Welcome back, my friends. This is Sam Collins, your coding and billing expert for the HJ Ross Company including ChiroSecure and your expert. We are around for you to make sure you’re doing well and what’s going to of course will be coming up is what’s happening in 2020, and specifically in today’s program what I want to focus in on, what’s going to be happening for Medicare, making sure we’re up to date.
Please be aware, whether we like it or not, Medicare is going to be a large payer for our practices simply because of Baby Boomers aging. About 10,000 people per day will become Medicare-eligible every single day for the next 10 to 15 years. I want to say, I think it’s by 2032 or 2030 there will be more people in the United States who are over 65 than under 18, which will be for the first time. So clearly a lot of patients will be Medicare and I want to make sure that we’re not fearful of Medicare. Medicare is not hard, it’s just unique. Once you understand the uniqueness, we probably can resolve most of the issues.
So let’s get ready for a very prosperous 2020, let’s move to our slides and talk about 2020 Medicare. As you take a quick look here, how many of you might have your own bobbleheads? I’m pretty excited, someone had a bobblehead made for me so I just thought I would share it with you. That being said, let’s talk about what’s going on for 2020 and Medicare.
First off, Medicare of course issued all Medicare recipients a new Medicare card. The one on the left is the standard Medicare card. The one on the right is for those with railroad Medicare because they have a little different Medicare. But you’ll notice the one thing that’s unique is that they have a new Medicare number. It’s no longer, of course, their Medicare number being their social security number. You would think in this day and age we shouldn’t have anything with social security plus the person’s date of birth, something of that nature.
Here’s the issue I want to bring up. You should already be using these new Medicare numbers. I can’t imagine you are not, but be aware, you cannot use the old numbers beginning January 1st. So the new numbers must be used by January 1st. Please verify with all patients as they come in, get the new Medicare card from them because they all have gotten them as of April of this year.
Also bear in mind though, when people bring in this Medicare card, that doesn’t necessarily mean they still have Medicare because they may have traded it for a Medicare Advantage, and that’s what I really want to kind of hit on today is what’s going on for 2020. Well, of course we know that Medicare is divided into two parts. We have Part A and Part B. Part A essentially is the hospital stuff, so it doesn’t involve chiropractic at all. Patients are essentially automatically enrolled in that plan and there’s essentially no premium. There can be depending on how much you paid into Medicare, but for the most part, no premium. Part B is the outpatient care. This is where chiropractic coverage resides, and of course the patient must pay for this additionally. So in other words, everyone automatically gets Part A, but not Part B. So you have to make sure that the patient is also signed up for Part B, and of course it will state such on their card.
Be aware that the premium for this benefit did increase from $135 to 144.60 for this coming year. So it is something that’s not completely free, if you will, they do have to pay a bit for it. The Part A deductible is $1,408. Again, makes no difference to us because we’re not in hospitals, which a slight increase of $44 there.
What does matter to us of course is the Part B deductible. The Part B deductible went from 185, for 2020 it will be 198. So this means that before Medicare will begin making any payment, the patient will pay out of pocket 198. Now bear in mind, this is for covered services. So in a chiropractic office, only manipulation counts. Considering about a 35 to $40 per visit, this means it’s going to take about five visits to meet deductible. So certainly a patient going to a medical doctor will meet it faster, but the first five visits, if they’ve not seen anyone, is going to go towards deductible, meaning the patients pay out of pocket.
Now what about the so-called next phase of Medicare that you’ve probably seen a lot about is so called Medicare Part C or Medicare Advantage. And what Medicare Part C is, is actually what I call a Medicare takeover policy. In other words, patients get these policies and it takes over the coverage from a private health insurance and takes over both Part A and B. So in other words, the patient no longer has Medicare, but the Medicare Advantage Plan, and these are going to be managed through Kaiser, and Aetna, and Cigna and many payers. You’ve probably seen a lot of TV ads recently indicating, “Hey, join our secure horizons.” That’s what these are for.
Now, these do have to cover all the same things that original Medicare does. So every person that has a Medicare Advantage will have Medicare benefits. Or excuse me, will have chiropractic benefits. They will often have even a little bit better benefits because it’ll include additional things such as dental, vision, hearing, prescription drugs, even acupuncture. But the bigger factor for us of course is additional benefits paid for chiropractic benefits. It’s not unusual for these Medicare part C clients to not only cover spinal manipulation, but additionally cover exams, x-rays, and possibly physical medicine, and may certainly allow a little higher reimbursement than what Medicare allows.
But how are you going to know the patient has this plan? They’re going to have a different card. So make sure when the patient comes in, you ask them for all their insurance cards, because they may still give you the Medicare Part B card, but in fact they’ve got a Medicare Part C, so ask them for everything because often what will happen is you think they still have Medicare, you bill Medicare and you get it denied saying there’s another payer. Well that other payer would be this Part C.
These Medicare Advantage plans have premiums though that patients have to pay. Often these premiums are zero depending on the plan the patient picks, or as much as 300. They’re generally a little bit better for most patients because it combines all of the coverage for Medicare, including hospitals and others. But again, it depends on what the patient has.
Overall, these plans often are lower than what patients pay for part B, so often it’s very attractive. So you may see a lot of patients getting these types of plans. So always ask not just for the Medicare card, but any of their insurance cards, because they do not make the patient give back their Medicare card when they get a Medicare Advantage Plan.
Now what does Part D? That doesn’t involve us, that’s basically prescription coverage. It’s drug coverage. Now there’s parts of drugs that are covered under Part B, but not many, so most people purchase a Part D to give them a little bit more coverage. The average costs, this is not expensive, for most patients about $33. And I’m giving this information more so to make sure that you can really just educate your patients. Because many patients who get Medicare just assume everything’s included in one thing, but of course there could be for sure at least two parts, A and B, probably D for prescription, or they can trade the whole thing for a Part C.
The deductible for prescriptions for this year or 2020 will be $435. Which means again, patients pay out of pocket that much, but many of these policies under this Part D have many drugs that don’t go towards deductible that don’t have any costs, hence why people choose these particular plans. So they can waive the deductible completely, or do you have a partial. So it’s not often that patients actually pay that amount.
Well let’s talk about what we care about, and of course that’s chiropractic benefits. Traditional Medicare Part B covers spinal manipulation related to a spinal subluxation only. Remember, Medicare requires subluxation. All other services other than spinal manipulation are the patient’s responsibility. This is going to include exams, x-rays, therapy. And if the patient has a secondary insurance, that may cover the patient’s a portion of it, but it often is only a supplemental, which means it only covers the portion of manipulation.
So do verify what type of secondary plan do we have? Is it a true secondary that covers all services, or does it cover only the covered services, meaning the 20%? but traditional Medicare Part B, only spinal manipulation.
On Medicare Advantage Plan, we’ll have to cover spinal manipulation 100%, but often may cover a broader range of services, exams, x-rays, and physical medicine. So don’t be afraid to get into these plans. They often will pay better, may pay more services than what Medicare allows, but unfortunately some of them may be only in network. So that’s something you want to verify. Do you have to be a provider for the plan? Often they have both in and out of network benefits, however.
Now of course, what are the chiropractic requirements for Medicare? And of course I’m sure you’re all aware, the requirements are a subluxation. This can be determined by a physical exam or an x-ray, but the bigger factor I want to make sure is that all Medicare claims must contain the diagnosis for subluxation or segmental dysfunction, which is generally M99.01 to M99.05. Remember, in some states you can use the subluxation codes M99.11 to 15, While others require only the M9901, so know your particular state and your Medicare carrier. But ultimately make sure of course to be paid by Medicare, you must have subluxation as a secondary … or excuse me, as a primary diagnosis.
In addition, there must be a secondary neuromusculoskeletal condition related to subluxation. Now in some states you will be allowed to bill without putting that secondary diagnosis on the claim form. However, on some states you will need it. But in either case, always make sure the chart notes have the secondary diagnosis. For instance, if you’re in a state that uses national government services, those don’t require it on the claim form, but must be in the notes. So do always remember beyond the subluxation, there has to be a secondary neuromusculoskeletal diagnosis. And remember, every state or every Medicare carrier does have a list of codes that they allow. Make sure you do know what your state codes are to be sure that you’re not denied. Because if you use a code that’s not on the list, they of course will deny the claim.
Now, Medicare has specific modifiers and this is where we run into problems. Most of these you’re going to be pretty aware of. Obviously spinal manipulation, when it’s considered corrective, must have modifier At, I think everyone knows that, no big deal. You build a manipulation code, modifier AT, non-issue, means it’s payable. If you don’t put a modifier, of course it gets denied. So unless the care is maintenance, it would always get an AT, meaning manipulation.
Now all other services, and this includes anything but spinal manipulation, is not included. And the modifier for all those services are GY. So make it very simple. If it’s not spinal manipulation, the modifier for the code that’s not spinal manipulation is GY, so that means everything else, being there’s only three spinal manipulation codes, it’s everything else, pretty straightforward. So by example, notice here, it’s billed 99203, 25 modifier assuming there’s treatment, and then notice the GY. And the GY’s just to tell Medicare it’s excluded.
Now, physical medicine codes have a unique thing we have to do beyond just using the GY. All physical medicine codes are excluded, so they require GY. But, in order for it to get a proper denial or for Medicare to submit it to have patient responsibility, you must use what’s called the always therapy modifier. And that modifier is GP. So this is the modifier that must go on all physical medicine codes. So notice the example I have here, 97110 for exercise, as GP GY. That is to indicate that it’s an always therapy, and of course it’s an excluded service.
But when codes need more than one modifier, they must appear, but the order does not matter. So if you wanted to put 97110 GP GY, that’s fine, or GY GP. Or here’s an example of one that would require three modifiers. Notice manual therapy, it’s excluded, so it’s a GY. It’s a therapy, so we get the GP. But to show it’s a separate region we also have to put a 59. That’s one way you could do it, but here’s another way, you could put it in any order, so 59 GY GP. Again, I want to emphasize the order is not important. What is important is that you include all the particular modifiers.
Now what about maintenance care? Maintenance care of course means that manipulation is no longer corrective, it’s just to keep the patient feeling good. And to indicate that we have to put a special modifier on the claim form, and that claim form modifier is GA, but what it really means is that the patient has been provided an advanced beneficiary notice, an ABN. Once the patient has been given the ABN and signed it, we then indicate the GA on the manipulation code to indicate that the patient has understood it’s going to be not covered by Medicare and their responsibility.
I do want to highlight though, if a patient chooses option two, that’s on the ABN, if you’re familiar with the option two, you do not need to bill Medicare, the patient just simply pays you directly. So that’s a nice thing that Medicare now equates that we can do that. If it’s maintenance care and the patient agrees and understands its maintenance care, they do not require that you have to send a claim to Medicare so long as the patient’s picked option two.
Something I do want to make sure you’re aware of, I think a lot of people are not, your regular fees may be charged when maintenance. So here’s what it says in the Medicare manuals, specifically section 50.7.3. And it says, “A beneficiary who has been given a properly written and delivered ABN, and agrees may be held liable,” of course, that’s what the whole point of the ABN is. But notice what it says, and I put it in red, “The charge may be the supplier provider’s usual and customary fee for that item or service and is not limited to the Medicare fee schedule.” So that means during maintenance care or non-covered periods, could you charge the patient your regular fee? You can. Now it’s not required you do so. In my dad’s practice, he always just charged the Medicare rate because he was in a very blue collar area. But depending on your region, if patients can afford it, is there anything wrong with charging your regular rate? You certainly can, just understand it is your choice based on Medicare law.
Now with Medicare Advantage claims, not really any different. You’re going to build them just like Medicare. Diagnosis would be same as Medicare. Please include a secondary neuromusculoskeletal diagnosis. The CMT codes get an AT, so in other words everything like Medicare. But physical medicine codes, though they do get a GP, don’t use any other modifiers. Medicare Advantage plans do not use GY, or GA, or any of those. So for Medicare Advantage plans, subluxation was secondary, use of AT modifier, GP on therapies, but you never have to put excluded or maintenance. Those aren’t allowed on those type of plans or not needed.
Medicare fees for this year coming will be available on the websites of your Medicare carrier. You’ll have to check the site for the regions. However, some areas are a little bit tardy, probably look the last week of the year or right first of the year, because often they’re very late and putting them out because they’re waiting for Congress to vote. But here’s what I can see so far from my observation. There is a slight increase in the fees for 98040. For 40 and 42, that’s about 50 cents approximately with the 98941, essentially flat, we’re about a 2 cents decrease.
So bear in mind it’s going to go up a little bit. RVUs, likely that means have gone up for 40 and 42, which they did in 2019 for 41, hence why I think we see the difference. If you’re participating, remember, don’t panic if you don’t know the fees. You can always bill Medicare your regular rate. When you’re par, Medicare will automatically reduce you to their allowed amounts. If you’re not aware what the fee is, just bill your normal fee, the EOB for Medicare will give you that newest fee. Of course you can go online and Google it as well, but pretty straight forward. If you’re a non participating provider, of course you have to look it up to find your limiting charge.
Remember, if you want to change your participation status, you don’t have much time. It’s December 31st. Now the day that I’m doing this is December 10th, so you basically have three weeks from today if you want to change during the open enrollment period. If you are par and want to become non-par, you have to write a letter to Medicare on your letterhead, include all your information, NPI and so forth, and just indicate you wish to change your status. If you are non participating and wish to be participating, you have to send [inaudible 00:16:47] particular form, it’s called the Medicare participating physician supplier agreement form CMS 460.
Remember, if you don’t update your participation status by December 31st, you will remain that same status through the year. And it’s up to you, par, non-par has advantages and disadvantages depending on your practice.
And one last thing for today, and I’m sure you’re all remembering the big panic that was through the profession about you have to report to Medicare. Remember the whole PQRS, it’s now called MIPS, which stands for merit-based instead of payment systems. But 99% of chiropractic providers are exempt. And here’s why. You have to do at least $90,000 in Medicare Part B services. Unfortunately, most of us don’t do that much, so if you’re not doing at least 90,000 in Medicare, then of course it’s not something you have to do. Clearly for chiropractic practice, if you’re doing that, you would want to go ahead and report these because you can get a slight bonus. But don’t be afraid that if you are exempt, there’s no worry of doing all these things, the electronic health records. And again this is part of the panic I think we all went through thinking it was mandatory. And again you can see here chiropractic is exams. My hope is you’re all doing well more than 90,000 and can report, because the bonuses can result in maybe as much as nine or 10% which is pretty good money.
That being said, thank you for spending some time with me today, this is Sam Collins with the HJ Ross Company, your coding and billing expert. Please take a look at our sites. We’re on Facebook, we are on Instagram and others. We have upcoming programs and seminars to help you. We’re here to be your resource. Don’t forget, we’re the source for care. ChiroSecure is your source for protection and risk management, and I bid you adieu and thank you so much for spending some time.
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