Medicare Workbook. Version 2

Transcription

1 Medicare Workbook Version 2

2 CPT five-digit codes, descriptions, and other data only are copyright American Medical Association. All rights reserved. No fee schedules, basic units, relative value or related listings are included in CPT. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability of data contained or not contained herein. CPT only copyright American Medical Association. All rights reserved. No part of this manual may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying and recording, for any purpose other than the personal use of the purchaser without the written permission of Dr. Donald M. Hodges. Copyright 2013 Dr. Donald M. Hodges. All rights reserved. The information provided in this document is not intended to take the place of either the written law or regulations. The specific statutes, regulations, and other interpretive materials should be reviewed for a full and accurate statement of their contents. This document was current at the time it was published; However, please be aware that Medicare policies can and do change frequently. Information in this document is subject to change without notice and does not represent a commitment on the part of Dr. Donald M. Hodges or of ChiroWise, Inc. ChiroWise is a registered trademark of Dr. Donald M. Hodges. ChiroWise, Inc. POB 2069 Jonesboro GA

3 Table of Contents Part 1 Medicare Limited Chiropractic Coverage Medicare is for: The Medicare Eligible Patient Medicare Card Alternative Medicare Plans Medicare Providers Participating Providers (PAR) Non-Participating Providers (Non-PAR) Changing the Provider Agreement Assignment How Medicare Participation Status Affects Payment Medicare fees Medicare Deductible Fraud and Abuse Civil Monetary Penalties Law (CMPL) Prohibited Inducement Permitted Inducement Part 2 Getting Paid to Take X-rays Getting Paid for Durable Medical Equipment (DME) Locum Tenens and Substitute Doctors Bundled Services Noncovered Services Services Performed by Relatives Indications and Limitations of Coverage and/or Medical Necessity Contraindication of Manual Manipulation of the Spine Acute and Chronic Conditions Maintenance Therapy Subluxation may be Demonstrated by X-ray Subluxation may be Demonstrated by Physical Exam Diagnoses that Support Medical Necessity Documentation Requirements: Initial Visit Documentation Requirements: Subsequent Visits Signature Requirements When Medicare is the Secondary Insurance When Medicare is Secondary to Auto Insurance Medicaid Medigap and Medicare Supplementals Policies

4 Table of Contents Part 3 Advanced Beneficiary Notice (ABN) Example of a Completed ABN Modifiers General Billing Guidelines Medicare is the Only Insurance Patient has Medicare and Medicaid Medicare is Secondary - Patient is Working Medicare is Secondary - Spouse is Working Form Bottom - Covered Services Form Bottom - Non-Covered Services Diagnoses on the Claim Form Part 4 The Explanation of Benefits Sample of Standard Paper Remittance Claim and Detail Information Claim and Detail Information (cont) EOB Summary Fields Coding of Payment Adjustments Glossary Section Returned claims Clerical Error Reopening Process Denials Sample Letter of Medical Necessity The Appeal Process First Level of Appeal Sample Redetermination Request Form Second Level of Appeal Third Level of Appeal Fourth Level of Appeal Fifth Level of Appeal Medicare Overpayments Collection Process Part 5 Medicare Audits Responding to Audits Assemble Records Completed Response Sample Audit Cover Letter Sample Abbreviation Key Certified Mail

5 ChiroWise Insurance Program Medicare The Medicare insurance program is a Federal program which includes Chiropractic. Coverage is provided under of the program which is for services. Part A of the program is for Part D of the program is for services and benefits. The US Congress makes the rules and passes legislation which affect Medicare regulations. The Department of Health and Human Services (HHS) oversees the Medicare program. It is run by the Center for Medicare and Medicaid Services (CMS). To make a change to the Medicare program it takes. Independent insurance carriers referred to as Medicare Administrative Contractors (MACs) administer the Medicare program for the government. These insurance companies have some discretion in how the rules are interpreted. But for the most part they simply follow and enforce the rules when paying Medicare claims. Limited Chiropractic Coverage Chiropractic coverage under Medicare is limited to the of the to correct a. adjustments are not covered. No other diagnostic or therapeutic services furnished by a chiropractor are covered. Even if you are allowed to order MRIs, X-rays, Blood work and Durable Medical Equipment (DME) in your state under a chiropractic license, currently Medicare will not pay for it. The adjustment or manual manipulation is referred to in Medicare as Chiropractic Manipulative Treatment (CMT). This is interpreted to mean by the use of the hands. Copyright 2013 Dr Donald M Hodges. All rights reserved. 1

6 ChiroWise Additionally, certain manual devices may be used by chiropractors in performing manual manipulation of the spine. These include instruments that are with the thrust of the force of the device being controlled manually (i.e., such as an activator instrument). Medicare is for: 1. People that are retired and on Social Security, railroad or civil service retirement. 2. individuals. 3. individuals who are eligible for Social Security disability benefits (there is a 24 month waiting period before Medicare benefits begin) and are in the following categories: a. disabled workers of any age b. disabled widows of workers who are fully or currently insured through federal government, civil service, Social Security Administration (SSA), supplemental security income (SSI), or the Railroad Retirement Act and whose husband qualified for benefits under one of these programs c. adults disabled before age 18 whose parents are eligible for or retired on Social Security benefits. 4. Children and adults with. 5. donors (all expenses related to the transplant are covered). Spinal manipulation is not considered necessary in the case of kidney donors. The Medicare Eligible Patient In order for a patient to be eligible for Medicare benefits, the patient must have to Medicare for the benefits, the Medicare premiums and a Medicare card. If the patient has never applied for Medicare benefits, the patient may be considered not to be eligible and the Medicare rules to the patient - they are a patient. It is possible that the patient has Medicare Part A only. They didn t apply for and don t have Part B coverage. Since chiropractic is covered under part B, the patient is not considered to be eligible, the Medicare rules do not apply and they should be treated as a patient. Copyright 2013 Dr Donald M Hodges. All rights reserved. 2