by Wyn Staheli, Director of Research
February 25th, 2019
The nice thing about MediGap policies is that they pay for some of the healthcare costs that an original Medicare plan (Part B) does not cover. So when a patient has Medicare and a Medicare supplement (MediGap) and their condition is related to an extremity (a noncovered service), Medicare must be billed for the denial in order for the Medicare supplement to consider payment. However, the exact manner of billing this situation has prompted some to ask:
- Does the claim for Medicare list an extremity diagnosis and will this yield a denial with the correct PR codes?
- When billing Medicare (even when the extremity condition is the primary reason for the encounter) must a spinal subluxation be listed as the diagnosis for the claim to be pushed through Medicare to get a proper denial?
Keep in mind that MediGap policies generally pay for the deductible and coinsurance for covered services. MediGap policies must follow federal and state laws and it must clearly be identified as a “Medicare Supplement Insurance.” Even though “Supplement” plans mainly involve Medicare Part A and Part B out-of-pocket costs, like deductibles and copayments, some Medicare Advantage (Part C) policies also cover additional benefits such as:
- Routine vision services
- Routine dental services
- Private-duty nursing services
- Hearing aids
Note: Medicare Supplement plans do NOT cover Medicare Advantage plan costs.
Because there are many supplement plans available, it is up to the provider to verify which normally, noncovered Medicare benefits might be covered by the patient’s policy along with any specific billing requirements.
Generally speaking, we ALWAYS advise billing according to the most appropriate diagnosis and service provided. If there WAS a subluxation treated with CMT, and the HPI identifies the spinal issue, then follow the regular Medicare rules so that portion of the claim is paid.
To answer the question about billing for the CMT of an extremity, the best thing to do is get the supplemental payer guidelines regarding their billing preferences. Without knowing the specifics of the patient’s supplemental policy, an educated guess is that it would be similar to other non-Medicare payer guidelines for reporting extremity CMT. If the supplemental billing guidelines do not specifically address the billing of extremity adjustments, just bill it as you would any other non-Medicare payer and be sure the claim links the CMT with the diagnosis pointer (Item Number 24E of the 1500 Claim Form) to an extremity diagnosis.
|Correction Notice 2019-04-01: “Medicare Advantage (Part C) policies” was left out of the sentence about additional benefits. MediGap does not cover the additional benefits in the bullet list.|