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in this segment, we're going to be discussing Medicare specifically.

Medicare covered procedures.

Medicare modifiers and the Medicare diagnosing guidelines.

You're going to notice we've broken Medicare down into multiple

segments to help best explain that because Medicare can be

a bit daunting and overwhelming.

We wanted to break it down to help you best be able

to understand and implement Medicare and of course get paid by Medicare,

communicate to your patients and know what to expect.

So let's get started discussing specifically the Medicare covered procedures,

modifiers and the diagnosis.

So I want to start off by first just

referencing other Medicare related topics that we've covered.

One of them is being what you're going to look at on the Medicare cards

for coverage because we know that Medicare part

B is where a chiropractic coverage is.

And so we want to make sure that that's in place.

Next.

You're going to learn in another segment about Medicare

involvement and the requirements for a chiropractic provider.

Just to quickly summarize the chiropractors do not have an opt out option,

which means if you're treating a Medicare patient,

you must be enrolled with Medicare

as either participating or non participating, but in either case,

enrollment is required.

Now,

coverage services like you see here on the screen include only the three procedure

codes when they're medically necessary and the

Medicare documentation and coverage guidelines are met.

I'm going to give you an introduction to those in a moment.

But for now, let's take a look at the code. Specifically

I before we jump into that, I want to quickly share with you.

This data was specifically pulled from a local

coverage article from one of the Medicare contractors,

What's important to note about this is all of the Medicare

contractors have other own coverage articles and details with that being said

coverage is the same across the board,

across the entire United States and the territories related to this.

Uh, that as far as what's to be build,

what's allowed to be built how to diagnose those types of things.

And so although this reference was pulled from one article related to Medicare,

it's applicable across the board everywhere.

If you'd like to be able to access your own

Medicare contractor and their own information for reviewer records.

Certainly you're welcome to do that. Just reach out to the building connection.

We're happy to connect you with that information directly.

And we've provided those resources for you as

well right here within the billing connection.

So getting started,

there are three covered procedure codes for chiropractors that of

course are enrolled as either participating or non participating.

Once the Medicare guidelines have been met and

those covered procedures are only the spinal adjustments,

so the different levels of the spine are all covered.

So long as the criteria is met, like I mentioned a moment ago,

those three procedure codes are 9894098941 and 98942.

Next, if you look to the lower portion of the screen,

you're going to see that Medicare has listed six diagnosis

codes that are what they consider their primary diagnosis codes.

Now,

what I want to first explain is the M 99.0 is shown in their data,

but this is to the head which is considered an extremity.

So this is not one of the diagnosis that's going to be

allowed as a primary diagnosis for coverage for the spinal adjustment.

So,

those primary diagnosis for coverage for the spinal

adjustment include only M 99.1 through M 99.5.

And this relates to specific regions of the spine that were adjusted.

And of course, you'd use the number of diagnosis that you are being your billing for.

And of course, meeting the Medicare criteria.

The next thing that's important about this is Medicare

does require a secondary or supporting diagnosis code,

which means that we must,

once we have determined the level of the spine that was adjusted

and that's the level that we're going to be building for.

Because we've met the criteria,

we then have a primary diagnosis code that's

listed in the claim and the patient's notes,

of course.

And then each primary diagnosis must then

be followed by a secondary or supporting diagnosis

in that rotating fashion.

So primary diagnosis, supporting secondary, primary, supporting secondary

and so on up to the level of the spine that your billing.

So if your billing, the 98941,

which is the manipulation of 3 to 4 regions of the spine,

you must ensure that you have at least 3 to 4 primary diagnosis.

Each followed then by supporting your secondary diagnosis

are supporting and secondary diagnosis are the symptoms or

conditions that relate to that region of the spine.

And so those are basically

any other diagnosis that's under the providers scope of practice

that better clarifies

conditions and symptoms related to the reason that the patient is being treated

and other provider findings or records.

They have reviewed from other providers,

provider types X rays and that sort of thing.

So primary diagnosis followed by secondary supporting primary,

secondary supporting that's how the diagnosis must

appear on the claim form for coverage.

Now moving on in the local coverage article.

What I wanted to touch upon here is this is an

outstanding resource and unnecessary resource for a couple of different people.

One of them is the providers

providers must review the local coverage articles because this includes coverage

guidelines and includes the documentation

requirements by Medicare to ensure that

we're in the best position to get paid for what we're

doing and to keep the money that we have been paid.

So ultimately minimizing the risk of

audit recruitment and challenges with Medicare

and of course helps with our patient relationships and so on.

The other person that needs to be familiar with

this information is the person in charge of billing

and the reason this is is because this person is responsible

for preparing and submitting clean claims and within these guidelines,

it tells us exactly what's expected

to be appearing on a claim and how in order

for a Medicare claim to be submitted and payable.

So you learn about this specifically as it relates to the

claim form as you go through the CMS 1500 billing segment.

So we're not going to touch on that here as much other than just

making sure we know that this is a reference that is available to us.

That's so critically important for documentation and for billing.

So really,

although the revenue cycle process as it relates to our Medicare patients,

Medicare does a phenomenal job of providing information

to us in a clean and clear manner.

We just need to know how to access it.

So we're helping you to begin to do that here in this segment.

Now,

Medicare also has specific modifiers that they

are going to require in order for coverage

or for proper processing of claims is probably the better way to say that.

And I'm going to discuss the modifiers with you in an upcoming slide.

The purpose for this particular slide is just to let you know.

Medicare has that dish again covered in detailed in their local coverage articles,

which is a phenomenal reference and resource to you like I mentioned.

So definitely want to make sure that you have access to that review it once a year,

at least for your compliance and your understanding.

Certainly if you're having problems with Medicare claims,

this is the go to resource for you in order to ensure that you have your

claims being prepared as clean as possible and

to ensure that you are submitting them properly

now within Medicare,

they also say that documentation must include uh

the description of if the patient is being seen

for acute chronic or acute exacerbations for the purpose

of the training that we're doing right now.

I'm just sharing with you this,

these descriptions are provided in detail by Medicare,

so feel free to references to your doctor

for the documentation but acute chronic acute exacerbation,

all of those types of terms are required to be defined within the

patient's documentation in order to define the

case and ultimately support medical necessity,

if that's what your intent is. And so it's an important piece of documentation

that's often overlooked.

So definitely something to share with your provider

because it is necessary to support coverage.

And so,

like I mentioned a moment ago, Medicare has defined these quite well.

In fact, I've got that on the screen for us here,

as far as what Medicare's expectations are

because we want to make sure to meet that within the documentation.

Moving on again,

just another piece of the terminology and you can review this in detail.

We'll have it in other resources for you as well and to help the doctors,

but I just want to show you what a

phenomenal resource this is because that's necessary for coverage.

Medicare also goes on to discuss maintenance care,

which of course we know is not covered

by Medicare. Maintenance care is a

non payable procedure or non payable benefit which

means at this point we issue the A.

B. M.

The advanced beneficiary notice of non coverage

to our Medicare patient and follow those

guidelines once the patient has reached maintenance care and we've covered the A.

B. And in another segment as well. So you know exactly how to implement that.

What I want to share with you on this particular slide additionally,

is that Medicare also has done a pretty great job of defining maintenance care.

So this is another element that you'd want to

review as the biller as well as have the doctor

review because once the documentation begins to reach the

status where maintenance care is what's really being defined,

we need to make sure that we are following protocol implementing the Abyan properly

coding properly and submitting our claims properly

and following the other Medicare guidelines.

And so make sure we're familiar with the Medicare terminology which is included

In those guidelines. So now let's talk about the modifiers.

So the procedure codes like I mentioned the (989) 404 1

and for two are the covered procedures that

we can submit to Medicare for reimbursement.

So the modifiers that apply the first one is the 80 modifier.

This one is only ever going to be appended

to the spinal adjustment of the 9894041 or four.

To code once we've met the

medical necessity standards and we're expecting Medicare

to reimburse were indicating to Medicare this is acute or active treatment.

In other words we expect Medicare to cover it.

If we forget a modifier,

that claim will be denied is not

medically necessary and also not patient responsibility,

which means you have to write it off.

Medicare patients are not responsible for billing errors on behalf of providers.

Next we have the G. A. Modifier and this

indicates we have the waiver of liability on file.

That waiver of liability is the Medicare eh bien.

So this is the modifier we replaced the 80 with and add the G. A instead

again only to the spinal adjustment when care is medically

necessary and otherwise not expected to be paid by Medicare.

The G. A only ever to be used again with the 9894041 or four. To procedure codes

You will never use the G. A. or 80 modifiers together.

Next we have the G.

P modifier and this is for outpatient physical therapies

and this is appended to all therapies on claims.

Including

those codes. The procedure codes you see in the list there but not limited to those.

So any outpatient therapy must have the G. P.

Modifier to indicate that it's an outpatient

therapy if you're submitting those procedure codes.

And even if you're not submitting them because they're not covered,

you really should code properly.

Next we have the G. Y.

modifier and this is indicating it's a statutorily excluded item

or service which indicates every other procedure other than the

spinal adjustment that we would be appending this to the

one exception where we don't use any modifier at all.

With Medicare is our extremity adjustment. That 98943 does not require a modifier.

Otherwise our X rays exams, re exams and our therapies would all require the G. Y.

Modifier to indicate these are statutorily

excluded procedures which just simply means

Medicare doesn't pay for this. Medicare doesn't ever pay for it.

It's important to note also for our outpatient therapies with the G. P. Modifier.

These will also require the G. Y.

Modifier to indicate these are outpatient therapies and

also the statutorily excluded from Medicare benefit.

Any other modifiers that may apply to those

procedure codes would be used as well and we'll

cover this in detail with examples as we

go through other specific coding segments for you.

Right now we're just introducing you to those modifiers so you

can recognize what they're for and how they're to be applied.

So in summary the 80 never to be used

on any procedure code other than the spinal adjustment

if you're expecting Medicare to pay because the acute

care or active treatment guidelines have been met.

G. A.

Is what we replace the 80 with on the spinal adjustment when the patient has

transitioned to maintenance care or otherwise expecting Medicare

to not pay for that spinal adjustment.

And this indicates that we've issued the baby into the patient properly.

So we have to make sure we're following those eh bien protocols,

GP modifier for outpatient therapies only

and the G. Y. Modifier for all excluded procedures, which is everything else.

Uh like our X rays exams,

re exams like I mentioned a moment ago

and our outpatient therapies will require the G.

P.

And the G. Y.

As well as any other modifier that may

be applicable to those individual procedure codes.

And again, those specific examples will be up and coming for you

in another Medicare segment.

So those are the common Medicare modifiers that we will be using.

And so this is really just an introduction,

the covered codes and the modifiers and a reminder of a couple

of important things related to Medicare

coverage and the expectations of coverage.

If you have questions through this segment or any other

segments of the building connection definitely reach out to us.

We're happy to help. We'll see you in another segment

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