Medicare & Chiropractic – Back to the Basics
Written by Editor   
Thursday, May 14, 2015 12:00 AM

by Yvette Yarbrough, Executive Director, TBCE

All chiropractors should have completed eight hours of continuing education in Medicare coding and documentation by now, but many of you still have questions.

This article cannot even begin to scratch the surface of all of the nuances of Medicare practice, so if you have questions, RUN – don’t walk – to an attorney who specializes in chiropractic law or a subject matter expert in Medicare coding and documentation. However, a large number of questions we receive deals with a doctor’s status with Medicare and how Medicare patients can be seen, so we’ll try to provide some clarity in that area here.

The first thing that needs to be understood is what your relationship to Medicare is. Chiropractors are included within the definition of “physician” under the Medicare statute (Section 1861(s) of the Social Security Act), but chiropractors are differentiated in that you cannot “opt out” of Medicare. You can, however, choose whether to be participating or non-participating. All patients must be informed as to the doctor’s status as participating or non-participating.

Participating and non- participating refers to the acceptance of Medicare fee schedules and the assignment of reimbursement of Medicare claims. Under an assignment agreement, the beneficiary transfers to the doctor the beneficiary’s right to Medicare benefits for the services rendered, and the doctor accepts the Medicare-approved charge for the services rendered. Thus, participating doctors agree to Medicare’s fee-schedule amount as payment-in-full for a given service and they further agree to collect the Medicare portion of the payment-in-full directly from Medicare, rather than the patient. (Co-pays and the deductible are still collected from the patient, however.)  These doctors are enrolled with Medicare but choose to receive payment in a different method and amount than participating doctors.

Non-participating doctors may handle Medicare patients in two ways. First, the non-participating doctor can choose to not accept assignment of benefits and bill the Medicare patient directly for rendered services. In this case, the doctor must still submit a bill to Medicare (CMS 1500) so the patient may be reimbursed for the portion of the charges for which Medicare is responsible. When a non-participating doctor does not accept assignment of benefits, the doctor will be subject to a limiting charge amount for his/her services.

Second, non-participating can sometimes choose on a case-by-case basis to accept assignment of benefits. In this case, the doctor accepts a portion of the Medicare fee schedule amount as payment (currently about 75.5%) and then collects a co-pay from the Medicare patient. The amount paid to the non-participating doctor by the Medicare patient for covered services is reported in Item 29 of the CMS 1500 claim form. The Medicare patient will then be reimbursed (if applicable) prior to Medicare sending payment to the doctor.

A non-participating doctor may not fragment bills by accepting assignment for some services and requesting payment from the Medicare patient for other services performed for that same patient at the same place on the same occasion. Whether or not non-participating doctors choose to accept assignment of benefits, the Medicare reimbursement is less than for a participating provider.

It is not advisable (and it may even be illegal) to treat Medicare patients without being first registered with Medicare. This is critical to do as soon as you are licensed. Registration is done via PECOS – the Medicare Provider Enrollment, Chain, and Ownership System – available at https://pecos.cms.hhs.gov. Additionally, you must obtain a National Provider Identifier (NPI), which is separate from registering with Medicare, but still required. (You can obtain an NPI number by going to https://nppes.cms.hhs.gov or calling 1-800- 465-3203 to request an application.)

When a patient walks in your door, the first thing you need to ask is whether they are covered by Part B of Medicare. If they are, you MUST follow Medicare billing rules. Again, chiropractors cannot “opt out” of Medicare or choose of their own accord to not file with Medicare for a Medicare patient.


Source: Texas Chiropractic Board Report; April 2015 Volume II, Issue 4