Q: Our question to you is in regards to Medicare. We have already contacted Medicare and it seems that we get conflicting answers depending upon who you speak to. Anyway, because we do have Medicare patients that will continue to get adjusted for life...is it mandatory to continue to send in claims although Medicare specifically states that maintenance therapy is not covered under the Medicare program? We have been told that we are required to submit claims to Medicare whether it's maintenance therapy or not, and they will make the determination. AND we have also been told that we do not need to submit claims for services that Medicare does not cover (i.e.., maintenance therapy?). One point that is baffling to us is, if we are in fact to submit claims for the patient throughout their lifetime (10 years, 20 years, 30 years, etc.) then that is alot of time & resources that is being wasted, when in fact we already know that Medicare does not cover these services. We're not sure if you would be able to advise us if you have had any similar experience or if you're able to direct us to anyone that may provide reliable answers. We just want to make sure that we are complying with government laws. A: The following answer comes from Dr. Brad Hayes who is an insurance consultant Dr. Joel Margolies asked me to answer your Medicare question. I am an insurance instructor and consultant. That answer has definitely been decided. I will give you the answer, attach the reference, and direct you to more information. First, the answer is that you have to bill Medicare. Medicare has released new modifiers to bill this type of service with. The Centers for Medicare & Medicaid Services (CMS), formerly HCFA, Program Memorandum, B-01-58, dated September 25, 2001, provides an explanation on the use of the new GY and GZ modifiers. These modifiers were developed to allow practitioners to bill Medicare for services that are statutorily non-covered or do not meet the definition of a Medicare benefit and services not considered reasonable and necessary by Medicare. It also provides an explanation on the use of the GA modifier. The new modifiers, GY and GZ, will be effective January 1, 2002. GY: Item or service statutorily excluded or does not meet the definition of any Medicare benefit. The new GY modifier must be used when physicians want to indicate that the item or service is statutorily non-covered or is not a Medicare benefit. This is the modifier to use for a maintenance patient. It should be affixed to the 98940-98942 code you are using. In Block 19 of the HCFA 1500 claim form it would be prudent to state: "These services are for maintenance care". GZ: Item or service expected to be denied as not reasonable and necessary. The new GZ modifier must be used when physicians want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an Advance Beneficiary Notification (ABN) signed by the beneficiary. GA: The GA modifier must be used when physicians want to indicate that they expect that Medicare will deny a service as not reasonable and necessary and they do have on file a valid ABN signed by the beneficiary. This modifier could also be used. With this you would have the patient sign an Advance Beneficiary Notice Form and state that the reason is that this is maintenance care and Medicare does not cover Maintenance Care. Either way would be acceptable. I have included additional information in the attachment. The Website address for your carrier is: : http://www.noridianmedicare.com/. You will find all of this information. Look up 26 Medicare B News Issue 193. Use their search engine. Also the new Advance Beneficiary Form is at www.hcfa.gov/medicare/bni. Hopefully this answers your questions. If you have further questions, please contact me. Regards, Brad Hayes, D.C. DCBrad1@aol.com Chiropractic‚New Modifiers and Waiver The Centers for Medicare & Medicaid Services (CMS), formerly HCFA, Program Memorandum, B-01-58, dated September 25, 2001, provides an explanation on the use of the new GY and GZ modifiers. These modifiers were developed to allow practitioners to bill Medicare for services that are statutorily non-covered or do not meet the definition of a Medicare benefit and services not considered reasonable and necessary by Medicare. It also provides an explanation on the use of the GA modifier. The new modifiers, GY and GZ, will be effective January 1, 2002. Discontinued Code A9170‚Non-covered service by chiropractor New Modifiers for Chiropractic Use GY GZ Established Modifier for Chiropractic Use GA Use of the GA, GY and GZ Modifiers for Chiropractic Services . GY Item or service statutorily excluded or does not meet the definition of any Medicare benefit. The new GY modifier must be used when physicians want to indicate that the item or service is statutorily non-covered or is not a Medicare benefit. GZ Item or service expected to be denied as not reasonable and necessary. The new GZ modifier must be used when physicians want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an Advance Beneficiary Notification (ABN) signed by the beneficiary. GA The GA modifier must be used when physicians want to indicate that they expect that Medicare will deny a service as not reasonable and necessary and they do have on file a valid ABN signed by the beneficiary. The GY, GZ and GA modifiers should be used with the specific, appropriate HCPCS code. Advance Beneficiary Notice (ABN) Usage Advance Beneficiary Notices advise beneficiaries, before items or services actually are furnished, when Medicare is likely to deny payment for them. ABNs allow beneficiaries to make informed consumer decisions about receiving items or services for which they may have to pay out-of-pocket and to be more active participants in their own health care treatment decisions. Medicare Announces New Patient Liability Notice In July 2001, CMS announced revised Advance Beneficiary Notices (ABNs) which may be used in onnection with Medicare claims. The new ABNs are part of CMS¼s Beneficiary Notices Initiative (BNI). Go to the BNI Web page (www.hcfa.gov/medicare/bni/) to see ABNs and other BNI notices. They are designed o be more beneficiary-friendly, more readable nd understandable, with patient options more clearly defined. New ABN Instructions Complete ABN instructions will be formally published in the Medicare Carriers Manual. Publication by December 31, 2001, is planned. This manual may be accessed via the CMS Web site at www.hcfa.gov/pubforms/. The manual instructions will be the official Medicare program dissemination of policy and procedures that providers and Medicare carriers are to follow with respect to ABNs. Waiver of Liability Provision The Omnibus Budget Reconciliation Act of 1986 (OBRA) included a limitation of liability (or waiver of liability) provision to the Social Security Act for both assigned and non- assigned claims. This provides beneficiaries with protection from liability when they, in good faith, receive services from a Medicare provider for which Medicare payment is subsequently denied as not „reasonable and necessary.¾ A waiver statement need only be obtained for services that Medicare may deny as „not reasonable and necessary¾ (Reason Code CO-50 on the provider remittance advice). This includes services with diagnosis restrictions (e.g., 714.0 rheumatoid arthritis and 138 late effects of poliomyelitis), frequency limitations (e.g., maintenance) and services for which Medicare has a Local Medical Review Policy (e.g., Chiropractic Special, Medicare B News, dated March 2000). Information regarding such restrictions and medical policies is published in the Medicare B News bulletin. Services not payable due to ånot reasonable and necessary¼ provisions must be billed to Medicare even though they will likely be denied. Generally, services necessitating a signed waiver are payable in some instances but not payable in others. By understanding these provisions, providers can protect their practice or company from financial liability for these denied services. Nonparticipating providers who provide services to Medicare beneficiaries on a non-assigned basis that are subsequently determined not to be „reasonable and necessary¾ are required to refund any amounts collected from the beneficiary, unless one of the two following circumstances applies. I. Provider Liability Protection There are two circumstances in which the provider will not be held liable under the limitation of liability provision. 1. The provider did not know and could not have reasonably been expected to know that Medicare would not pay for the service. There are several notification processes that the Medicare carrier considers in determining whether the provider should have known that Medicare would not cover a service. The most frequent notifications include general notice to all providers (such as the Federal Register or the carrier¼s Medicare newsletter) and notice to an individual provider (such as a letter or a previous denial of a similar service in a similar situation). 2. The provider notified the patient in writing, prior to performing the service that Medicare would likely deny the service and the reason for that belief, and after being so informed the beneficiary agreed, in writing, to pay for the service. Acceptable evidence of prior notification to a Medicare beneficiary (or a person acting on the beneficiary¼s behalf) must include all of the following: A. The notice must be in writing, using approved notice language (refer to the Sample Beneficiary Notice below); B. A copy of the agreement must be retained in the provider¼s files. Blanket waiver statements are not acceptable. Providing the beneficiary with a copy of the agreement is allowed; GZ Item or service expected to be denied as not reasonable and necessary. The new GZ modifier must be used when physicians want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an Advance Beneficiary Notification (ABN) signed by the beneficiary. GA The GA modifier must be used when physicians want to indicate that they expect that Medicare will deny a service as not reasonable and necessary and they do have on file a valid ABN signed by the beneficiary. The GY, GZ and GA modifiers should be used with the specific, appropriate HCPCS code. Advance Beneficiary Notice (ABN) Usage Advance Beneficiary Notices advise beneficiaries, before items or services actually are furnished, when Medicare is likely to deny payment for them. ABNs allow beneficiaries to make informed consumer decisions about receiving items or services for which they may have to pay out-of-pocket and to be more active participants in their own health care treatment decisions. Medicare Announces New Patient Liability Notice In July 2001, CMS announced revised Advance Beneficiary Notices (ABNs) which may be used in connection with Medicare claims. The new ABNs are part of CMS¼s Beneficiary Notices Initiative (BNI). Go to the BNI Web page (www.hcfa.gov/medicare/bni/) to see ABNs and other BNI notices. They are designed to be more beneficiary-friendly, more readable and understandable, with patient options more clearly defined. New ABN Instructions Complete ABN instructions will be formally published in the Medicare Carriers Manual. Publication by December 31, 2001, is planned. This manual may be accessed via the CMS Web site at www.hcfa.gov/pubforms/. The manual instructions will be the official Medicare program dissemination of policy and procedures that providers and Medicare carriers are to follow with respect to ABNs. Waiver of Liability Provision The Omnibus Budget Reconciliation Act of 1986 (OBRA) included a limitation of liability (or waiver of liability) provision to the Social Security Act for both assigned and non- assigned claims. This provides beneficiaries with protection from liability when they, in good faith, receive services from a Medicare provider for which Medicare payment is subsequently denied as not „reasonable and necessary.¾ A waiver statement need only be obtained for services that Medicare may deny as „not reasonable and necessary¾ (Reason Code CO-50 on the provider remittance advice). This includes services with diagnosis restrictions (e.g., 714.0 rheumatoid arthritis and 138 late effects of poliomyelitis), frequency limitations (e.g., maintenance) and services for which Medicare has a Local Medical Review Policy (e.g., Chiropractic Special, Medicare B News, dated March 2000). Information regarding such restrictions and medical policies is published in the Medicare B News bulletin. Services not payable due to ånot reasonable and necessary¼ provisions must be billed to Medicare even though they will likely be denied. Generally, services necessitating a signed waiver are payable in some instances but not payable in others. By understanding these provisions, providers can protect their practice or company from financial liability for these denied services. Nonparticipating providers who provide services to Medicare beneficiaries on a non-assigned basis that are subsequently determined not to be „reasonable and necessary¾ are required to refund any amounts collected from the beneficiary, unless one of the two following circumstances applies. I. Provider Liability Protection There are two circumstances in which the provider will not be held liable under the limitation of liability provision. 1. The provider did not know and could not have reasonably been expected to know that Medicare would not pay for the service. There are several notification processes that the Medicare carrier considers in determining whether the provider should have known that Medicare would not cover a service. The most frequent notifications include general notice to all providers (such as the Federal Register or the carrier¼s Medicare newsletter) and notice to an individual provider (such as a letter or a previous denial of a similar service in a similar situation). 2. The provider notified the patient in writing, prior to performing the service that Medicare would likely deny the service and the reason for that belief, and after being so informed the beneficiary agreed, in writing, to pay for the service. Acceptable evidence of prior notification to a Medicare beneficiary (or a person acting on the beneficiary¼s behalf) must include all of the following: A. The notice must be in writing, using approved notice language (refer to the Sample Beneficiary Notice below); B. A copy of the agreement must be retained in the provider¼s files. Blanket waiver statements are not acceptable. Providing the beneficiary with a copy of the agreement is allowed; C. The notice must be signed and dated by the beneficiary (or a person acting on the beneficiary¼s behalf) prior to the service being provided; D. The notice must cite the specific service or services for which payment is likely to be denied; and E. The notice must cite the physician¼s specific reason(s) for believing Medicare payment will be denied. (The notice is not an acceptable waiver if it is no more than a preprinted statement to the effect that there is a possibility that Medicare may not pay for the service.) The reason must be encounter specific for each individual date of service. Examples of acceptable specific reasons may include or are not limited to the following: The information in your case does not support: Ä the need for this service, Ä the need for this treatment, Ä the need for this many services within this period of time, Ä the need for this many visits or treatments, Ä the need for the level of service as shown on the claim, or Ä the need for more than one visit per day; etc. Physicians should not give notices to beneficiaries unless the physician has some genuine doubt regarding the likelihood of Medicare payment as evidenced by his or her stated reasons. Giving ABN notices for all claims is not an acceptable practice. Use of either of the following ABN forms is acceptable. 1. Sample Beneficiary Notice‚Established ABN‚page 28 2. Sample Beneficiary Notice‚Revised ABN‚page 29