(Medicare Claims Processing Manual)

E. Computation of Limitation    A/B MACs (B) determine the Medicare approved payment amount for services subject to the limitation.  They:     Multiply the approved amount by the limitation percentage amount;      Subtract any unsatisfied deductible; and,      Multiply the remainder by 0.8 to obtain the amount of Medicare payment. The beneficiary is responsible for the difference between the amount paid by Medicare and the full Medicare approved amount.    The following examples illustrate the application of the limitation in various circumstances as it is gradually reduced under section 102 of the Medicare Improvements for Patients and Providers Act (MIPPA).  Please note that although the calendar year 2009 Part B deductible of $135 is used under these examples, the actual deductible amount for calendar year 2010 and future years is unknown and will be subject to change.    Example #1:   In 2010, a clinical psychologist submits a claim for $200 for outpatient treatment of a patients mental disorder.  The Medicare -approved amount is $180.  Since clinical psychologists must accept assignment, the patient is not liable for the $20 in exces s charges.  The patient previously satisfied the $135 annual Part B deductible.  The limitation reduces the amount of incurred expenses to 68  percent of the approved amount.  Medicare pays 80 percent of the remaining incurred expenses.  The Medicare paym ent and patient liability are computed as follows:    1. Actual charges..$200.00  2. Medicare- approved amount   ..$180.00  3. Medicare incurred expenses (0.6875 x line 2) .....$123.75  4. Unmet deductible..$0.00  5. Remainder after subtracting deductible (line 3 minus line 4) ..$123.75  6. Medicare payment (0.80 x line 5).$99.00  7. Patient liability (line 2 minus line 6).$81.00    Example  #2:   In 2012, a clinical social worker submits a claim for $135 for outpatient treatment of a patients mental disorder.  The Medicare -approved amount is $120.  Since clinical social workers must accept assignment, the patient is not liable for the $15 in exc ess charges.  The limitation reduces the amount of incurred expenses to 75 percent of the approved amount.  The patient previously satisfied $70 of the $135 annual Part B deductible, leaving $65 unmet.  The Medicare payment and patient liability are computed as follows:    1. Actual charges..$135.00  2. Medicare- approved am........$120.00  3. Medicare incurred expenses (0.75 x line...$90.00  4. Unmet deductible...$65.00  5. Remainder after subtracting deductible (line 3 minus line   6. Medicare payment (0.80 x line ...$20.00  7. Patient liability (line 2 minus line 6)..........$100.00    Example #3:   In calendar year 2013, a physician who does not accept assignment submits a claim for $780 for services in connection with the treatment of a mental disorder that did not require inpatient hospitalization.  The Medicare -approved amount is $750.  Because the physician does not accept assignment, the patient is liable for the $30 in excess charges.  The patient has not satisfied any of the $135 Part B annual deductible.  The Medicare payment and patient liability are computed as follows:    1. Actual charges. .$780.00  2. Medicare- approved amount..$750.00  3. Medicare incurred expenses (0.8125 x line 2....$609.38  4. Unmet deductible ..$135.00  5. Remainder after subtracting deductible (line 3 minus line  4 6.  4)...$474.38 7. Medicare payment (0.80 x line 5)  ..$379.50  8. Patient liability (line 1 minus line 6)    $400.50    Example #4:   A patients Part B expenses during calendar year 2014 are for a physicians services in connection with the treatment of a mental disorder that initially required inpatient hospitalization, with subsequent physician services furnished on an outpatient ba sis.  The patient has not satisfied any of the $135 Part B deductible.  The physician accepts assignment and submits a claim for $780.  The Medicare -approved amount is $750.  Since the limitation will be completely phased out as of January 1, 2014, the ent ire $750 Medicare -approved amount is recognized as the total incurred expenses because such expenses are no longer reduced.  Also, there is no longer any distinction between mental health services the patient receives as an inpatient or outpatient.  The Me dicare payment and patient liability are computed as follows:    1. Actual charges..$780.00  2. Medicare- approved amount ..$750.00  3. Medicare incurred expenses (1.00 x line     ..$750.00  4. Unmet deductible    ..$135.00  5. Remainder after subtracting deductible (line 3 minus line 4) ..$615.00  6. Medicare payment (0.80 x line 5).$492.00 7.  Beneficiary liability (line 2 minus line 6).$258.00   220 - Chiropractic Services  (Rev. 3721, Issued: 02- 24-17, Effective: 05 -25-17, Implementation: 05- 25-17)  A.   Verification of Chiropractor's Qualifications   Establish a reference file of chiropractors eligible for payment as physicians under the criteria in Pub. 100- 02, Benefits Policy Manual, Chapter 15, Sections 30.5 & 240A.  Pay only chiropractors on file.  Information needed to establish such files is furnished by the RO.  The RO is notified by the appropriate State agency which chiropractors are licensed and whether each meets the national uniform standards.  B.   Durable Medical Equipment Regional Carriers Processing Claims When a Chiropractor is the Supplier   Effective July 1, 1999, except for restrictions to chiropractor services as stipulated in 1861(s)(2)(A) of the Social Security Act, chiropractors (specialty 35) can bill for durable medical equipment, prosthetics, orthotics and supplies if, as the supplier, they have a valid supplier number assigned by the National Supplier Clearinghouse.  In order to process claims, the Common Working File has been changed to allow specialty 35 to bill for services furnished as a supplier.   C.   Documentation   The following information must be recorded by the chiropractor and kept on file.  The date of the initial treatment or date of exacerbation of the existing condition must be entered in Item 14 of Form CMS -1500.  This serves as affirmation by the chiropract or that all documentation required as listed below and in Pub. 100- 02, Benefits Policy Manual, Chapter 15, Section 240.1.2 is being maintained on file by the chiropractor.   1. Specification of the precise spinal location and level of subluxation (see Pub. 100- 02, Benefits Policy Manual, Chapter 15, Section 240.1.4) giving rise to the diagnosis and symptoms.   2. Effective for claims with dates of service on and after January 1, 2000, the x-ray is no longer required .  However, the x- ray may  still be used to demonstrate subluxation for claims processing purposes.  Effective for claims with dates of service on or after October 1, 2000, when the x- ray is used to demonstrate subluxation, the date of the x -ray must be entered in Item 19 of Form C MS-1500 and the date must be within the parameters specified in Pub. 100- 02, Benefits Policy Manual, Chapter 15, Section 240.1.2.  For claims with dates of service prior to January 1, 2000, and for claims with dates of service on or after October 1, 2000, for which an x- ray is still used to show subluxation, the following instructions on documentation apply:   An x -ray film (including the date of the film) is available for your review demonstrating the existence of a subluxation at the specified level of the spine.  If the beneficiary refuses to have the x -ray, the chiropractor must submit one of the appropriate  HCPCS codes for chiropractic manipulation in addition to modifier GX (service not covered by Medicare), and the claim will be denied as a technical denial.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.   Group Code: PR  CARC: 96  RARC: M111  MSN: 3.1  NOTE:  The refusal of the beneficiary to have an x -ray taken will no longer need to be coded for claims with dates of service on or after January 1, 2000.   D.   Claims Processing   Edits and suggested MSN and RA messages.   1. Do not pay for manual manipulation of the spine in treating conditions other than those indicated in Pub. 100- 02, Benefits Policy Manual, Chapter 15, Section 240.1.3.  The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.   Group Code: CO  CARC: 50  RARC: N/A  MSN: 15.4  1. Deny claims for treatment of any condition not reasonably related to a subluxation involving vertebrae at the spinal level specified.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  The CARC below is not included in the CAQH CORE Business Scenarios.  Group Code: CO  CARC: B22  RARC: N/A  MSN: 15.4  2. Edit to verify that the date of the initial visit or the date of exacerbation of the existing condition is entered.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 2.   Group Code: CO  CARC: 16  RARC: MA122  MSN: 9.2  E.   X -ray Review  Effective for claims with dates of service on and after January 1, 2000, the x -ray is no longer required.  However, effective for claims with dates of service on or after October 1, 2000, should the chiropractor choose to use the x- ray to show subluxation, the x -ray review process is still required as outlined below minus the requirement in the last sentence of number 2. For claims with dates of service prior to January 1, 2000, all aspects of the following instructions still apply.   1. Carriers should conduct post -payment reviews of x -rays on a sample basis.  Prepayment review should be undertaken in all questionable cases.  2. It is the responsibility of the treating chiropractor to make the documenting x-ray(s) available to the carrier's review staff.  If x -rays are not made available, or suggest a pattern in failing to demonstrate subluxation for any reason, including unacceptable technical quality, the carrier should conduct prepayment review of x-rays in 100 percent of the subsequent claims for treatments by the practitioner involved until satisfied that the deficiency will no longer occur.  Where there is no x-ray documentation of subluxation on prepayment review, the claims, of course, should be denied.  (The  last sentence of this paragraph only refers to claims with dates of service prior to January 1, 2000.)   3. The x -ray film(s) must have been taken at a time reasonably proximate to the initiation of the course of treatment and must demonstrate a subluxation at the level of the spine specified by the treating chiropractor on the claim.  (See Pub. 100-02, Benef its Policy Manual, Chapter 15, Section 240.1.2.)   4. An x -ray obtained by the chiropractor for his own diagnostic purposes before commencing treatment should suffice for claims documentation purposes. However, when subluxation was for treatment purposes diagnosed by some other means and x -rays are taken t o satisfy Medicare's documentation requirement, carriers should ask chiropractors to hone in on the site of the subluxation in producing x- rays.  Such a practice would not only minimize the exposure of the patient but also should result in a film more clea rly portraying the subluxation.  5. An x -ray will be considered of acceptable technical quality if any individual trained in the reading of x- rays could recognize a subluxation if present.