Author Topic: Chiropractor billing!!!  (Read 2431 times)

Misil

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Chiropractor billing!!!
« on: February 11, 2014, 01:16:10 PM »
A Chiropractor is going to joining our doctor's clinic.
I will have to bill for that Chiro, but totally new to this specialty.

Can anyone help me out with following questions? (It's a clinic with medicare patients.)
1. When do you use cpt code 98941 & 98940?
2. How many visits can you bill each code per patient in a month?
3. Do we have to get any authorization numbers to bill for chiro?
4. If we have to get the authorization number(s), where do I have to contact?



DMK

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Re: Chiropractor billing!!!
« Reply #1 on: February 11, 2014, 01:57:11 PM »
Wow....this is all pretty elementary.  Are they just throwing you to the wolves?

98941 Is for adjusting 3-4 areas (you must use a modifier AT (active treatment) for Medicare)
98940 Is for adjusting 1-2 areas (ditto)

Diagnosis must be in the correct order for your LCD.

The number of visits allowed by Medicare is dependent on the severity of the injury, it's not set in stone.  But treatment must be medically necessary, and ACTIVE treatment.  You can not bill Medicare for  "maintenance" treatment.

Medicare doesn't require authorization for chiropractic treatment, but patient must have Part B benefits. (Most do)  Some other plans do require authorization.

Misil

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Re: Chiropractor billing!!!
« Reply #2 on: February 11, 2014, 02:13:02 PM »
1. Then do patients have to get a referral from the provider in order to get the chiro treatments?

2. Is there initial & re-evaluation for chiro? if yes, then what are they?

3. For some other plans, where do I have to get the authorization?

Since you said 'this is all pretty elementary', I assume that you're billing for chiro for years.
Thank you for the information you posted.  Your continuous replies with information will help me alot.


shanbull

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Re: Chiropractor billing!!!
« Reply #3 on: February 11, 2014, 03:58:13 PM »
Definitely check this out: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Chiropractic_Services_Booklet_ICN906143.pdf

Patients do not need a referral from an MD to get chiropractic treatment, but on the flipside, the CPT's Medicare will pay for are very limited. You will need an MD referral for things like X-Rays, DME (this is new as of January), etc.

Evaluations are a little silly, the chiropractor fills out a PART form every 6 months and that goes into the patient's file, but it's not submitted anywhere. If you're audited they will ask for them so it is crucial to do them. Info here: http://www.acatoday.org/content_css.cfm?CID=1217. Since this doesn't get submitted anywhere, Medicare is unlikely to come back and say you're billing for maintenance care instead of active care. I think the record # of chiro visits for one Medicare patient at our clinic is now over 700, which gives you an idea of how useful this process is.

Private insurers have wildly varying requirements, some do not require prior authorization ever, some require prior authorization based on their own rating of the chiropractor, some require prior authorization after X number of visits, some require prior authorization for every visit. Some want to see documentation of evaluations at regular intervals, others don't care to ever see proof an evaluation was done. # of visits allowed per month also tends to vary among insurers. Usually it's 6-8. The easiest way to find out about authorization requirements is the insurers' websites and provider manuals.

Not sure where you are located, but in our jurisdiction Medicare requires 3 ICD codes for 98940 and 4 ICD codes for 98941:
739.1 - cervical
739.2 - thoracic
739.3 - lumbar
And the final ICD code must be symptomatic to the primary ICD code (723.1 cervical, 724.1 thoracic, 724.2 lumbar).

Using any other ICD's gets the claim rejected no matter what.

Our state's Medicaid has the same requirements, but different ICD's. Non-government insurers tend not to be anywhere near as strict about the ICD coding. Just don't try to bill for something a chiropractor has no business treating without the patient also seeing an MD (concussions, non-spinal injuries, underlying medical conditions, etc.).

If you aren't already doing so, be prepared to bill car insurance and worker's comp policies, and to appeal to health insurance policies when the auto/worker's comp caps are hit. Often this involves submitting dated proof of denial on the part of the liability insurance (timely filing limits for health insurance mean nothing to auto and worker's comp or the amount of time they take to make payment decisions, most health insurers will waive timely filing deadlines if you can prove you billed the health insurance policy within 30 days of the denial from the liability insurer). Also bills and records requests from parties involved in arbitration and litigation are common (and do not let them rush you or get you to make promises you have no control over, they tend to be pushy - today I had someone at a law firm tell me she had sent a "legal request" as if that had any bearing on how long it would take the Dr. to finish his notes).

I have more, but I will stop for now and let you take in the information.
« Last Edit: February 11, 2014, 04:02:30 PM by shanbull »

DMK

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Re: Chiropractor billing!!!
« Reply #4 on: February 12, 2014, 11:24:48 AM »
1. Then do patients have to get a referral from the provider in order to get the chiro treatments?

2. Is there initial & re-evaluation for chiro? if yes, then what are they?

3. For some other plans, where do I have to get the authorization?

Since you said 'this is all pretty elementary', I assume that you're billing for chiro for years.
Thank you for the information you posted.  Your continuous replies with information will help me alot.

A referral from an MD is not required for Chiropractic care (on Medicare).  However, if the Chiro wants x-rays or other tests, the MD must order them, so communication with the patient's MD is a really good idea.

The Chiro must do a new patient exam but they don't get paid for it.  Be sure to code the exam with a GA if you have a signed ABN or GY if not.  With the GA code, some secondary insurances will pay for it, but you can bill the patient for it as long as there's a signed ABN and you've informed the patient that it's required but not covered.

For other plans it will depend on who you're contracted with.  ASHG is providing authorizations for a lot of companies (mainly Anthem of California) and OPTUM is doing some for United HealthCare plans (they have an easy "group ID search" on their web site so you can find out right up front if an auth is required or not.) 

It is a really good thing to ask, if you call for benefits, "is a referral or authorization required?". 

Also, on Medicare (depending on your LCD) the ORDER of your diagnosis is imperative.  In my area you can only get paid for 98940, 98941, 98942.  Your #1 dx must be the 1st area of complaint, #2 is the problem with #1 (if it's cervical, #2 must be whether it's sprain/strain, disc degeneration, herniation etc) #3 would be the next area of complaint (if there is one), #4 the next area (if there is one).  With the new HCFA form in April, there will be more room for more dx codes, but the first 4 will still be the ones that get you paid for a 98940 (1-2 areas) or 98941 (3-4 areas).

I hope I didn't offend you when I said this was "elementary", I just hate it when bosses throw employees to the wolves and tell them to "figure it out".

Best of luck to you!  Chiropractic billing is pretty easy, but the criteria and coverages are changing by the moment!


Billing2

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Re: Chiropractor billing!!!
« Reply #5 on: February 13, 2014, 08:36:50 PM »
I would look in to H.J. Ross seminar or a Target Coding Seminar.

Don't for get to get your ABN signed.