Coding Questions: To participate-or not-in Medicare?

Published: 2009-11-01 22:01:08
Author: Marty Kotlar | Chiropractic Economics | April 2008

I received my National Provider Identifier (NPI) number and want to start seeing Medicare patients, but I have to decide between being a participating provider or nonparticipating provider within the Medicare program. What do you recommend?

You will need to decide what’s best for your particular situation after reviewing the differences between being a participating and nonparticipating provider — keeping in mind that participating and nonparticipating providers must follow the same rules and regulations as it pertains to proper and compliant documentation.

For example: Medicare participating and nonparticipating providers need to establish the existence of spinal subluxation through the P.A.R.T. exam or x-rays, understand the AT, GA, GP, GY, and GZ modifiers create treatment plans with specific treatment goals, choose compliant CPT/ICD-9 codes, know when and how to incorporate the ABN form, and know how to document the initial and subsequent visits properly.


A Medicare participating provider is one who voluntarily and in advance enters into an agreement in writing to provide all covered services for all Medicare Part B beneficiaries on an assigned basis. A participating provider:

• Agrees to accept Medicare-approved amount as payment in full; and

• May not collect more than the applicable deductible and coinsurance for covered services from the patient. Payment for noncovered services may also be collected.

Additionally, Medicare providers understand that:

• Charges are not subject to the limiting charge;

• Medicare payment is paid directly to the provider;

• Mandatory claims submission applies;

• Their name appears in the directory of participating providers (MEDPARD);

• Reimbursement is 5 percent higher than the nonparticipating amount; and

• Medigap information is transferred.


Medicare nonparticipating providers are those who have not entered into an agreement to accept assignment on all Medicare claims. They:

• Can elect to accept assignment or not accept assignment on a claim-by-claim basis; and

• Cannot bill the patient more than the limiting charge on non-assigned claims.

Additionally, if you are a nonparticipating provider, you understand that:

• The beneficiary receives payment on non-assigned claims;

• Mandatory claims submission applies;

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