“A client recently asked us ‘What can I charge Medicare patients for wellness care?”  The answer, as is often the case with insurance, is ‘it depends’. There are several factors that must be considered and a few Medicare regulations that have to be reviewed”

Medicare has covered and non-covered services, as you know.

Non-covered services for chiropractic are easy. Exams, x-rays, extremity adjustments (98943), and therapies are all non-covered services and you may charge the patient whatever your fee is or whatever you have worked out. (WPS Medicare Fraud & Abuse Manual, pages 18-19; Sect 1862(a)(1), Waiver of Liability). Any of these services may be billed with a –GY modifier (indicating they are billed for denial purposes only), but they will be denied regardless (http://www.medicarenhic.com/providers/pubs/Chiropractic%20Billing%20Guide.pdf , page 21-22).

Non-covered services are never paid by Medicare. These services are not considered a benefit of the Medicare program. Because of this, there are no restrictions on what you may charge for these services or what a supplemental insurer may pay (ibid). You do not even need to bill them to Medicare except that you may want them to be denied or to be forwarded to a secondary.

Covered services for chiropractic included spinal adjustments (98940-2) when billed for a covered diagnosis (L30328, http://www.wpsmedicare.com/part_b/policy/active/local/_files/l30328_chiro001.pdf ). A covered service can be paid or can be denied as not medically necessary.

If you are a participating provider, and you bill an adjustment (98940-2) with the correct diagnosis and with the –AT modifier, it will generally be paid by Medicare at 80% of the par fee amount. The fee schedule is published annually (http://www.wpsmedicare.com/part_b/fees/physician_fee_schedule/) and is mailed to you on a disk near the end of every year.

If a covered service (98940-2 -AT) is paid, no problem.

If a covered service is denied as not medically necessary, AND you have notified the patient in advance that Medicare may deny the claim (with your ABN form), then you may collect from the patient.

If you have had the patient sign the ABN, and you are doing an adjustment for an acute or active problem as defined above, then you are billing with the 9894x – AT – GA code and modifiers to indicate it was acute care and that the patient signed the ABN (L30328),
(http://www.chirobase.org/19Insurance/CR3449.pdf page 3, http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3449.pdf ).

If you are doing a maintenance or wellness adjustment, and you have had the patient sign the ABN form, you are billing without the –AT modifier but with the –GA modifier (9894x – GA) indicating you are billing a covered service and notified the patient in advance that Medicare will deny the claim. You must still bill Medicare for the service, as it is a covered service (http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0749.pdf , page 4, point#6).

If you are doing a maintenance or wellness adjustment or if you are doing services that are not medically necessary (98940-2), and Medicare denies the claim, AND you did NOT have the patient sign the ABN form, the patient should not be billed for the claim, not even for the deductible or co-insurance (Sect 1862(a)(1), Waiver of Liability). The secondary may or may not pay the claim and Medicare does not have any problem or jurisdiction if the secondary or supplemental insurance pays the claim.

Now, hopefully that is all clear. If not, you can go to the references I hyperlinked for further clarification. I always suggest you go directly to the sources on these.

So the simple question is, IF you bill for the adjustment (98940-2) without the –AT modifier, but with the –GA modifier, indicating it is maintenance care and you notified the patient in advance, what can you charge?

Here is what Medicare states:

“The only situation in which non-opt-out physicians or practitioners, or other suppliers, are not required to submit claims to Medicare for covered services is where a beneficiary or the beneficiary’s legal representative refuses, of his/her own free will, to authorize the submission of a bill to Medicare. However, the limits on what the physician, practitioner, or other supplier may collect from the beneficiary continue to apply to charges for the covered service, notwithstanding the absence of a claim to Medicare.”

“If an item or service is one that Medicare may cover in some circumstances but not in others, a non-opt-out physician/practitioner, or other supplier, must still submit a claim to Medicare. However, the physician, practitioner or other supplier may choose to provide the beneficiary, prior to the rendering of the item or service, an Advance Beneficiary Notice (ABN) as described in the Medicare Claims Processing Manual Chapter 30. (Also see §40.24 for a description of the difference between an ABN and a private contract.) An ABN notifies the beneficiary that Medicare is likely to deny the claim and that if Medicare does deny the claim, the beneficiary will be liable for the full cost of the services. Where a valid ABN is given, subsequent denial of the claim relieves the non-opt-out physician/practitioner, or other supplier, of the limitations on charges that would apply if the services were covered.”

(http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf , Medicare Benefits Policy Manual)

Read the whole section. I have underlined the key point. Medicare does not reprice your normal fees in this case and you are free to charge the patient accordingly.

I know that was a long way around to the answer, but this was not just a yes or no question, as you have to understand Medicare and the factors that are involved.

Dave