Mario Fucinari DC, CCSP, CPCO

Changes in Medicare and Blue Cross continue to batter claims in 2018.  Medicare has instituted changes late last year and in the first quarter of 2018.  It is incumbent upon each chiropractic office to keep up with these changes.  Here is a brief synopsis of the major changes affect chiropractic.


Congress passed the Bipartisan Budget Act of 2018 on 2/9/2018, changing the Medicare physician fee schedule and the processing of Medicare services. Section 50201 of this Act has made a change to the work Geographic Practice Cost Index (GPCI) floor, effective retroactive to 1/1/2018. Any area that previously was in an area with a work GPCI of less than 1.000 will be impacted. The Act issues a floor of 1.000 to the work GPCI which will cause any fee schedule for any service in those areas to increase.

What does this mean to you?  Certain zones will see a reimbursement increase.  Keep in mind that the fees you receive may be impacted by your status as a participating provider or a non-participating provider and any penalties levied against you for failure to do PQRS coding properly and EHR Meaningful Use.  The sequestration reduction of 2% will continue through 2027.  Consult your Medicare Administrative Carrier’s Physician fee schedule for updates as of March 1, 2018.


On January 1, 2018, new therapy caps were instituted in Medicare.  Due to these caps, all therapy performed on a Medicare patient is tabulated.  Even though physical therapy is not reimbursed by Medicare, the tabulation mandate is not specialty specific.  Therefore, all therapy performed in the chiropractic office, which is filed with Medicare, must bear the GPGY modifiers.  If the GPGY modifier is not appended to any therapy codes bearing the CPT 97XXX code, Medicare will reject the code for improper therapy utilization. We will continue to monitor this situation and ask providers to forward any information they obtain from payers regarding this issue to OCA.


The Advance Beneficiary Notice of Noncoverage (ABN) Form is issued by providers in situations where Medicare payment is expected to be denied. Guidelines for mandatory and voluntary use of the ABN are published in the Medicare Claims Processing Manual, Chapter 30, Section 50.

A new ABN form was instituted in November 2017 for non-participating providers.  This form is different in its language because it not expected that Medicare will pay a non-participating provider.  Keep in mind that under Medicare guidelines, a non-participating provider is one who is not “in-network.”  Since chiropractors cannot opt out of Medicare, if you see a patient for active care and perform spinal manipulation, you must file a claim within one year from the date of service, whether you are a participating or non-participating provider.

ABN Form:


On November 12, 2017, Blue Cross instituted new software edits in some localities.  The primary result in chiropractic has resulted in denials of the examination (E & M) code when it accompanies a manipulation code.  When claims include both an E/M visit and CMT, modifier 25 may be added to the E/M service.  As long as your documentation clearly meets all the requirements for reporting E/M and CMT services, then denials should be appealed and include an appeal letter explaining the appropriateness of the service.

We are recommending to continue to bill these services when circumstances warrant it.  If a denial ensues, then it is recommended to appeal the denial as instructed in the PPO manual.