Care Plans: Key to Medicare Chiropractic Reimbursement

Care plans have always been important in Chiropractic billing to Medicare, and that was only reinforced in 2018 with their changes to reporting Physical Therapy codes.

“454 Qualifier”

Medicare has long required Chiropractors send the date of the current care plan on their claims. This is referred to as the “454 Qualifier.” This is not to be the date of injury, but rather the date you first created the care plan for the patient. If the patient presents with a new issue and a new care plan is created, don’t forget to update this date in your Practice Management system.

Physical Therapy Coding

Beginning in 2018, Medicare requires physical therapy coding be sent with modifier “GP” when “services are delivered under an outpatient physical therapy plan of care.” Without this modifier, Medicare rejects processing of this code set when sent by Chiropractors.

Why does this matter if Medicare does not cover these services for Chiropractors anyway? For a few reasons.

  1. If you render the services and Medicare does not even process them, that means they are not crossed over to the secondary plans and they are processed to provider liability. Many patients have secondary plans that will cover these services if they are processed to patient responsibility.
  2. Even in the absence of a secondary plan, if you are intending on charging the patient for services rendered, you will need the EOB to process to patient responsibility.

For a line item example, sending your claim as:

97140-GP-GX will process on the EOB to patient responsibility.

Sending your claim as:

97140-59 or 97140-XS will now return as provider liability.

In Short:

  • Be mindful of ensuring you have current care plans on file and those dates current in your billing system. Medicare does not require your care plans be sent with your claim, only the date.
  • Update your software programs to include “GP” when physical therapy is rendered under the care plans.

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