification number (complete with letter), (not always his/her SS#). NOTE: Starting in 2018, Medicare will no longer use SS# for ID numbers.
Step 5. Medicare requires documentation of medical necessity in SOAP notes. Since x-rays are no longer required (01/01/00), an examination must be documented to indicate the somatic/segmental dysfunction diagnosed using the P.A.R.T. (Pain/Asymmetry/Range of Motion/Tissue tone or tenderness) format, two of the 4 items must be documented with one being either the A or the R.
Step 6. The primary diagnosis must be of a segmental dysfunction, M99.0__ code(s). There must be an active symptom associated with the subluxation to justify the service as "medically necessary." When diagnosing several regions (C/T/L), you must diagnose the segmental dysfunction, then the symptom that relates to that region. Use only ONE symptom per region. Link the adjustment code to “A” only. You may list all diagnoses in the medical record.
Step 7. The only reimbursable service is CMT codes for manipulation. You do not need to file for "non-covered" services unless the patient asks you to do this for purposes of a denial for secondary policies. You may use the proper CPT code, with the modifier “GY” on all non-covered services. NEVER BILL CODES 97010 (hot & cold packs) or 99070 (supplies) to Medicare.
Step 8. There must be documentation for the medical necessity of the service in the patient's chart, in the form of SOAP/PART notes.
Step 9. The onset date in box 14 of the claim form, is the first adjustment for that incident. Make sure to document the incident completely and do a P.A.R.T. exam for the medical records.
Step 10. Providers are always required to file a Medicare claim for the patient (beneficiary). Patients cannot file their own claims. Even non-par, non-assigned claims must be filed by the provider. Mandatory filing is ONLY exempt if the patient signs an ABN and choses option 2.
PAIN ASSESSMENT
usually used on the last visit
FUNCTIONAL OUTCOME ASSESSMENT
First Name M.I.Last Name
Have you had spinal X-rays, MRI or CT Scan?
□No
□Yes, Date(s) and place taken
Please check all of the following that apply to you or check:
□ NONE APPLY
NOYESNOYES
□□History of recent Infection□□Recent Trauma
□□Recent Fever□□Prostrate Problems
□□HIV / AIDS□□Frequent Urination
□□Diabetes□□Pregnancy, # of Births:
□□Corticosteroid Use□□Abnormal Weight Gain/Loss
□□Surgery, Type:______□□Epilepsy / Seizures
□□High Blood Pressure□□Visual Disturbances
□□Stroke, Date:□□History of low/mid back pain
□□Dizziness / Fainting□□History of neck pain
□□Numbness in Groin / Buttocks□□Arthritis
□□Urinary Retention□□History of alcohol use
□□Aortic Aneurysm□□History of tobacco use
□□Cancer / Tumor□□Medications:
□□Osteoporosis
Does your family have a history of any of the following?
□ Cancer□ Diabetes□ High Blood Pressure□ Cardiovascular Problems / Strokes
Signature: Date:
PAST MEDICAL HISTORY
RECENT SURGERY:
PROLONGED HOSPITALIZATION:
PREVIOUS INJURY TO AREAS OF COMPLAINT:
PRELIMINARY / SUBJECTIVE INFORMATION
AREA OF COMPLAINT / NECK / MID-BACK / LOW BACK / OTHERTYPE OF PAIN
FREQUENCY
NOCTURNAL:
AM/PM PAIN:
NUMBNESS OR TINGLING:
HEADACHES:YES NO
NAUSEA:YES NO
VOMITING:YES NO
VERTIGO:YES NO
TINNUS:YES NO
DYSPHALGIA: YES NO
BOWEL OR BLADDER PROBLEMS:YES NO
EENT:
WHAT MAKES THE CONDITION WORSE?
WHAT MAKES THE CONDITION BETTER?
MEDICATION CONCERNS:
ALLERGIES:
Comments regarding History as stated above.
Description of the present illness including:
Mechanism of trauma;
Quality and character of symptoms/problem;
Onset, duration, intensity, frequency, location, and radiation of symptoms;
Aggravating or relieving factors;
Prior interventions, treatments, medications, secondary complaints; and
Symptoms causing patient to seek treatment.
Comments Regarding History of Onset and or injury
To the best of my abilities I have answered all questions completely and correctly. Today, I am here for an evaluation and possible treatment of my condition.
Patient Signature: ______Date: ______
P.A.R.T. Exam
Pain/tenderness evaluated in terms of location, quality, and intensity;
Pain –identified through one or more of the following:
Observation percussion palpation provocation
Assessed using: visual analog scalesalgometers pain questionnaires
*Asymmetry/misalignment identified on a sectional or segmental level;
Asymmetry/misalignment – identified on a sectional or segmental level through: observation (posture and gait analysis) static palpation
*Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility);
Range of motion abnormality –identified through the following:
Motion palpation observation range of motion measurements
Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament.
Tissue/Tone texture identified through the following procedures:
Observation palpation use of instruments
tests for length and strength
Signature of Provider of service:
NAME: ______DATE: ______
Diagnosis: M99.01 to M99.05 From LCD list Only
Primary Region: 21.A______Symptom: 21.B ______
Secondary Region: 21.C ______Symptom: 21.D______
Third Region: 21.E______Symptom: 21.F______
Fourth Region: 21.G______Symptom: 21.H______
Fifth Region: 21.I______Symptom: 21.J______
Date of first adjustment for this course of treatment: ______
(date in box 14 on claim form)
Treatment Plan:
Recommended level of care (duration and frequency of visits);
Specific treatment goals;
Objective measures to evaluate treatment effectiveness.
(examination findings, Functional Rating Index and Pain Scale)
Doctor’s Signature: ______
Daily SOAP/PART Documentation Notes:
Brief History
Review of chief complaint;
Changes since last visit;
System review (if relevant)
Evaluate/examine
Exam of region(s) of spine involved in diagnosis;
Assessment of change in patient condition since last visit;
Evaluation of treatment effectiveness.
Documentation of treatment given
Specific level of spine adjusted:
PART findings: (Pain, *Asymmetry/misalignment, *ROM, Tissue/Tone)
Next visit (scheduled or PRN):
Signature of Provider of service:
NOTICE OF STATUTORY NON-COVERED SERVICES
PLEASE BE AWARE OF THE FOLLOWING MEDICARE REGULATIONS CONCERNING
CHIROPRACTIC CARE
In accordance with the Medicare Act. Section 1842(i), this letter is to advise you that Medicare will only pay for services that it determines to be “reasonable and necessary” under Section 1862(a)(i) of the Medicare Act. If Medicare determines that a particular service, although it would otherwise be covered, is not “reasonable and necessary,” under Medicare program standards, Medicare will deny payment for that service.
- Medicare limits chiropractic reimbursement to manual manipulation. Reimbursement is based on medically necessary correction care only; maintenance care is not covered.
- Medicare DOES NOT reimburse for charges of exams, x-rays, therapy, extremity adjustments, acupuncture, spinal decompression, cold laser, supplements or supports from a chiropractor.
- X-rays and/or an exam may be required to update your condition should a new course of treatment be initiated.
- Medicare patients will be responsible for deductible amounts, non-covered charges and possibly any denied visits which exceed Medicare guidelines.
- Medicare supplemental policies and or secondary policy benefits may be affected by Medicare denials.
______Our office agrees to Accept Assignment
Your will be responsible for 20% co-payment on the allowable charge for manual manipulation in addition to those charges not covered which are listed above.
______Our office DOES NOT ACCEPT ASSIGNMENT
You will be responsible for all charges incurred. Charges for manual manipulation will be assessed at Medicare’s Limiting Charge. Our office will file your claims for you and reimbursement from Medicare will be based on 80% of the allowable charge for manipulation only.
I have read and understand the limitations of my Medicare coverage and the affects it may have on any supplement or secondary policies. I am aware that I will be responsible for any charges that Medicare denies or deems over “reasonable and necessary”.
______
Signature of Patient Date
“OUCH” FORM/INCIDENT REPORT
Patient’s Name ______Date______
Please list any new problems ______
______
Where is the pain?______
When did it start?______
What where you doing when you first noticed it? ______
______
PAIN SCALE
Please circle the number that best describes your pain
0 1 2 3 4 5 6 7 8 9 10
NONE SLIGHT MODERATE SEVERE
Patient’s Signature: ______