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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