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Medicare Guidelines
Depending on the state in which you
practice, the way that Medicare claims are processed differs greatly. In some states,
Medicare reimbursement is limited to the 12-visit screen. Once the patient has received
reimbursement for twelve visits, the patient’s coverage is cut off. In other states,
patients are routinely granted 24 or 36 visits before additional documentation is
required. Even though Medicare is a federal program, there is little consistency in the
way it is administered. Since that is the case, we should look to the federal guidelines
for uniformity.
According to the guidelines, the patient
must have a significant neuromusculoskeletal condition necessitating treatment. The
manipulation rendered must have a direct therapeutic relationship to the patient’s
condition. In addition, the level of subluxation must be indicated with accompanying
symptoms. After the 12-visit screen, Medicare may require additional documentation to
substantiate further treatment. However, it was not the intent of the legislation that a
12-visit limit be imposed; the screen is a trigger for additional documentation, not a
limit.
There are at least three ways to document
the need for more than twelve visits. They are as follows:
•A fully documented secondary
neuromuscular diagnosis. This diagnosis should indicate pathology or abnormal physiology
of the neuromuscular system.
• A new condition demonstrated by
x-ray denoting a change in the level of subluxation.
• An acute exacerbation of an existing
condition, documented by the description of the incident causing the new trauma.
So what happens in real life when your
Medicare patient receives a rejection because "there are more visits or treatments
for this diagnosis and condition than Medicare covers unless there are unusual
circumstances"? First, don’t accept the rejection at face value. You can fight
it. If your patient has a documented condition requiring additional care, don’t roll
over and play dead. Force Medicare to follow their own rules.
Second, learn the review process. In most
circumstances, you have 6 months to file a written request for review. That request should
be accompanied by additional documentation to substantiate the claim. In the review
request, reference to the underlying condition should dominate. A review request might be
written like one of these:
#1 -- Medicare Inquiry Request — Part B
Claim Control #: 3058487593
Provider Name: John Smith, D.C.
Provider I.D.: 0G750064951
Beneficiary Name: Sarah Hurtful
Beneficiary HIC #: 345765324A
Dates of Service: 7/1/92 — 10/15/92
Procedure Codes: A2000
We are requesting an informal review
because we are dissatisfied with the initial claim determination. Copies of the claim and
voucher are attached.
Level of subluxation: C5, C6, & C7
(839.08)
Neuro-muscular-skeletal diagnosis: Cervical
intervertebral degeneration (722.4); cephalagia (723.1)
Reason for request:
Due to the degeneration of the
intervertebral discs at C5, C6 and C7, the patient experiences periodic neck pain and
headaches. On occasion, the headaches approach migraine intensity and are accompanied by
dizziness, nausea and fatigue. The underlying disc degeneration is a significant
permanent, chronic condition which will not be altered by ongoing chiropractic care.
However, the patient reports substantial symptomatic relief from the mobilization of the
vertebrae during a chiropractic adjustment. It has been determined that treatment on a
biweekly basis can even avoid the onset of symptoms.
Therefore, it is our belief that the
patient’s condition meets the guidelines of medical necessity for treatment beyond
the 12-visit screen. We are requesting that the initial claim determination be reversed.
#2 -- Medicare Review Request -- Part B
We are requesting an informal review
because we are dissatisfied with the initial claim determination. Copies of the claim and
voucher are attached.
Level of subluxation: T4-9 (839.21)
Neuromusculoskeletal condition: Scoliosis
(737.30); brachial neuritis (723.4); muscle spasm (728.85); thoracic pain (724.1)
Due to an underlying scoliotic condition,
this patient experiences frequent mid-back pain which radiates into the arms and
accompanying paravertebral muscle spasms. The scoliosis is a pre-existing condition, first
diagnosed in childhood. With the effects of the aging process, the scoliosis has worsened,
impinging nerve supply which results in radiculitis.
Without weekly chiropractic care, the
patient is unable to perform the daily routine tasks such as cooking, personal care, etc.
due to the intensity of the back and arm pain.
Therefore, it is our belief that the
patient’s condition meets the guidelines of medical necessity for treatment beyond
the 12-visit screen. We are requesting that the initial claim determination be reversed
and that weekly chiropractic care be authorized indefinitely.
#3 -- Medicare Review Request
We are requesting an informal review
because we are dissatisfied with the initial claim determination. Copies of the claim and
voucher are attached.
Level of subluxation: L4, L5 (839.20)
Neuromusculoskeletal condition: Sciatica
(724.3); lumbar intervertebral disc degeneration (722.5); 847.2 lumbar strain
On 8-15-92, this patient lifted her
grandchild resulting in a lumbar strain. Due to the underlying intervertebral disc
degeneration, the lifting motion caused subluxations of L4 and L5. With the vertebral
misalignment, sciatic pain presented itself two weeks later and gradually worsened.
The typical course of treatment for
sciatica will have to be extended for this patient due to abnormal changes already present
in the lumbar area of the spine. We are currently treating the patient twice weekly. It is
anticipated that the patient will need treatment on a weekly basis for at least three
months until the sciatic inflammation has decreased. Therefore, it is our belief
that the patient’s condition meets the guidelines of medical necessity for treatment
beyond the 12-visit screen. We are requesting that the initial claim determination be
reversed and that weekly chiropractic care be authorized for a six-month period. The
patient will be evaluated at the end of six months to determine the future course of
treatment.
The samples above are just that —
samples. Since each patient is different, the letters you write should reflect the
patient’s individual condition.
Medicare has 45 days to respond to your
request for a review. If the claim is still denied, you may request a hearing. Usually,
the claim must total a minimum of $100 for a hearing, but the hearing request can involve
more than one patient so that the minimum is reached. In most cases, you must request
either an in-person, telephone or on-the-record hearing. If traveling to the hearing
location poses a problem, you might request a telephone hearing so that you have the
satisfaction of providing personal input. Medicare has 120 days to schedule the hearing.
If the hearing decision is not acceptable,
the law provides for an audience before an administrative law judge. The request must be
filed within 60 days of the hearing decision and involve a minimum of $500. Once again,
the minimum of $500 can be a combination of claims with similar denials.
Unless offices are willing to force
Medicare to provide the coverage it has promised, the unwarranted denials will continue.
Spend some time researching the Medicare review process in your state and then become
active in fighting for the necessary coverage.
Contributed by: Marilyn Gard, President, Clinic Pro
Chiropractic Software, marilyn@clinicpro.com
This information provided by Clinic Pro Chiropractic Software - your key to
success in a chiropractic office.
Call us about our FREE chiropractic electronic billing: (866) 333-2776
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