(12/27/2007)

The article, titled “Addressing Misinformation Regarding Chiropractic Services and Medicare,” is available on the CMS MLN Matters Web page at:

http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0749.pdf

What You Need to Know

CMS has released this special edition article to correct misinformation in the chiropractic community regarding Medicare and its regulations as they relate to chiropractic services. This article is informational only and represents no changes to existing Medicare policy.

Following is an overview of the specific issues. Click the hyperlink above to view additional information.

Misinformation 1: There is a 12-visit cap or limit for chiropractic services.
Correction: There are no caps/limits in Medicare for covered chiropractic care rendered by chiropractors who meet Medicare’s licensure and other requirements as specified in the Medicare Benefit Policy Manual, Chapter 15, Section 30.5.

Misinformation 2: If providers are non-participating (non-par), they do not have to worry about billing Medicare.
Correction: All Medicare-covered services must be billed to Medicare. A non-par provider has enrolled to be a Medicare provider but chooses to receive payment in a different method and amount than Medicare providers classified as participating.

Misinformation 3: If providers are non-par, they will never be audited nor have claims reviewed, etc.
Correction: Any Medicare claim submitted can be audited/reviewed; the non-par or participating (par) status of the physician does not affect the possibility of this occurring. CMS audits/reviews are intended to protect Medicare trust funds and identify billing errors. Correct coverage, reimbursement and billing requirements are available in CMS Medicare manuals and MLN Matters articles.

Misinformation 4: Providers can opt out of Medicare.
Correction: Chiropractors may decide to be par or non-par with regard to Medicare, but they may not opt out. For further discussions of the Medicare “opt out” provision, see the Medicare Benefits Policy Manual, Chapter 15, Section 40.

Misinformation 5: Providers should have an Advance Beneficiary Notification (ABN) signed once for each patient. This will apply to all services, all visits.
Correction: The decision to deliver an ABN must be based on a genuine reason to expect that Medicare will not pay for a particular service on a specific occasion for that beneficiary due to lack of medical necessity for that service. The ABN allows the beneficiary to make an informed decision about receiving and paying for the service.

Misinformation 6: Maintenance care is not a covered service under Medicare.
Correction: Spinal manipulation is a covered service under Medicare; however, maintenance care is not medically reasonable and necessary and therefore not reimburseable by Medicare.

Misinformation 7: Non-par providers do not have the same documentation requirements as par providers.
Correction: Chiropractic care has documentation requirements to show medical necessity. The participating status of the provider is irrelevant to the documentation requirements. Specific details regarding documentation are in the Medicare Benefit Policy Manual, Chapter 15, Sections 30.5 and 240, and the Medicare Claims Processing Manual, Chapter 12, Section 220.