There have been several “issues” caused by the changes in billing Medicare for 2018. Many practices, including Chiropractic offices are now having claims “rejected” by CMS rather than being “denied and forwarded” to the secondary insurance.

A rejected claim does NOT PROCESS through the system at all and therefore is NOT a valid denial for purposes of collection from the patient or their secondary coverage carrier. Offices that are not following the new reporting requirements have found themselves in a revolving door of re-submissions.

Chiropractic Office Issues: You all know that Medicare policy states a chiropractor should bill any service they provide that is not covered by Medicare for their specialty with modifier GY to receive a formal denial of the service and, when possible, have the denial forwarded to the patient’s secondary carrier for payment. This was proper UNTIL 2018 when there was a change to this process FOR ALL PROVIDER TYPES that may have been overlooked.

CMS implemented a change (MM101076) effective 1/1/2018 for always therapy services that contained an additional billing requirement for any always therapy service provided by any provider specialty type.

All providers were informed that each code designated as “always therapy” must always be accompanied by one of the therapy modifiers GN, GO or GP in addition to any other relevant payment modifier.

What you need to do:
Based on this policy change, all providers, including a chiropractor providing an always therapy service must append the appropriate therapy modifier (normally GP) for the service being billed IN ADDITION TO modifier GY to indicate the service is non-covered by Medicare for their provider type.

If one of the therapy modifiers, GP,GO or GN, is not appended then the claim will reject and not process through the Medicare processing system AT ALL.

Chiropractors will need to refile the claim with the appropriate modifiers for it to process for denial.

Medical offices will encounter a CO 4 denial ” The procedure code is inconsistent with the modifier used or a required modifier is missing”  with a MA130 remark “Your claim contains incomplete and/or invalid information and no appeal rights are afforded because the claim is unprocessable.  Please submit a new claim with the correct information”

Again, the ruling applies to ALL PROVIDERS who bill therapy services to Medicare.