Q: Chiropractic Billing vs Medical Billing – “I recently switched from coding & billing with a 97.5% collection rate to billing for a chiropractic group. Now, 50% of my claims are being denied – particularly with Medicare, and I’m not doing anything differently than I did at my prior job.”
Jo-Anne — A: Chiropractic billing is very, very different than medical billing for a physician, and the most important task at hand is to research each payer rule for chiropractic, and that goes for other specialties, too, like, podiatry and so forth.
There are limitations with some specialties. Coding should not be an issue with this specialty but knowledge of the guidelines is imperative. Many health insurance plans do not offer chiropractic benefits and other plans offer this as an additional coverage for a fee for patients, but please note that anyone on Medicare, Medicare has stringent guidelines, and offers minimal coverage for services provided.
What does Medicare pay for? Chiropractic care has limited coverage. Medicare covers manipulations only of the spine if medically necessary to correct a subluxation. Office visits are not covered. X-Rays are not covered. Manipulation of extremities, hands and feet are not covered. A subluxation which is an incomplete or partial dislocation of the vertebrae must be the primary diagnosis always followed by a secondary neuromusculoskeletal condition.
VIDEO: Chiropractic Billing vs. Medical Billing
The subluxation must be demonstrated in the patient documentation in the event of an audit, and it, by either an x-ray, or a physical exam, and the specific vertebrae must be documented. Chiropractic manipulation codes must be appended with a modifier AT to indicate the care is active or corrective. Omission of this modifier will result in an automatic denial with no patient responsibility.
That’s very important, but again this is Medicare, and if you’re not using that modifier or you’re billing for an office visit like you would for a doctor, or medical doctor that’s why your collections are so poor because it’s just very specific rules.
On the CMS-1500 Form, block 14 must have a date, and not necessarily a date of injury or first symptom, but the date of the first visit for the current episode. If the patient just came in that day to start her treatments, that would be the date of service. Block 19 must indicate an x-ray date if there was an x-ray taken and used to identify the subluxation.
There were only three codes that Medicare accepts for billing and that’s the 98940, which is 1-2 regions, 98941 3-4 regions of the spine, and 98942 for 5 regions of the spine. If you look in the CPT manual you’ll actually see a 98943 for extremities because I’m talking about Medicare, those are the only three that are accepted.
As far as Advanced Beneficiary Notices, all other services, the chiropractic with Medicare, such as exams, x-rays, therapies are not statutorily covered services when performed by a chiropractor, so therefore you’re not required to give your patients an ABN to sign. If a doctor, a chiropractic who gives out an ABN is strictly voluntary, and all the rules are chiropractic coverage, which is listed below here.
How Do Other Payers Reimburse for Chiropractic? You really have to visit your payers’ websites and search for the Chiropractic Billing Guidelines, and you also have to know your patient eligibility. Some Blue Shield plans will pay for an initial evaluation with a manipulation only. No massage, no heat, nothing. Subsequent visits for Blue Shield they may only pay for manipulation and a massage, but definitely no visit, so these are things that you’re billing like an office visit with the manipulation even as a subsequent that’s why you’re getting denied.
Other carriers will pay for an office visit, manipulation and a modality, but most of these plans do have limitations, so it is to your advantage to know them, so that may be the biggest reason is not understanding what the plans and the billing rules are for each one and why your collection is so low.
In terms of your accounts receivable of you saying that they are poor, just keep in mind that, number one, you want to collect your co-payments at the time of service because even if the insurance allows $57 for the service, the doctor may only receive $17 from the insurance company because the co-payment is 40.
If you’re not collecting that copayment, your receivables are just going to inflate, you really have to pay attention to the rules of chiropractic because it definitely is different than billing for any type of medical profession, so that’s probably why you’re down so much and your collection rate is so low. That’s it for chiropractic, and believe me I know my husband is one, so I see all the little things that go along with that, and it’s a pain.
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