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Medicare Billing Requirements Non Covered Services

  1. Default Medicare Billing Requirements Non Covered Services
    Medical Coding Books
    Does anyone have any clarity on what providers are required to bill to Medicare (not Advantage Plan)?

    If we provide services, such as vaccines that are never covered, are we required to bill the service to Medicare? It was my understanding that all services whether covered or not are to be billed. Of course, there's ABN requirements and things for typically covered services, but I am asking specifically about services that are non-covered all of the time.

    Also, if we are providing services, such as acupuncture, massage therapy and chiropractic services from providers who are NOT enrolled as Medicare providers (they do not have PTN), to Medicare entitled patients, is this ok? Does any provider who treats a Medicare patient need to be enrolled with Medicare? Or is it ok, as long as Medicare is not billed? Please help!! Thank you for your insights!!

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    Quote Originally Posted by skybeck View Post
    Does anyone have any clarity on what providers are required to bill to Medicare (not Advantage Plan)?

    If we provide services, such as vaccines that are never covered, are we required to bill the service to Medicare? It was my understanding that all services whether covered or not are to be billed. Of course, there's ABN requirements and things for typically covered services, but I am asking specifically about services that are non-covered all of the time.

    Also, if we are providing services, such as acupuncture, massage therapy and chiropractic services from providers who are NOT enrolled as Medicare providers (they do not have PTN), to Medicare entitled patients, is this ok? Does any provider who treats a Medicare patient need to be enrolled with Medicare? Or is it ok, as long as Medicare is not billed? Please help!! Thank you for your insights!!
    For services that are never covered by Medicare you are not required to submit claims for them, unless the patient has a secondary insurance that might cover the service. In that case you would need the Medicare denial in order to submit the claim to the secondary insurance.

    http://www.cms.gov/manuals/downloads/bp102c15.pdf

    For the rest of your question, I suggest you go to the CMS Manual in this link and look at Section 40. Pay particular attention to Section 40.4 which describes who may, and may not, "opt-out" of Medicare. Chiropracter and physical therapists specifically may not opt out, so they cannot see Medicare patients if they are not contracted with Medicare.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

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