Medicare 25-Visit Review Tips

The GCA office and Medicare Subcommittee has received numerous calls regarding the new Medicare rule that requires a records review after 25 visits in a 12-month period. Please note the rule is NOT based on a calendar year, but a rolling year.

After the patient's 25th visit in a 12-month period, Medicare will automatically deny the visit, forcing D.C.s to file an appeal and send in records to substantiate the medical necessity. The Medicare Subcommittee suggests keeping track of Medicare patient visits to determine whether you should expect a denial.

If you have a patient who has over 25 visits in a 12-month period (for example July 10, 2011 - July 10, 2012), you have two options:

  1. Have the patient sign an ABN and ask for payment up front until the rolling year ends. File appeals on the denials, and have the patient file an appeal, too, or at least write a letter to include in your appeal.
  2. Have the patient sign the ABN, but don't make the patient pay up front. Appeal the denial, and ask the patient to write an appeal and/or a letter to include in your appeal.

It is imperative that you file the appeal, and your records demonstrate the need for care, a care plan with goals and that you are making progress with the patient and that the care is not maintenance care. If the patient is at MMI then put them on maintenance care and make them pay for it. Use the maintenance care ABN for that circumstance.  

GCA has heard doctors say the appeals process is too much to go through for a $30 Medicare visit. However, if we don't file the appeals on care that is medically necessary, then Medicare will incorrectly assume that no one really needs over 25 visits in a year and will implement screens at 20 visits in 12 months next year.