Chiropractors from Missouri to New Jersey to California, who referred a Medicare patient to a facility for X-rays, were discovering that Medicare was refusing to reimburse the physician performing the X-rays, due to the fact that the Chiropractor had referred the patient. This began a troubling pattern of Chiropractors not having their referrals accepted by the radiology or other facility.
Chiropractic OnLine Today is pleased to present the memorandum issued by the Department of Health & Human Services. (Please note that all emphasis has been added.) For more information, the ACA may be contacted at 1-800-986-4636 (INFO), ext. 240.
From: Director
Office of Physician and Ambulatory Care Policy, BPD
Subject: Clarification of Ordering and Referring Diagnostic X-Rays by Chiropractors
To: All Regional Administrators
Attn.: All Associate Regional Administrators
This is to clarify the current policy regarding the payments of diagnostic x-rays when either ordered by or referred by a chiropractor. As stated in 42 CFR 410.22(b) (2), Medicare Part B does not pay for x-rays, or other diagnostic or therapeutic services, ordered by a chiropractor.
Thus, current Medicare policy is to deny as not covered any diagnostic x-rays, or other diagnostic or therapeutic service ordered by chiropractors. This policy has been in regulations and in the carriers manual for many years. Recently, we have heard from various chiropractors and their national specialty society about more vigorous interpretations by carriers of this policy. The claims for diagnostic x-rays are being denied even if the chiropractor has only referred the patient to the x-ray provider. The chiropractors assert that in many cases, the radiologist or other physician is actually ordering the test that was referred to them by the chiropractor.
Our policy prohibits payment for the test if ordered by a chiropractor. If the test was ordered by a physician, but referred to the physician by the chiropractor, we should not deny the x-ray on the basis of the "ordering" prohibition. In these cases, we expect that the dual use of ordering and referring on the Form 1500 may be reflecting the wrong provider number. That is, item 17 may be showing the referring provider (chiropractor) when it should be the ordering provider (physician). The instructions for completing item 17 define the use of the terms referring and ordering physicians, as follows:
Referring Physician: A physician who requests an item or service for the beneficiary for which payment may be made under the Medicare program.
Ordering Physician: A physician who orders non-physician services for the patient such as diagnostic laboratory tests, clinical laboratory tests, pharmaceutical services, or durable medical equipment.
Although the primary concern has focused on x-ray, this policy applies equally to other diagnostic or therapeutic services as referenced in the regulation at 410.22. Please notify the carriers in your region to contact providers where claims are being denied on the basis of the "ordering" prohibition, and ask them to include the ordering physician's UPN, or other identification in item 17 of the form 1500. Of course, if the ordering provider is the chiropractor, that is, there is no physician ordering the diagnostic x-ray, current policy requires that this claim be denied.
The chiropractors have raised an additional issue with us concerning the payment to a chiropractor for the technical component of the x-ray service. We do not believe that a chiropractor is any different from any other supplier providing diagnostic tests. That is, as long as the chiropractor meets the relevant state licensure requirements (if any), they can be issued a supplier number by the carrier and be paid for the technical component of diagnostic tests. However, as a supplier, the payment for the diagnostic test is covered only when ordered by a physician.
We are taking a fresh look at all of our policies regarding chiropractors. If you have any comments or observations about the payment or coverage policies for chiropractors, we would appreciate hearing from you.
Elizabeth Cusick