General Questions and Answers about the Medicare Demonstration Project
Please be advised that answers to the questions in this FAQ are directed towards doctors of chiropractic practicing in one of the Medicare Chiropractic Demonstration Project areas.
These areas are:
- All of Maine
- All of New Mexico
- 26 Counties in Illinois, including: Cook, Dekalb, DuPage, Grundy, Kane, Kendall, McHenry, Will, Boone, Bureau, Carroll, Henry, Jo Daviess, Kankakee, Lake, LaSalle, Lee, Marshall, Mercer, Ogle, Putnam, Rock Island, Stark, Stephenson, Whiteside, and Winnebago
- Iowa: Scott County
- 17 Counties in Virginia, including Pittsylvania, Campbell, Appomattox, Nelson, Buckingham, Fluvanna, Louisa, Caroline, Hanover, New Kent, Henrico, Richmond City, Goochland, Cumberland, Powhatan, Amelia, and Danville City
If this FAQ does not answer your question:
Beneficiaries
Q: Do beneficiaries need to reside in the demonstration areas to receive services?
A: Per a Centers for Medicare & Medicaid Services (CMS) FAQ, the answer is: "No, beneficiaries do not need to reside in the demonstration areas to receive services. Only the chiropractors that provide demonstration services must be located in these areas."
Q: If a beneficiary located in the demonstration area is a member of a Medicare Advantage (MA) plan, can they receive the expanded chiropractic services?
A: Per a Centers for Medicare & Medicaid Services (CMS) FAQ, the answer is: "At this point, MA plans, both risk and cost-based, have not chosen to participate in the demonstration, so beneficiaries that are members of these plans would not be eligible to receive these demonstration services. Chiropractors should notify those beneficiaries that are risk MA members that they will be responsible for the cost of all services beyond the current Medicare coverage for manual manipulation of the spine. Beneficiaries enrolled in cost plans will have to pay for the additional services, if they are provided by a plan network provider; however, if a beneficiary goes out of network to receive services, Medicare will pay for the additional services, but the beneficiary will have to pay any coinsurance and deductibles."
Q: Will Part B beneficiaries with RR (railroad) Medicare have demonstration benefits?
A: Yes.
See also: Participation.
Billing
We highly recommend that doctors of chiropractic, whether participating in the demonstration project or not, invest in the ACA Chiropractic Coding Solutions Manual 2005 and the ACA Clinical Documentation Manual. These items are particularly vital for doctors within the project. Additionally, please check our Seminars area on the main demonstration project page to see if an ACA Medicare Demonstration Project Seminar is coming to your area.
Q: Are chiropractors required to bill the currently covered services on a totally separate CMS 1500 form from that of the demonstration services?
A: Per a Centers for Medicare & Medicaid Services (CMS) FAQ, the answer is: "Yes, chiropractors must submit claims for demonstration services on a separate form from current services provided under Medicare (98940-98942). Billing requirements for current services will not change."
Q: Will chiropractors be required to use the AT modifier under the demonstration?
A: Per a Centers for Medicare & Medicaid Services (CMS) FAQ, the answer is: "Yes, chiropractors must include the AT modifier for every service (that is not maintenance care) on every claim. Maintenance services are not covered under the demonstration and would, therefore, not have an AT appended."
Q: Do we still have to use a 739.* code, and then a secondary diagnosis, or can we use any of the approved codes? There is a table in the Medlearn Matters Article of approved codes, but it doesn't specify that we have to use a 739.* code.
A: 739.* will still be required as a primary diagnosis for spinal CMT. As for the other (demonstration) codes, any diagnosis from the approved list (Table 6 of the Medlearn Matters Article) will be fine as long as it is logical for the service provided. This includes 739.*. Some LCD's (local coverage determinations) specify certain diagnosis codes to be used under certain circumstances, so LCD's should always be checked for further clarifying information. LCD's are available from your carrier: check the state-specific section of http://www.acatoday.com/demo to find your carrier and LCD.
Q: For extraspinal manipulation, do we have to use a subluxation diagnosis code?
A: Any diagnosis from Table 6 will be fine (as long as it is logical), including 739.* (subluxation). 739.* is acceptable, but not required.
Q: In the demonstration project, if a patient has Medicare benefits and also has 1) Employer health insurance, 2) workers' compensation, or 3) auto/liability coverage, do will still have to send a claim to Medicare?
A: In any 'Medicare as a Secondary Payer' (MSP) situation, the physician or supplier must first bill the primary insurer before they can bill Medicare for secondary payment. For example, if a Medicare beneficiary is working and has health insurance through his/her employer, the physician or supplier must send the bill to the employer health plan first. The primary insurer will process and pay the claim as appropriate. The remittance advice must then be sent to Medicare, along with the bill, for secondary payment. The same process must be followed for workers' compensation or auto/liability claims when Medicare is involved as the secondary payer.
See also: Participation, Laboratory Testing.
Budget Neutrality
Q: If the demonstration is not budget neutral, will chiropractors have to refund the fees that they collected under the demonstration?
A: Per a Centers for Medicare & Medicaid Services (CMS) FAQ, the answer is: "One year after the demonstration concludes, the Secretary will submit a preliminary report on the demonstration to Congress. CMS anticipates submitting a final report on budget neutrality when all of the claims information is available in 2009. Any permanent expansion of Medicare services beyond the three current chiropractic codes would require a legislative change."
Coding
See: Billing
Impact of Demo
Q: Who will make the decision whether to expand Medicare coverage of chiropractic services permanently after the end of the demonstration?
A: Per a Centers for Medicare & Medicaid Services (CMS) FAQ, the answer is: "One year after the demonstration concludes, the Secretary will submit a preliminary report on the demonstration to Congress. CMS anticipates submitting a final report on budget neutrality when all of the claims information is available in 2009. Any permanent expansion of Medicare services beyond the three current chiropractic codes would require a legislative change."
Since permanent expansion would require a legislative change, we at the ACA would encourage you to participate in our Legislative Action Center. Click here for ACA Legislative & Regulatory Action, including information on the demonstration project itself.
Incident to Requirements
Q. Can trained office staff who are not chiropractors, such as chiropractic assistants, assist the chiropractor in providing therapy services? For example, can a chiropractic assistant or other trained office staff place electrodes on a patient and have the chiropractor verify placement and start the machine, or is it necessary for the chiropractor to do the entire procedure him/herself?
A: "Chiropractors must follow the 'incident to' requirements for therapy services as described in the physician regulation. When a physical therapy service is provided 'incident to' the service of a chiropractor, the person who furnishes the service must be a physical therapy qualified practitioner other than licensure (meeting the physical therapy definition at 42 CFR 484.4 - other than licensure). Chiropractors cannot split a therapy service and have a staff person perform part of it if that person does not meet the qualifications described in the regulations."
The ACA has objected on several occasions to the incident to regulations, filing comments as early as October of 2003. ACA continues to have a dialogue with CMS on this issue and the situation could change. Please subscribe to the ACA Demo e-Alert to be sure that you are apprised of the latest developments where the incident to regulations are concerned.
Q: We currently have a college graduate, with an exercise physiology degree, performing trigger point/soft tissue therapy on our Medicare patients. Must we stop offering this service to our Medicare patients so we can participate in the demonstration project?
A: You do not need to stop offering the service, but you do need to ensure that the provider of the service meets the incident to requirements. The exercise physiologist mentioned would not be able to perform therapy services on Medicare patients because they do not meet the incident to requirements (unless, in addition to their exercise physiology degree, they have graduated from one of the approved curriculums discussed previously).
See also: Physical Medicine.
Laboratory Testing
Q: When clinical laboratories bill Medicare for laboratory testing ordered by a chiropractor, does the clinical laboratory need to append any specific modifier to the CPT codes submitted to denote to the Medicare Part B contractor that the tests were ordered by a chiropractor within the demonstration project?
A: Per a Centers for Medicare & Medicaid Services (CMS) FAQ, the answer is: "Clinical laboratories do not need to append any special modifier to denote that tests were ordered by a chiropractor in the demonstration area. Clinical laboratories should list the chiropractor's UPIN as the ordering physician for the clinical lab service claim. For private laboratories, on the ASC X12 837P electronic format, you should report the ordering chiropractor's UPIN in loop 2420E. The value 1G should be entered in REF01 and the UPIN is entered in REF02. If you are using form CMS-1500, the chiropractor's name should be inserted on line 17 and their UPIN number on line 17a. For outpatient hospital claims, on the ASC X12 837I electronic format, you must report the ordering chiropractor's UPIN (REF02 (REF01=G)) in the 2310C REF (other provider secondary identification) segment."
Non-Covered Services Under the Demo
Q: A chiropractor treats a patient for a condition that is not covered by the demonstration project (e.g., asthma, sinusitis), the services rendered are listed under the demonstration project but not the diagnosis. Can this chiropractor still participate in the demonstration project? Would the beneficiary pay for the care as is currently done with non-covered services?
A: The doctor can still participate in the project. The care would not be reimbursable by Medicare; the patient would pay in full for the services.
Participation
Q: If a chiropractor currently provides services under Medicare, are they required to participate in the Medicare chiropractic demonstration?
A: Per a Centers for Medicare & Medicaid Services (CMS) FAQ, the answer is: "No, they can choose whether or not they want to participate in the demonstration. Chiropractors must inform the beneficiary of their participation status prior to providing services. If they are not participating in the demonstration, they need to clarify to the beneficiary that the beneficiary will be responsible for the cost of expanded services. Chiropractors can choose to change status during the demonstration. Chiropractors choosing to stop providing services during the demonstration should provide advance notice to beneficiaries."
Q: Can a chiropractor participating in the demonstration choose which services to submit claims to Medicare for under the demonstration, while billing the patient for other demonstration services?
A: Per a Centers for Medicare & Medicaid Services (CMS) FAQ, the answer is: "No, chiropractors who choose to participate in the demonstration must submit claims to Medicare for all of the services they provide to beneficiaries. They cannot choose which services to submit claims for while charging Medicare beneficiaries for other services."
For a list of the services which may be submitted to Medicare for reimbursement under the demonstration project, please review the Medlearn Matters article on the demonstration project.
Q: Can a chiropractor that has chosen to participate in the demonstration choose not to provide certain demonstration benefits?
A: Per a Centers for Medicare & Medicaid Services (CMS) FAQ, the answer is: "Yes, a chiropractor that is participating in the demonstration may choose not to provide all of the services covered under the demonstration can refer the beneficiary to another provider for these services. For example, if a chiropractor participating in the demonstration decides he does not want to provide therapy services under the demonstration, he or she may refer the beneficiary to another provider for these services."
Q: Do chiropractors need to enroll to participate in the Medicare Chiropractic Demonstration?
A: Per a Centers for Medicare & Medicaid Services (CMS) FAQ, the answer is: "As long as a chiropractor is located in the demonstration area, he or she does not need to enroll to participate in the demonstration. Chiropractors in demonstration areas who choose to participate in the demonstration can start to bill for demonstration services April 1, 2005."
Q: How will Medicare differentiate between one of the DCs within the demonstration area and one of them not within the demonstration area?
A: Per a Centers for Medicare & Medicaid Services (CMS) FAQ, the answer is: "When a chiropractor submits a claim for demonstration services, Medicare will review the zip code of the chiropractor's office location (Box 32) to determine whether they are located in a demonstration area."
See also: Beneficiaries.
Physical Medicine
See: Incident to Regulations
Q: Do I need a treatment plan when providing therapy services?
A: Yes. You will need an initial treatment plan and then, every 30 days, this plan will need to be updated and 'recertified'.
Q: To 'recertify' a therapy treatment plan, must I perform and bill an E/M service?
A: No, this is not a requirement.
Referrals
Q: Is there a special radiology referral/order form required for the demonstration project?
A: No, there is no special form for Medicare. Institutions may have their own order forms. Chiropractors should just make referrals in the same manner they did previously.
See also: X-Rays.
Secondary/Supplemental Insurance
Q: Will secondary or supplemental insurance companies cover the Medicare deductible under the demonstration?
A: Per a Centers for Medicare & Medicaid Services (CMS) FAQ, the answer is: "For beneficiaries with Medigap, the coinsurance and deductible will be covered. Beneficiaries with employer-based coverage should confirm with their employer that they will be providing coverage for the demonstration services."
Q: How should a chiropractor submit claims for services which are covered under the demonstration, but they want to be denied for secondary insurance purposes if they are not participating in the demonstration?
A: Chiropractors who are located in a demonstration area, but who are not participating in the demonstration, should submit claims for services covered under the demonstration with a GY modifier, which indicates they are knowingly submitting the claim as a non-covered service. These services will then be denied by the Medicare carrier, rather than rejected for a lack of information.
X-Rays
Q: A chiropractor takes x-rays, interprets those x-rays, and writes a report. Medicare has indicated that they reimburse for taking x-rays but not interpreting them. Does this mean the demonstration participant would only charge the technical component of the x-rays taken?
A: X-ray codes are "global" codes, which means they include both the technical and professional components. If the doctor is taking and reading the x-rays (and, of course, writing a report), it would be billed as the global fee - just bill the x-ray code. This is reimbursable, what is not reimbursable is when the reading is billed independently.
See also: Referrals.
Medicare as a Secondary Payer (MSP)
See: Billing.
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