Tell Medicare patients before the visit what Medicare covers and what it does not, and put the Advance Beneficiary Notice in front of the patient before any service Medicare is expected to deny. GoHighLevel can flag Medicare patients, send the explanation, and track the signed notice. The bottom line: Medicare covers one chiropractic service, and a clinic that explains that early avoids both surprise bills and denied claims it cannot collect.
What Medicare covers and what it does not
According to the CMS Medicare Coverage Database, coverage of chiropractic services is a limited benefit that is limited to manual manipulation for the treatment of subluxation, and all other services ordered or performed by a chiropractor are excluded. Claims for the manipulation codes 98940, 98941, and 98942 must carry the AT modifier when the treatment is active or corrective, and CMS says that once the maximum therapeutic benefit has been reached, ongoing maintenance therapy is not considered medically necessary under Medicare. Medicare also does not cover extraspinal manipulation, and billing guides add that exams, X rays, and therapy modalities performed by a chiropractor are not covered. Billing guides say that before continuing with maintenance care the practice must obtain a signed Advance Beneficiary Notice, so the patient knows Medicare will not pay and they are responsible, and that the GA modifier shows the notice is on file.
What each type of visit means for the patient
| Type of visit or service | Medicare treatment | What the clinic does first |
|---|---|---|
| Active, corrective spinal manipulation for a subluxation | Covered when documented and billed correctly | Explain that coverage depends on the doctor's documentation |
| Maintenance care after maximum therapeutic benefit | Not covered | Doctor explains, patient signs the ABN before treatment, and the clinic bills with the GA modifier |
| Exams, X rays, and therapy modalities by a chiropractor | Not covered | Tell the patient the fee in advance, and use an ABN where billing the patient depends on it |
| Extraspinal manipulation | Not covered | Same as above |
Medicare Advantage and commercial plans vary, so ask for the plan type at booking and do not assume. This article describes original Medicare.
What the clinic can automate and what it cannot
A message can flag the patient, explain the general rule in plain words, and ask the patient to arrive early to review a form. It cannot decide that care has become maintenance. That is the doctor's clinical judgment, and the notice must be given by the clinic before the service, in the form CMS requires. Use the current CMS ABN form, and ask your Medicare contractor whether it accepts an electronic version before you route it through an e signature tool.
Build it in HighLevel
- Add a contact field Insurance type with the values Medicare, Medicare Advantage, Commercial, and Self pay, set at booking.
- Create a workflow that starts when a new patient books and the field is Medicare, and send a short message with what to expect and the fee schedule link for non covered services.
- Add a doctor task called Maximum benefit review that the doctor can trigger from the patient record, which moves the patient to the tag Maintenance discussion.
- When the tag is added, create a front desk task to prepare the ABN and send a message asking the patient to arrive 10 minutes early.
- Store the signed form in the patient's file, and add the tag ABN on file with the date, so the front desk sees it before the next visit.
- Add an If/Else on the tag before any maintenance visit reminder so a patient without the tag gets a task for the front desk instead of a standard reminder.
- Review the Medicare list each month for patients near their plan's end date.
A message, written out
Sample: Hi Dana, this is [Clinic]. Before your first visit, a quick note about Medicare. Medicare generally covers spinal adjustments when your doctor documents that they are treating a condition, and it does not cover exams, X rays, or visits that are only for maintaining how you feel. We will tell you before any visit that Medicare is not expected to cover. Questions? Call [number]. Reply STOP to stop messages.
Worked example
A clinic with 400 active patients, 25 percent of them on Medicare, has 100 Medicare patients (400 times 0.25). If 15 of them reach maintenance care in a given quarter, that is 15 notices to prepare before treatment, and 15 conversations that happen early instead of at the front desk after the visit. The 25 percent and the 15 are assumptions to replace with your own numbers.
Wording to avoid in messages to Medicare patients
Avoid saying that a visit is covered, free, or approved, since coverage depends on documentation and the doctor's judgment at the visit. Avoid promotional language for maintenance or wellness plans in the same message as coverage information. Keep the message to what Medicare covers in general, who to ask about a specific visit, and when the clinic will tell the patient about a charge. A message that over promises is harder to fix than one that says less.
Medicare Advantage and other plans
The description here is for original Medicare. Medicare Advantage plans and commercial plans have their own rules and may cover different services, visit counts, and notices. Ask for the plan type and the member ID at booking, verify the benefits before the first visit, and use a separate message for each plan type. Do not reuse the original Medicare wording for a plan that works differently.
How this was handled before
A paper ABN lived in a drawer, and the front desk remembered it when the doctor mentioned maintenance care. Some patients first heard about non covered fees after the visit. A flag and a tag make the notice part of the visit, not an afterthought.
What to measure
Track Medicare patients flagged, notices signed before maintenance visits, claims denied for missing notices, and patient complaints about surprise bills. The number of denials without a notice should be zero.
Questions people ask
What does Medicare cover for chiropractic care?
Only manual manipulation of the spine to correct a subluxation, according to CMS. Exams, X rays, therapy modalities, extraspinal manipulation, and maintenance care are not covered.
When is an ABN required for chiropractic care?
Before a service Medicare is expected to deny, such as maintenance care, so the patient knows they may be responsible for the cost. Claims then use the GA modifier.
Can a text message replace the ABN?
No. The notice has to be the CMS form given before the service. A message can explain the rule and prepare the patient.
You can start a GoHighLevel account here and build the Medicare flag and notice tracker, or see documents and workflows together in our capabilities demo.