Download (or other) link, be advised that these files contain

NOTE: Should you have landed here as a result of a search engine (or
other) link, be advised that these files contain material that is copyrighted
by the American Medical Association. You are forbidden to download
the files unless you read, agree to, and abide by the provisions of the
copyright statement. Read the copyright statement now and you will
be linked back to here.
Provider Outreach and Education
Objectives





Identify the service performed by a chiropractor that may be covered by Medicare
Recognize non-covered services performed by chiropractors
Identify information required on chiropractic claims submitted to Medicare
Recognize documentation requirements for chiropractic medical records
Provide resources for chiropractors








Coverage
Documentation
Common Claim Denials
Claims Filing
Recovery Audit Contractor
Comprehensive Error Rate Testing
Self-Service Tools
Provider Outreach and Education
Agenda
Coverage
What is Covered?
The only chiropractic service covered by Medicare is manual manipulation of the spine. No
other diagnostic or therapeutic services furnished by a chiropractor, or furnished on his/her
order, are covered. The treatment must be medically necessary. Services must provide a
reasonable expectation of recovery or improvement of function.
Coverage Criteria
Beneficiary must have a significant health problem in the form of a neuromusculoskeletal
condition necessitating treatment. Services must have a direct therapeutic relationship to the
patient’s condition.
CPT Codes for Chiropractic Services



98940 – Spinal, 1-2 regions
98941 – Spinal, 3-4 regions
98942 – Spinal, 5 regions
o Cervical
o Thoracic
o Lumbar
o Sacral
o Pelvic
ICD-9 Codes for Chiropractic Services
739.0 – Nonallopathic lesions of head region not elsewhere classified
739.1 – Nonallopathic lesions of cervical region not elsewhere classified
739.2 – Nonallopathic lesions of thoracic region not elsewhere classified
739.3 – Nonallopathic lesions of lumbar region not elsewhere classified
739.4 – Nonallopathic lesions of sacral region not elsewhere classified
739.5 – Nonallopathic lesions of pelvic region not elsewhere classified
Use of these codes does not guarantee reimbursement. The patient's medical record must
document that the CMS coverage criteria have been met.
Billing For Chiropractic Services
Page 2
HCPCS Modifier AT
When a chiropractor provides active/corrective treatment, for either acute or chronic
subluxation, the service must be submitted with HCPCS modifier AT. If the service qualifies
as “maintenance therapy,” it must be submitted without HCPCS modifier AT and the service
will be denied. Use of HCPCS modifier AT does not automatically mean the service meets the
“medical necessity” guidelines. The patient’s medical record must support the use of this
modifier.
Frequency of Chiropractic Visits
There is no set limit on the number of treatments. For acute subluxation problems, the patient’s
condition will determine the frequency. In the first few days, treatment may be quite frequent but
will decrease over time or as the patient’s condition improves. “Chronic” subluxation implies that
the condition has existed for a longer period of time, so the involved joints may have set. “
Chronic conditions may require a longer treatment time, but not at a higher frequency. Medicare
will reimburse one treatment per day unless documentation supporting the medical necessity for
additional services is submitted with each claim.
What is Subluxation?
“A motion segment, in which alignment, movement integrity, and/or physiological function of the
spine are altered although contact between joint surfaces remains intact.” Patient must have
subluxation of the spine, demonstrated by X-Ray or physical exam.
Physical Exam
If subluxation is demonstrated by physical exam, the medical record must include 2 of the
following 4 criteria (either #2 or #3 is required): [P A R T]
1. Pain/tenderness evaluated in terms of location, quality, and intensity
2. Asymmetry/misalignment identified on a sectional or segmental level
3. Range of motion abnormality (change in active, passive, and accessory joint
movements resulting in an increase or decrease of sectional or segmental
mobility)
4. Tissue, tone changes in the characteristics of contiguous or associated soft tissues,
including skin, fascia, muscle and ligament
History requirements are the same as for initial visit.
Billing For Chiropractic Services
Page 3
X-Rays
There is no requirement for chiropractors to obtain x-rays prior to treatment. If subluxation is
demonstrated by x-ray, there is no requirement for X-ray at each level of subluxation or repeat
x-rays in patients with chronic conditions. X-rays that are ordered, taken, or interpreted by
chiropractors can be used for claims processing purposes, but they are not covered by
Medicare. X-ray must be taken proximate to the initiation of a course of treatment. X-ray should
be no more than 12 months prior, or 3 months following the initiation of treatment. An older xray/diagnostic test may be accepted for certain chronic subluxation cases, such as scoliosis. A
previous CT scan and/or MRI is acceptable evidence if subluxation is demonstrated.
Acute Subluxation
Acute Subluxation means the patient being treated for a new injury. X-ray date or other
diagnostic test, first date of treatment, and diagnosis must be reasonably proximate. Result is
expected to be an improvement in, arrest or retardation of the patient’s condition.
Chronic Subluxation
“Chronic” condition is not expected to completely resolve. The result is expected to be “some
functional improvement.” Once patient’s functional status has remained stable for that
condition, further manipulative treatment is considered “maintenance therapy” and is not
covered.
Documentation of Symptoms
The symptoms must be directly related to the level of subluxation and documentation should
reflect symptoms causing the patient to seek treatment. Symptoms should refer to body part:





Spine (spondyle or vertebral)
Muscle (myo)
Bone (osseo or osteo)
Rib (costo or costal)
Joint (arthro)
Symptoms should be reported as:
 Pain (algia)
 Inflammation (itis) or
 Signs, such as swelling or spasticity
o Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand
problems, leg and foot pain and numbness
o Rib and rib/chest pain are also recognized symptoms
 In general, symptoms must relate to the spine
Subluxation Documentation



Exact level of subluxation must be specified
Subluxation may be documented by physical exam or X-ray
Be sure to:
o List the exact vertebrae (examples: C5, C6) OR
o Use a description of the area, if that area is specific to only certain vertebrae.
Spinal Areas/Vertebrae
The level of subluxation must be identified in your documentation.
Billing For Chiropractic Services
Page 4
Billing For Chiropractic Services
Page 5
The nature of the subluxation must be identified in your documentation:
 Off-centered
 Misalignment
 Malpositioning
 Spacing – abnormal, altered, decreased, increased
 Incomplete dislocation
 Rotation
 Listhesis – antero, postero, retro, lateral, spondylo
 Motion – limited, lost, restricted, flexion, extension, hyper mobility, hypomotility, aberrant
“Manual Manipulation” Synonyms






“Correction”
“Treatment”
Spine or spinal adjustment by manual means
Spine or spinal manipulation
Manual adjustment
Vertebral manipulation or adjustment
Non-Covered Services
Manipulation is not covered when:
 An absolute contraindication exists.
 Mechanical or electrical equipment is used.
 The x-ray or diagnostic test does not support one of the primary covered diagnoses.
 The claim lacks one of the primary covered diagnoses.
 Medicare never covers CPT code 98943 (extraspinal manipulation).
Contraindications
Certain conditions add a significant risk of injury to the patient when dynamic thrust is
performed:
 Relative contraindications
 Absolute contraindications
Relative Contraindications
For relative contraindications, the chiropractor should discuss the risks with the patient and
record notes about the discussion in the beneficiary's medical record. Relative contraindications
to dynamic thrust are:
 Articular hypermobility and circumstances where the stability of joint is uncertain
 Severe demineralization of bone
 Benign bone tumors (spine)
 Bleeding disorders and anticoagulant therapy
 Radiculopathy with progressive neurological signs
Billing For Chiropractic Services
Page 6
Absolute Contraindications








Acute arthropathies characterized by acute inflammation and ligamentous laxity and
anatomic subluxation or dislocation; including acute rheumatoid arthritis and ankylosing
spondylitis
Acute fractures and dislocations or healed fractures and dislocations with signs of instability
An unstable os odontoideum
Malignancies that involve the vertebral column
Infection of bones or joints of the vertebral column
Signs and symptoms of myelopathy or cauda equina syndrome
For cervical spinal manipulations, vertebrobasilar insufficiency syndrome
Significant major artery aneurysm near the proposed manipulation
What is Maintenance Therapy?
CMS defines maintenance therapy as “a treatment plan that seeks to prevent disease,
promote health, and prolong and enhance the quality of life; or therapy that is performed to
maintain or prevent deterioration of a chronic condition.” Continued repetitive treatments without
an achievable, clearly-defined goal are considered maintenance therapy. Medicare does not
cover maintenance therapy.
Non-Covered Services
Non-covered services include:
 X-rays
 Physical Therapy
 Treatment for diagnoses which are not considered to be medically necessary
 Office visits
 Manipulation of body parts other than the spine
 Laboratory tests
 Traction
 Supplies
 Drugs/Injections
 EKGs or other diagnostic tests
 Nutritional supplements/counseling
 Services ordered by chiropractors
Billing For Chiropractic Services
Page 7
Initial Visit Documentation
Initial Visit
The beneficiary's medical record must include:
1. History.
2. Description of the present illness. Must include symptoms related to subluxation:
 Symptoms should refer to the affected body part(s)
 Associated symptoms should be described
3. Evaluation of musculoskeletal/nervous system through physical examination.
4. Diagnosis.
5. Treatment plan.
6. Date of the initial treatment.
History
SFPMQOAP








Symptoms causing patient to seek treatment
Family history, relevant
Past health history
Mechanism of trauma
Quality and character of symptoms/problem
Onset, duration, intensity, frequency, location, and radiation of symptoms
Aggravating or relieving factors
Prior interventions, treatments, medications, secondary complaints
Description of Present Illness






Mechanism of trauma
Quality and character of symptoms/problem
Onset, duration, intensity, frequency, location, and radiation of symptoms
Aggravating or relieving factors
Prior interventions, treatments, medications, secondary complaints
Symptoms causing the patient to seek treatment
Documentation

Evaluate the musculoskeletal/ nervous system through physical examination. The primary
diagnosis must be subluxation, including the level.
Treatment Plan
Recommended level of care (duration and frequency), specific treatment goals and objective
measures to evaluate treatment effectiveness. The date of the initial treatment must be
documented.
Billing For Chiropractic Services
Page 8
Sample Treatment Plan
05-05-06 CMT and adjunctive modalities daily for 1 week and 3x/wk for the following 2 weeks.
Re-eval at that time; Off work 2 weeks.
Sample Treatment Plan
Short term goals:
 Minimize pain(<3) and spasm
 Increase pain free LS flexion (>45)
Long term goals:
 Restore ability to tie shoes w/o pain
 Sit/stand for prolonged periods (>2hrs.)
 Get in and out of vehicles w/o difficulty
 Return normal sleep patterns
Subsequent Visit Documentation
Subsequent Visits: Documentation



History:
o Review of chief complaint
o Changes since last visit
o System review if relevant
Physical Exam:
o Exam of area of the spine involved in diagnosis
o Assessment of change in the patient’s condition since the last visit
o Evaluation of treatment effectiveness
Treatment:
o Documentation of treatment given on the day of the visit. Do not just refer to the plan
from the initial visit without also giving the current day’s findings.
SOAP Note



S: Review of chief complaint, note any changes since the last visit, review of systems if
relevant.
O/A: Physical/regional exam. Examine the area of the spine involved in the diagnosis and
note findings. Assess change in the beneficiary's condition since the last visit. Evaluate the
treatment for effectiveness.
P: Document the treatment given on the day of the visit and any adjunctive therapy.
Sample Subsequent Note
05-15-06: Patient notes diminished intensity/frequency of LBP. VAS decreased to 4/10. Overall
lumbar paraspinal spasm/tenderness bilaterally, but decreased since last visit. Joint fixation at
L4-L5 and right SI. Condition resolving. L5 RSI adjusted with side posture. Continue treatment
plan as prescribed on initial visit on 05-05-06. Return Tuesday. Dr. Signature
Billing For Chiropractic Services
Page 9
Record Review
Do your records contain:
 Precise subluxation(s) documented by physical exam or x-ray
 A complaint consistent with subluxation levels found
 A past health history
 A check for contraindications
 Quality and intensity of chief complaint
 Aggravating and relieving factors
 Physical exam substantiating the condition and the subluxation
 Primary diagnosis of subluxation
 Treatment plan with specific goals
 Notations of specific changes
 The adjustment clearly recorded as being accomplished
 Notations on the effectiveness of treatment that would qualitatively and quantitatively
substantiate the need and frequency of treatment
 The adjustment is for acute or chronic care (or maintenance care along with the appropriate
documentation)
Why is Documentation Important?
Clinical Documentation is an important source of evidence when the services provided are
reviewed. It provides a legal, historical account of encounters with a beneficiary, it ensures the
services were provided safely and effectively. It also shows compliance with federal, state,
payor, and local requirements. Documentation establishes support for reimbursement of
services, may be a basis for research and serves as a communication vehicle between other
disciplines and/or providers.
How to Avoid Documentation Pitfalls








Look for pages without any patient identification
Document at the same time as the intervention if you can, or as close to it as possible
Do not leave space so you can add more documentation later
Documentation that's later squeezed into the space available could look like a cover-up or,
more generally, raise questions about why documentation was done after the fact
Make sure you have the right chart before you begin writing
Write legibly
Do not alter a patient record
Do not chart ahead of time
Abbreviations
“Abbreviations can cause legal nightmares. What you document must be understandable today
and in the future. If you get creative and deviate from the approved abbreviation list, how can
you prove what you meant by the abbreviation?” – Abbreviations: A Shortcut to Disaster By
Fay Yocum, MSN, RN



HA: Heart attack or headache?
HL: Heparin lock or Hickman line?
SOB: Shortness of breath or side of bed?
Billing For Chiropractic Services
Page 10
Illegible Handwriting
What is This Order For?
Billing For Chiropractic Services
Page 11
Documentation Tips










Patient’s name on each page
Signatures – legible and for each patient encounter
Treatments performed
Medical necessity substantiated
Measureable goals and timeframe
History – for a subsequent visit
Progress toward goals
Records must be legible
Entries must be dated
Do not leave blank space on a page
Common Claim Denials
Medically Unnecessary Services


Non-acute conditions that do not meet medical necessity
Acute conditions that do not show reasonable expectation of recovery or improvement of
function
Services Incorrectly Coded


Upcoding: Billing for preventive or maintenance care on areas in excess of the acutecondition regions under active treatment
Failure to use the GZ modifier, if advance notice of non-coverage was not provided to the
patient
Insufficient Documentation







Patient’s name not on each page of documentation
Physician signature missing or illegible for each date of service and/or the service
Actual treatments not documented
Missing medical necessity for the treatment of an acute condition
Lacking measurable goals and time period for improvement during initial visit
Subsequent visits lacking key items of the: history, physical exam, and documentation of
treatment
Lacking progress toward goals in subsequent visits
Billing For Chiropractic Services
Page 12
Claims Filing
Special Requirements for Chiropractic Claims
Requirements
CMS-1500 Claim Form
Initial treatment date
X-ray date (if using X-ray to
demonstrate subluxation)
Diagnosis of subluxation
Item 14
Item 19
Item 21
Electronic Claims
(ANSI 4010A1)
Loop 2300, DTP/439,03
Loop 2300, DTP/455, 03 or
Loop 2400, DTP/455,03
Loop 2300, HI, 01-2
Advance Beneficiary Notice




Use ABN Form CMS-R-131 for services for which Medicare is likely to deny payment due to
frequency or medical necessity.
Examples of when you should ask the patient to sign an ABN:
o Treatment is given for a diagnosis not related to subluxation
o Treatment is given for maintenance therapy
If patient refuses to sign, notate refusal on form, have two staff members sign and date
form, submit claim with HCPCS modifier GA.
References
www.cms.hhs.gov/BNI/01_overview.asp
Financial Responsibility Modifiers
HCPCS Modifier
GA
GZ
GY
Description
ABN on file
Service expected to be denied as not
reasonable and necessary
Statutorily excluded or not a Medicare
benefit
Financial Responsibility
Patient
Contractual Obligation
Patient
HCPCS Modifier AT




When a chiropractor provides active/corrective treatment, for either acute or chronic
subluxation, the service must be submitted with HCPCS modifier AT.
If the service qualifies as “maintenance therapy,” it must be submitted without HCPCS
modifier AT and the service will be denied.
Use of HCPCS modifier AT does not automatically mean the service meets the “medical
necessity” guidelines.
The patient’s medical record must support the use of this modifier.
Modifier Use
HCPCS Modifier
AT
AT + GA
Description
Patient under active or corrective treatment
D.C. has patient under active treatment but feels Medicare may deem as
not medically necessary
Billing For Chiropractic Services
Page 13
Chiropractic Specialty Resources



www.PalmettoGBA.com/bsc
o Fee schedules
o Information for your Medicare patients
Medicare Advisory
o Monthly newsletter available on our Web site
www.cms.hhs.gov/manuals
o 100-01, Chapter 5, section 70.6 (chiropractor definition)
o 100-02, Chapter 15, section 30.5 (coverage)
o 100-02, Chapter 15, section 240 (necessity for treatment)
o 100-04, Chapter 12, section 220 (documentation requirements)
Recovery Audit Contractor (RAC)
Recovery Audit Contractor (RAC)




The Medicare Modernization Act (MMA) of 2003 requires the use of Recovery Audit
Contractors (RACs) to:
o Review paid claims to ensure they meet Medicare statutory, regulatory and policy
requirements and regulations
o Analyze billing trends and patterns
o Identify Medicare over/underpayments
o Recoup overpayments
Claims are reviewed on a post-payment basis
RACs use the same Medicare policies as Carriers, FIs and MACs
o NCDs, LCDs, CMS Manuals
Two types of review:
o Automated (no medical record needed)
o Complex (medical record required)
What does this mean to you?


SC Selected for First Phase of Implementation
Connolly Consulting Associates, Inc.
o Contractor for South Carolina
o Connolly and CMS held Kick Off Town Hall Meeting March 20, 2009
RAC Contractor Reviews
o
o
o
o
o
Review of physician claims for level of coding
Authorized to look back 3 years from the date the claim was paid
Initially RAC will not go beyond October 1, 2007
RAC will review claim history and request medical records
Providers will have 45 days to submit records
2009 Medical Record Limits

Medical request limits in place for Physicians, Podiatrists, and Chiropractors
o Sole Practitioner: 10 medical records per 45 days per NPI
o Partnership 2-5 individuals: 20 medical records per 45 days per NPI
o Group 6-15 individuals: 30 medical records per 45 days per NPI
o Large Group 16+ individuals: 50 medical records per 45 days per NPI
Billing For Chiropractic Services
Page 14
What is different?





If an overpayment is detected, the RAC will pursue payment
Overpayment/demand letter is issued by the RAC
RAC will offer an opportunity for the provider to discuss the improper payment determination
(this is outside the normal appeal process)
Issues reviewed by the RAC will be approved by CMS prior to widespread review
Approved issues will be posted to a RAC Web site before widespread review
Prepare for Implementation







Know identified “risk areas” for improper payments
Review OIG and CERT reports
o www.oig.hhs.gov/oas/cms.asp and www.cms.hhs.gov/CERT
Appoint a specific person for RAC to contact and provide
o Name
o Complete address
o Phone
o Fax
o e-mail address
Respond to medical record requests fully and promptly
Track dates and number of requests received
Conduct an internal assessment to identify whether you are in compliance with Medicare
rules
Learn from experience
o Keep track of denied claims and look for patterns
o Determine actions needed to avoid improper payments
RAC Resources

CMS Web page: www.cms.hhs.gov/RAC/
o Overview of program
o Strategy to expand the RAC program
o Press releases
o Frequently Asked Questions (FAQs)
Medicare Claims Data: CERT
Medicare Claims Data

The Comprehensive Error Rate Testing (CERT) program measures the accuracy of
Medicare claims.
o Paid Claims Error Rate: measures percentage of incorrect payments and $ incorrectly
paid
o Provider Compliance Error Rate: measures the accuracy of submitted claims – seen as
a measure of how effectively contractors educate providers

Most recent data: May 2008
Billing For Chiropractic Services
Page 15
Paid Claims Error Rate
Billing For Chiropractic Services
Page 16
Medicare Claims Data


Types of Errors:
o Improper documentation
o Insufficient documentation
o Medically unnecessary
o Incorrect coding
o Service billed was not rendered
o No response to the CERT contractor’s request for medical records
The Provider Compliance Error Rate:
o Is based on how claims looked when they first arrived at Palmetto GBA
o Indicates there are ongoing problems with the accuracy of submitted claims

Across multiple specialties

Involving various categories of provider inquiries and claim denials
Provider Compliance Error Rates
Billing For Chiropractic Services
Page 17
Provider Compliance Error Rate Claims Data


Data is unavailable for specific types of errors
We use other sources to focus our education efforts:
o Top inquiry reasons
o Top denial reasons
May 2009 OIG Report on Chiropractic Services
Objective:
To determine the extent to which:
 Beneficiaries receiving more than 12 services from the same chiropractor were inappropriate
 Ensure claims were not for maintenance therapy
 Claims data can be used to identify maintenance therapy
 Claims were documented as required
 Inappropriate Medicare payment for chiropractic services:
o $178 million (out of $466 million) paid inappropriately

$157 million – maintenance therapy

$46 million undocumented

$11 million - miscoded
 To review the OIG Report, visit
o http://oig.hhs.gov
Provider Self-Service Tools and Technology
Palmetto GBA Provider Self-Service Tools and Technology

www.PalmettoGBA.com/bsc
o Palmetto GBA Web site
o Denial Finder
o Modifier Lookup
o Redetermination Status
o IVR
www.PalmettoGBA.com/bsc
Billing For Chiropractic Services
Page 18
Denial Finder
Modifier Lookup
Redetermination Status Tool
Interactive Voice
Response (IVR)




(866) 238-9654
Eight options are
available,
including:
o Payment
floor
o Claim
information
o Order a
duplicate
remittance
o Beneficiary
entitlement
o Beneficiary
Part B
deductible
NPI, PTAN, and
last five digits of TIN are required to obtain claims information
Beginning June 8th – HIC#, date of birth, beneficiary last name, and first name initial are also
required
Billing For Chiropractic Services
Page 19
Provider Outreach and Education
Provider Outreach and Education Department


Are you having a problem with filing your claims?
If you would like an Ombudsman to visit your office or to speak at a meeting:
o Complete the Provider Outreach and Education Request Form located on the Web site
Provider Outreach and Education



Formal workshops
o Face-to-Face Workshops
On-line workshops
o Interactive classroom setting
Technology Based Training Modules
o Self paced learning
The information provided in this workshop was current as of 06/16/2009. Any changes or new
information superseding the information in this workshop are provided in articles with publication
dates after 06/16/2009 posted at: www.PalmettoGBA.com/bsc.
Billing For Chiropractic Services
Page 20