Correctly Completing a Medicare Claim

Correctly Completing a Medicare Claim

This section was compiled by Frank M. Painter, D.C.
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FROM:   Dynamic Chiropractic ~ June 3, 2009 ~ FULL TEXT

Dr. Carl Cleveland III, David O'Bryon, Susan McClelland and Dr. Ritch Miller

This is the second in a series of articles on Medicare, documentation and related issues affecting the chiropractic profession.

The purpose of these articles is to familiarize the profession with the specific concerns raised in the Office of the Inspector General (OIG) 2005 report, and areas of documentation and claims submission about which doctors of chiropractic need to be especially cognizant.

Our purpose is to increase general understanding of the Medicare program. The first article addressed common myths prevalent within the profession. This second article pertains to billing Medicare claims. Although not specifically addressed in the OIG report, it is still a major source of error within the profession and contributes to the problems we face within the Medicare system.

Many people are not aware that Medicare is the largest health payer in the country (as well as being the largest purchaser of managed care). Currently supplying coverage for more than 43 million Americans and growing with the aging of the baby boomer population, the impact it has in the health arena cannot be denied.

A significant portion of our Medicare issues stem, quite simply, from filling out the claims improperly. It is crucial for our profession that all services be properly documented and properly represented on the claim form. The following information has been adapted from "Medicare Made Simple," as presented by Susan A. McClelland, BS, CCA, FICC (hc), for the Association of Chiropractic Colleges on May 3, 2007.

Avoiding Improper Claims Submission

Box 1a:   Reproduce the HICN as found on the Medicare card. This is normally a series of nine numbers and a letter. This series of characters should be reproduced exactly on the form, without using spaces or hyphens, or your claim will be denied.

Box 2:   Insert the name as found on the Medicare card. (You may know the patient as Bob Jones, but his real name may be Melvin Robert Jones. If you put "Bob" on the claim form and the Medicare card has him listed as Melvin Robert, your claim will be denied.)

Box 11:   Insert the word "NONE" (if Medicare is primary) or enter the primary insurance policy number (if Medicare is secondary). You must check if Medicare is primary and that you aren't dealing with personal injury, workers' compensation, or a primary employer health insurance.

Box 14:   Insert the date of the first visit for this course of care. Note: This date is not necessarily the first time the patient entered your office, but rather the first visit for this occurrence of the condition.

Box17/17b:   Insert the referring/ordering physician's name (this could be you) and personal NPI when billing X-ray, lab and/or consult codes.

Box 19:   X-ray date, if used to identify subluxation.

Box 21:   The primary diagnosis must be subluxation (739). Secondary codes must be NMS codes from an approved list.

Box 24D:   Spinal CMT is covered (98940/98941/98942). All other services are non-covered. Don't forget to use the correct modifiers, and that EMS should be coded as G0283 instead of 97014 (so it will be denied as non-covered vs. invalid).

Box 24E:   Diagnosis pointer. Only put one number in this column!

Box 24F:   Charges (may not be more than the limiting charge, if you are a non-par provider not accepting assignment).

Box 24J:   Provider NPI.

Box 32:   This must be the physical address designating where the services were rendered (not a P.O. box).

Box 32a/b:   Should be blank.

Box 33a:   Group or corporate NPI (if available); otherwise, personal NPI.

Modifiers:   Don't Forget Them

Here are the five most common Medicare modifiers used in chiropractic care:

-GY:   non-covered service;

-GA:   properly delivered ABN;

-GZ:   "Oops" - use on the rare occurrence that you should have gotten an ABN signed but, for some reason, did not (this modifier is optional);

-GP:   therapy services; and

-AT:   active (acute and chronic) spinal CMT.

Forgetting to include the appropriate modifier is a significant reason for claims denial.

As reported in DC, representatives from 39 chiropractic organizations, including membership organizations, educational institutions, and research and public education foundations, gathered in Las Vegas in January 2009 to seek common solutions and formulate collective action steps to address the new and daunting challenges looming before the chiropractic profession.

This fourth and expanded Chiropractic Summit meeting took place under the auspices of a broad-based steering committee comprised of representatives of the four major participating organizations: Dr. Carl Cleveland III, past president, Association of Chiropractic Colleges (ACC); Dr. Lewis Bazakos, former board chair, American Chiropractic Association (ACA); Dr. John Maltby, president, International Chiropractors Association (ICA); and Dr. Jerry DeGrado, president, Congress of Chiropractic State Associations (COCSA). A key focus of the discussion was Medicare and the upcoming national debate on system-wide health reform.

Detailed information on filling out a health insurance claim form (general) and a Medicare claim form is available online. Visit and, respectively.

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