insurance regulations Archives - Compliance and Auditing Services

The Use and Understanding Of X{EPSU} Modifiers

By Dr. John Davenport | Compliance, Insurance Coding | No Comments

I’ve been getting a lot of questions about the -59 modifier and the new X modifiers, so I thought I would take some time here to explain the use of these modifiers and to let you know why most insurers, including Medicare, still continue to use the -59 modifier.

Currently, providers can use the -59 modifier to indicate that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.

The -59 modifier is the most commonly used and commonly abused modifier. According to 2013 CERT Report data, incorrect -59 modifier usage amounts to a $77 million per year overpayment.

Because of this, CMS believes that more precise coding options are needed to reduce the errors associated with this overpayment.

As a result, CMS established the following four new HCPCS modifiers, referred to collectively as -X{EPSU} modifiers, to define specific subsets of the -59 modifier:

XE – “Separate encounter.” A service that is distinct because it occurred during a separate encounter. This modifier should only be used to describe separate encounters on the same date of service.
XP – “Separate Practitioner.” A service that is distinct because it was performed by a different practitioner.
XS – “Separate Structure.” A service that is distinct because it was performed on a separate anatomical area.
XU – “Unusual Non-Overlapping Service.” The use of a service that is distinct because it does not overlap usual components of the main service.

These X{EPSU} modifiers are intended to provide greater reporting specificity.

Though CMS will continue to recognize the -59 modifier, the Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available.
In some instances CMS may selectively require a more specific – X modifier for billing procedures at high risk for incorrect billing.

Because the X modifiers are more specific versions of the -59 modifier, it would be incorrect to include both modifiers on the same line.

Though the use of the new modifiers was scheduled to start January 1, 2015, don’t hold your breath.

Here’s why:

Chiropractors are only paid for 98940, 98941 and 98942. None of your adjustment codes would require modifier -59.
For now, secondary billing for Medicare is uncertain. Secondary (private) payers haven’t yet stated that they are willing to accept the XE, XS, XP or XU modifiers. It’s likely they will adopt the same rule sooner or later, so keep an eye out for changes.
To date, private payers are not requiring the new modifiers. Providers such as BCBS, Aetna, and Cigna haven’t yet stated that they are willing to accept the XE, XS, XP or XU modifiers. It is likely that they will in the future so watch for updates from private payers.

Though it is likely that the -59 Modifier days are numbered, until then continue to code as usual, with modifier -59.

The “Compliance Made Easy” program is the most complete course on office compliance and includes how to document the correct E/M code.

All the Best,
Dr. John Davenport
Chief Compliance Officer

Locum Tenens and Compliance

By Dr. John Davenport | Compliance, Insurance Coding | No Comments

As the compliance officer for Compliance & Auditing Services, I receive questions from chiropractic physicians from all over the country on chiropractic compliance.

This question came to me from a doctor in Florida looking for guidance regarding office coverage. Dr. Jonathan asked, “If I have a doc covering my office that is not in-network when I am out of the office can I still bill under my license/insurance participation? I’m asking about Medicare as well.”

This isn’t the first time I have been asked this question, so to help the other doctors who follow this site for compliance information, here is the answer to the question on locum tenens doctors.

It is a general practice for physicians to retain substitute physicians to take over their professional practices when the regular physicians are absent for reasons such as illness, pregnancy, vacation, or continuing education.

These substitute physicians are generally referred to as “locum tenens” physicians and the regular physician generally pays the substitute physician a fixed amount per diem, with the substitute physician having the status of an independent contractor rather than of an employee.

Medicare and many third-party payers do allow physicians to bill for services performed by locum tenens physicians during their absence and for the regular physician to bill and receive payment for the substitute physician’s services as though he/she performed them.

Under Section 125(b) of the Social Security Act, a regular physician may bill for the services of a locum tenens physicians if:

The regular physician is unavailable to provide the services.
The Medicare beneficiary has arranged for or seeks to receive the visit services from the regular physician.
The regular physician pays the locum tenens for his/her services on a per diem or similar fee-for-time basis. You cannot pay a locum a salary or have a revenue based incentive payment agreement.
The locum physician does not provide or bill for services to Medicare patients over a continuous period of longer than 60 days.

Billing Procedures:

Medicare requires claims for services provided by a locum physician to include the Q6 modifier, which designates services were performed by alocum tenens physician, in box 24D of the CMS-1500 form. The regular physician’s provider identification number goes in box 24J.

Regarding all other insurance carriers, the billing procedures would typically be the same, as most carriers follow the same guidelines set forth by Medicare. It is important that you review the contract that you have with each insurance carrier that you are contracted with to make sure of their individual policies for locum physicians.

If you need a question answered or need help with office compliance, Compliance & Auditing Services is here to help. The certified specialist at Compliance & Auditing Services help chiropractors handle compliance issues and you set up a compliance program that meets all state and federal laws with confidence.

If you have any questions about Locum Tenens or chiropractic compliance leave a comment or just call us.

CMS Targeting Against Payments for Chiropractic Services?

By Dr. John Davenport | OIG | No Comments

The Office of Inspector General (OIG) released a new report titled, “CMS Should Use Targeted Tactics to Curb Questionable and Inappropriate Payments for Chiropractic Services.”

OIG Report According to the Centers for Medicare & Medicaid Services (CMS) Comprehensive Error Rate Testing program, Chiropractic services have the highest rate of improper payments among Part B services.

Past OIG investigations found that between 40 and 47 percent of all paid chiropractic claims were for maintenance therapy and stated that, “Medicare paid out over $76 million for chiropractic services that were questionable.”

In addition, Medicare fraud cases suggested that vulnerabilities existed with other chiropractic services, such as physical therapy.

The OIG analyzed paid claims for chiropractic services to identify any chiropractors who exhibited questionable billing. Using the data, the OIG uncovered 809,945 claims resulting in overpayments. In addition, The OIG identified over twenty-five thousand chiropractors who received high amounts of questionable payments and then determined their locations, past questionable payments and whether their patients received same-day physical and occupational therapy.

Important to doctors of chiropractic is that the report outlined plans on how to determine questionable chiropractic claims and recoup payments using different measures.

The first area to be targeted is treatment that is suggestive of maintenance therapy. Using 20 services per beneficiary per year as a threshold, the OIG looks at all claims in excess of the threshold to be questionable and suggestive of maintenance therapy.

Even though there are legitimate reasons for a Medicare patient to need treatment more than 20 times per year, you need to be able to justify your reasoning and have good documentation that supports it.

Additionally, a common issue for chiropractors is that they forget to change the date in box 14 when a Medicare patient comes back to the office for a new injury or exacerbation of a chronic condition. Forgetting to change the date in box 14 makes Medicare think that you are continuing to treat the patient from the date of the original condition and not for a new condition.

Just know that if you regularly see Medicare patients more than 20 times in a year, you risk being reviewed by the Department of Health and Human Services.

The second target is to identify chiropractors with high, questionable payments for upcoding claims.

Statistically only 10-15 percent of all paid chiropractic services are for the five-area adjustment code, 98942. As a result, the OIG set a threshold to identify doctors who billed out higher percentages of their claims using the 98942 code.

In the third measure, the OIG developed three ways to identify paid claims that did not meet Medicare requirements for payment:

Submitted claims that, “Lack a Medicare Covered Primary Diagnosis. These claims lacked a primary diagnosis code that was covered by Medicare based on CMS guidance and the local coverage determination where the chiropractic service was provided.” In the report, almost 39 percent of chiropractors were identified as having filed at least one claim without a correct primary diagnosis. This amounted to a total of $20,709,516.00 in paid claims without the correct primary diagnosis. This means that Medicare requires an M99 subluxation or segmental dysfunction diagnosis as primary or the first coded diagnosis, except in Florida, the Virgin Islands and Puerto Rico. The local coverage determination for your state determines the M99 ICD-10 code you need to use as your primary diagnosis (ie subluxation or segmental dysfunction).
Claims for Duplicate Services, meaning services provided on the same day for a patient with the same diagnosis and procedure codes by the same chiropractor.
Claims Lacking the AT Modifier. “The AT modifier indicates active treatment is being provided and is a requirement for payment.”

Medicare only pays for chiropractic services to improve function (active treatment) but does not cover “maintenance therapy,” which is when further clinical improvement cannot be expected from ongoing treatment.

The next measure is an unlikely number of services per day on which paid chiropractic services totaled 16 hours or more. The threshold here is billing an average of 65 chiropractic services per day.

The OIG stated that, “This raises questions regarding the quality of patient care and, perhaps, whether these services were even rendered by the chiropractor.”

Lastly, according to experts in chiropractic practice and fraud detection, is the potential sharing of Medicare beneficiaries with claims from multiple chiropractors, which indicates potential kickback arrangements or medical identity theft.

The OIG stated, “We considered all of their payments for the beneficiaries seen by other chiropractors to be questionable.”

OIG Recommendations:

As a result of the study, the OIG made the following recommendations to the Centers for Medicare and Medicaid Services:

Establish a more reliable control for identifying Active Treatment
Develop and use measures to identify questionable payments for chiropractic services.
Collect overpayments based on inappropriately paid claims.
Ensure that claims are paid only for Medicare-covered diagnoses.
Take appropriate action on chiropractors with questionable payments.

In a separate memorandum the OIG said, “we will provide CMS with information on chiropractors with high questionable payments, so that it may take action. CMS and/or its contractors should review their claims and take appropriate action.

Such actions could include:

Recouping inappropriate payments.
Educating providers on proper billing.
Making referrals to law enforcement.
Imposing payment suspensions.
Revoking billing privileges.
Taking no action, if the payment is determined to be appropriate.
“Collect overpayments based on inappropriately paid claims. CMS should collect the $20.7 million in payments that resulted from the inappropriate claims we identified.”

So what does this mean to you as a chiropractic physician?

It should tell you that Medicare is stepping up its investigations and is continuing to develop the means to analyze your claims. Because of this increased scrutiny, chiropractic claims are going to be reviewed in more detail.

So don’t just sit back and hope the laws and regulations are going away; they’re not. It’s more important than ever for you to take advantage of everything Compliance & Auditing Services provides to its members.

If you’re not a member, the best advice I can give you is to take your head out of the sand. Thinking that it won’t effect you is no longer an option.

Review all of your documentation, coding and billing procedures to ensure you’re in compliance with all laws and regulations. Make sure you have a documented compliance program in place. If you’re too busy with running your office or feeling overwhelmed by all the laws and regulations, consider a compliance consultant that will develop, implement and help you maintain an office compliance program that will meet and exceed all government regulations.

The Use And Understanding Of X{EPSU} Modifiers

By Dr. John Davenport | Insurance Coding | No Comments

(updated February 2, 2023)

I’ve been getting a lot of questions about the -59 modifier and the new X modifiers, so I thought I would take some time here to explain the use of these modifiers and to let you know why most insurers, including Medicare, still continue to use the -59 modifier.

Currently, providers can use the -59 modifier to indicate that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.

The -59 modifier is the most commonly used and commonly abused modifier. According to 2013 CERT Report data, incorrect -59 modifier usage amounts to a $77 million per year overpayment.

Because of this, CMS believes that more precise coding options are needed to reduce the errors associated with this overpayment.

As a result, CMS established the following four new HCPCS modifiers, referred to collectively as -X{EPSU} modifiers, to define specific subsets of the -59 modifier:

XE – “Separate encounter.” A service that is distinct because it occurred during a “separate encounter.” This modifier should only be used to describe separate encounters on the same date of service.

XP – “Separate Practitioner.” A service that is distinct because it was performed by a different practitioner.

XS – “Separate Structure.” A service that is distinct because it was performed on a separate anatomical area.

XU – “Unusual Non-Overlapping Service.” The use of a service that is distinct because it does not overlap usual components of the main service.

These -X modifiers are intended to provide greater reporting specificity.

Though CMS will continue to recognize the -59 modifier, the Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available.

In some instances CMS may selectively require a more specific – X modifier for billing at high risk for incorrect billing.

Because the X modifiers are different versions of the -59 modifier, it would be incorrect to include both modifiers on the same line.

Though the use of the new modifiers was scheduled to start January 1, 2015, don’t hold your breath. Here’s why:

Chiropractors are only paid for 98940, 98941 and 98942. None of your adjustment codes would require modifier -59.

For now, secondary billing for Medicare is uncertain. Secondary (private) payers haven’t yet stated that they are willing to accept the XE, XS, XP or XU modifiers. It’s likely they will adopt the same rule sooner or later, so keep an eye out for changes.

To date, private payers are not requiring the new modifiers. Providers such as BCBS, Aetna, and Cigna haven’t yet stated that they are willing to accept the XE, XS, XP or XU modifiers. It is likely that they will in the future so watch for updates from private payers.

Though it is likely that the -59 Modifier days are numbered, until then continue to code as usual, with modifier -59.

The “Compliance Made Easy” program is the most complete course on office compliance and includes how to documentation requirements.

If you have any questions or concerns don’t hesitate to call or email, we’re here to help you.

All The Best,

Dr. John Davenport
Chief Compliance Officer
Compliance & Auditing Services

ICD-10: How To Code 7th Character Extensions

By Dr. John Davenport | ICD-10 | No Comments

Screen Shot 2015-09-23 at 10.14.40 PM For chiropractic physicians transitioning to ICD-10, most of the time they will be using chapter 13 (Diseases of the Musculoskeletal System and Connective Tissue.) For injuries however, they’re more likely to use chapter 19 (Injury, Poisoning & Other Certain Consequences of External Causes).

Chapter 19 codes are easy to identify in the tabular list because of the “S” at the beginning of each of these codes. The “s” codes represent conditions such as sprains and strains as in the following example, S13.4XXA, Sprain of Cervical Spine Ligaments, Initial Encounter.

The confusion comes in when the code asks for a seventh character extension. These are sometimes called the encounter codes.

As you look for a specific injury code in chapter 19, you will see directly underneath the code category or “Block,” the directions that the code requires a 7th character.

Example:

______________________________________________________

S13 Dislocation and sprain of joints and ligaments at neck level

The appropriate 7th character is to be added to each code from category S13

A initial encounter

D subsequent encounter

S sequela

______________________________________________________

The official guidelines indicate the following:

A – Initial encounter:

As long as patient is receiving active treatment for the condition.

D – Subsequent encounter: (CONSIDERED MAINTENANCE CARE)*

After patient has received active treatment and is receiving routine care for the condition.

S – Sequela:

Complications or conditions that arise as a direct result of a condition.

(e.g., scar formation after a burn)

Chiropractic physicians should always use the “A” character with injury codes as long as they feel the patient should be receiving “active treatment” and can show that the patient is improving with the treatment provided.

At seminars, I am often asked, “What If The Patient Comes Back To Your Office In Three Months With The Same Condition?” My answer is code “A” for active care.

To Medicare and the insurance companies, coding “D” means maintenance care and that means you will be denied payment.

When I queried the insurance companies, such as Anthem and Blue Cross Blue Shield they defer to Medicare rules.

So for now, “A” stands for active care and “D” stands for maintenance care when it comes to reimbursement from payers.

Dr. John Davenport DCM, CCSP, FIAMA, MCSP

Chief Compliance Officer

FCPA Compliance Adviser

About the Author

Dr. Davenport ran his own clinic for many years. He now provides expert witness testimony, insurance consulting, medical record audits, consulting, and online courses for healthcare providers. He also writes books and articles for trade journals, and is a sought-after seminar speaker.

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The Protected Health Information Cyber Attack Threat

By Dr. John Davenport | Compliance | No Comments

3d rendering of a monit with a chain around it.

Reports of cyber attacks on large corporations such as Nationwide, JPMorgan Chase and even the Pentagon have been make big news. Yet, every day there are attacks aimed at small to mid-size organizations.

With the increasing use of EHRs, practices are facing increased liability with regard to breaches of protected Health information (ePHI). Hackers know that healthcare providers are less likely to fully protect themselves.

At the same time, increased HIPAA and HITECH security regulations and penalties, for violations, also increase the healthcare providers liability for breaches of ePHI,

Many Doctors simply lack the knowledge and training needed to protect their offices against a cyber attack or meet HIPAA Security Rule requirements.

In this three part series we will discuss simple steps to reduce most major threats to the safety of ePHI. This should be considered basic computer security 101 and not a course on the HIPAA/HITECH rules.

Firewall Protection:

First, unless your practice is totally disconnected from the Internet, it should have a Firewall to protect against threats from outside sources.

Basically, a Firewall is a system that prevents unauthorized access to a private network and works like a filter between your computer network and the Internet. Anything that goes into or out of the network must pass through the firewall.

The firewall examines each message and can be configured to prevent employees from sending certain types of emails or transmitting sensitive data outside of the network.

Additionally, firewalls can be programmed to prevent access to certain websites (like social networking sites) and can prevent outside computers from accessing computers inside your network.

Most computer operating systems come with a firewall installed and firewall software is also available at stores that sell computer products. Both types of firewall software normally provide technical support and guidance for users without the technical savvy.

Anti-virus Protection:

In small offices, attackers compromise computers primarily through viruses, spyware and malware. Computers can become infected by outside sources such as CD- ROMs, e-mail, flash drives, and web downloads. Even a computer that has all the latest security updates to its operating system and applications can be at risk because of system flaws.

Anti-virus software is used to scan files to identify and eliminate computer viruses andmalicious software. It can also let you know when there has been an attempted threat to your system.

Anti-virus software analysis’s system files to look for known viruses, by means of a virus dictionary, and identifies suspicious behavior that might indicate an infection. Therefore, providing protection against brand-new viruses that do not yet exist in any virus dictionaries.

Without anti-virus software to identify infections, data may be stolen or destroyed. Reliable Anti-virus software is available at most stores that sell computer products, and are relatively inexpensive to buy.

Once you’ve down loaded anti-virus software to your computer, this includes hand held devices, make sure to keep it updated. Anti-virus products require regular updates in order to protect from new computer viruses.

Passwords:

Passwords are a first line defense in preventing unauthorized access to any computer and should be required to log into your system. In addition, passwords can be reviewed, using an audit trail log, to see who is accessing specific information and what changes where made to that information.

Passwords can also limit what information individual people have to certain information. This can include certain staff members, your IT contractor, your billing company or anyone who has remote access to your computer system.

Because criminals use special software to try to guess a password, it is important to use strong passwords. A Strong password should:

Be at least 8 characters in length
Include a combination of upper case and lower case letters, at least one number and at least one special character, such as a punctuation mark
Be changed periodically.

You should also have policies in place to remove passwords on staff that leave or are terminated.

An administrator password is used only when you need to make changes or updates to your operating system. This means that anyone with this code can go anywhere and change anything in your system.

To decrease the chance that the administrator password gets stolen, the person in your office authorized to make changes to your system should have a separate user code that is used for daily system access.

WINDOWS XP and HIPAA COMPLIANCE

By Dr. John Davenport | Uncategorized | No Comments

Tired-Man-computeriStock_000024086772Large Are you using computers that run on Windows XP in your office? If you are you may be violating HIPAA laws by doing so.

If you haven’t heard, on April 8^th, 2014 Microsoft ended support for windows XP; putting an end to the operating system.

Microsoft announced that they are no longer providing security updates and stated that:

“If you continue to use Windows XP after support ends, your computer will still work but it might become more vulnerable to security risks and viruses. What this means is that when using computers with Windows XP, you potentially expose your computers to a security risk. Also, as more software and hardware manufacturers continue to optimize for more recent versions of Windows, you can expect to encounter greater numbers of apps and devices that do not work with Windows XP.”

The OCR has been very clear that unsupported systems are NOT compliant. They cited this routinely during the audits last year whenever identified.

Unsupported systems by definition are unsecure and pose a risk, not only to the data they hold, but the network they reside on, as well.

Additionally, any known vulnerabilities of an operating system should be considered in the covered entity’s risk analysis.

For example, as a compliance and auditing specialist, I tell my doctors that an operating system which includes a known vulnerability, which XP does, has to be considered an issue with regard to your “risk analysis.”

Addressing the risks means that as a doctor, you know what can happen by running XP and that you have a written plan for minimizing the risk.

This plan must be described in detail in your risk analysis and should include a timeline for your transition away from Windows XP.

To stay protected after support ends, you have two options:

Update any current devices that are running Windows XP

This is definitely, the simplest route, and for most doctors offices, it’s the most cost effective.

Unfortunately few older computers will be able to run Windows 8.1, which is the latest version of Windows.

Compliance & Auditing services recommends that you download and run the Windows Upgrade Assistant to check if your PC meets the system requirements.

The Windows 8.1 system requirements are nearly the same as Windows 8, so if your PC can run Windows 8, in most cases, you can get the free update to Windows 8.1.

Upgrade Assistant will also check program and device compatibility, and provide a free compatibility report.

Here is a summary of the system requirements:

Processor: 1 gigahertz (GHz) or faster

RAM: 1 gigabyte (GB) (32-bit) or 2 GB (64-bit)

Free hard drive space: 16 GB (32-bit) or 20 GB (64-bit)

Graphics card: Microsoft DirectX 9 graphics device with WDDM driver

You will need to perform a “clean installation.” This means you won’t be able to keep any files, settings, or programs when you upgrade.

We recommend you back up all files and locate any program installation discs prior to updating.

If your current PC can’t run Windows 8.1, it’s time to consider a new one. Given the fact that the fines for a HIPAA Security Violation would be significantly in excess of purchasing a few new computers.

For most doctors, dealing with the technical stuff is a little bit challenging. After all, you’re an expert at treating patients not computers.

If this is you, then talk with your IT person. They have the expertise in this area and should know exactly what to do.

Regards,