Medicare 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

Changes To the Advance Beneficiary Notice of Non-Coverage

By Dr. John Davenport | Department of Health and Human Services, Medicare | No Comments

The Advance Beneficiary Notice of Non-Coverage (ABN), is a notice given to Medicare beneficiaries to convey that Medicare is not likely to cover the service provided, or it is issued by providers in situations where Medicare payment is expected to be denied.

It is important to note that physicians’ offices must complete the ABN and deliver the notice to beneficiaries or their representative for review, and any questions raised during that review must be answered before it is signed. This ensures that the patient or their representative has time to consider the options and make an informed choice.

Once all the blanks are completed and the form is signed, the physician’s office then gives a copy to the beneficiary or representative. CMS mandates that the provider retain a copy of the ABN on file.

All of this is required before providing the items or services that are the subject of the ABN. If these procedures are not followed or the form is filled out incorrectly, the ABN is considered invalid. In certain cases, an invalid ABN could require repayment by the provider for all services rendered, as well as sanctions.

To quote Medicare, “Medicare will hold any provider who either failed to give notice when required, or gave defective notice, financially liable. Additionally, when authorized by law and regulations, sanctions under the Conditions of Participation (COP) may be imposed. A provider who gave defective notice may not claim that she/he did not know or could not reasonably have been expected to know that Medicare would not make payment as the issuance of the notice (albeit defective) is clear evidence of knowledge.”

As a chiropractic compliance consultant, I’m always asked about filling out an ABN for non-covered services (i.e. therapies, exams, and x-rays). The ABN is only required when you feel a service will be denied, and for chiropractic physicians, the adjustment is the only covered service.

If you wish to issue an ABN as a courtesy to the beneficiary, advising them of any financial liability for services that Medicare never covers (anything that’s not an adjustment), you can. This is called a voluntary ABN and this is considered non-valid by Medicare. If an office chooses to issue a voluntary notice, the beneficiary doesn’t need to choose an option box and is not required to sign the notice.

A better way to do this would be to design a statement form that tells the patient that Medicare only covers the adjustment and that the patient will be financially responsible for non-covered services provided as part of your treatment.

The ABN is approved by the Executive Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 and is subject to re-approval every 3 years.

With that said, the form has been revised to include language informing beneficiaries of their rights to CMS non-discrimination practices and how to request the ABN in an alternative format if needed.

Providers are expected to exclusively use the current version of the ABN, and even though there are no changes to the form itself, providers must pay attention to the OMB approval date on the notice and obtain the current version. The date of mandatory use of the new ABN starts with claims made on or after 06/21/2017.

The new ABN form may be downloaded using the following links:

English version:

https://complianceandauditingservices.com/wp-content/uploads/2017/06/ABNEnglish2020v508.pdf

Spanish Version:

https://complianceandauditingservices.com/wp-content/uploads/2017/06/ABNSpanish2020-v508.pdf

You should be able to click on the links. If you have problems with the link just copy and paste it into the browser, then click enter.

Hopefully, this Compliance & Auditing Services notice will give you time to switch to the newly approved notices.

If you have any questions or need help, don’t hesitate contacting Compliance & Auditing Services.

All the Best,

Dr. John Davenport
Chief Compliance Officer
Compliance & Auditing Services

Get Ready for Medicare Provider Enrollment Revalidation

By Dr. John Davenport | Compliance, Medicare | No Comments

Section 6401 (a) of the Patient Protection and Affordable Care Act established a requirement for all enrolled providers to revalidate their Medicare enrollment information roughly every five years to prevent fraud within the Medicare system by ensuring that Medicare provider records are accurate.

Cycle 2 Revalidation began on February, 2016. Basically this means a physician’s maintenance of the Medicare billing privileges cycle. Simply put, revalidation is re-enrollment and all providers are required to revalidate their enrollment information.

If the provider doesn’t submit a complete revalidation application by their specific due date, the Medicare Administrative Contractor (MAC) may hold your Medicare payments or deactivate your Medicare billing privileges.

Typically, your Medicare Administrative Contractor (MAC) will send a revalidation notice within two to three months prior to your revalidation due date either by mail or to the email address reported on prior applications indicating the providers due date.

Note that your MAC must receive your enrollment application within 60 days of the revalidation request.

The best way to prevent a lapse in coverage is to verify your due date, listed on Data.CMS.gov/revalidation. The list will include all enrolled providers and will display the provider’s revalidation due date. In addition, a crosswalk to the organizations that the individual provider reassigns benefits will also be available as well.

For providers not up for revalidation, the list will display a “TBD” (To Be Determined) in the due date field. This means the provider’s due date is more than 6 months away.

The list was revised on April 10, 2017. All dates are updated every 60 days at the beginning of the month and are listed up to 6 months in advance. Do not submit a revalidation if you have not received an email/mailed letter from your MAC requesting you to revalidate, or your due date is not listed on the CMS revalidation website. If you do, it will be considered an unsolicited revalidation and will be returned.

If you are within 2 months of the listed due date on the CMS revalidation website and have not received a notice from their MAC to revalidate, as a chiropractic consultant I recommend that you make every effort to submit your revalidation application immediately.

The most efficient way to submit your revalidation information is thru the Internet Based PECOS. Here you can review information currently on file, update and submit your revalidation and electronically sign after uploading the supporting documents. If you wish, you can just print out your revalidation , sign and date it and then mail your paper certification along with supporting documentation to your Medicare Administrative Contractor (MAC).

It is important that providers check their due date immediately in order to avoid a hold on your Medicare payments.

If you have any questions or need help, don’t hesitate contacting the ACS or Dr. Davenport at complianceandauditingservices.com.

All the Best,

Dr. John Davenport DC, CCSP, FIAMA, MCSP, CIC

Certified Compliance and Insurance Consulting Services

Common Sense PQRS For Chiropractic Offices

By Dr. John Davenport | Insurance Coding | No Comments

Medicare PQRS

The Physician Quality Reporting System (PQRS) is a reporting program that requires doctors enrolled in Medicare, Participating or Non-Participating providers, to submit data on the reporting of specified quality measures.

Beginning in 2007, PQRS was a pay-for-reporting program. Doctors were eligible to receive incentives if they reported quality measures. However, in 2013 the program transitioned from an incentive program to one that assessed penalties to doctors who did not meet the reporting requirements.

Therefore, if doctor’s offices did not successfully report on quality measures for covered services during the 2013 reporting period (Jan.1 –Dec 31,2013), those providers saw a decrease in reimbursement by 1.5% beginning on January 1, 2015.

Additionally, if doctor’s offices did not successfully report on quality measures for covered services during the 2014 reporting period, those providers will see a decrease in reimbursement by 2.0% beginning on January 1, 2016.

Though PQRS is technically not mandatory, the Patient Protection and Affordable Care Act (PPACA) mandated that Medicare is required to adjust payments for providers who do not participate in PQRS. So, from 2016 and beyond, reimbursement will be decreased by 2% and based on the reporting of quality measures from the previous two years.

To comply, doctors of chiropractic must report certain measures on eligible Medicare beneficiaries. Through the proper use of these codes, CMS hopes to establish standards and promote evidence- based best practices to reduce claim fraud and streamline the reimbursement process.

Reporting PQRS:

To report PQRS, all you need to do is place G-codes on your claims. The G-codes correlate to an action that was taken (or not taken) by the provider. As a chiropractor, you only need to report two quality measures. These measures are:

Measure #131: Pain Assessment and Follow-Up

The purpose of this measure is to show when a pain assessment is done using a standardized tool, and a follow-up plan that includes a reassessment of pain is documented.

Pain assessment tools include, but are not limited to, Faces Pain Scale (FPS), McGill Pain Questionnaire (MPQ), Numeric Rating Scale (NRS), Verbal Numeric Rating Scale (VNRS), and Visual Analog Scale (VAS).

Measure #182: Functional Outcome Assessment

The purpose of this measure is to show when functional outcome assessments are conducted, using a standardized tool, along with the creation of a treatment plan based on the functional deficiencies found.

Functional outcome assessments measure a patient’s physical limitations when performing activities of living, such as low back pain which inhibits the patient’s ability to walk or sleep.

Standardized functional outcome assessment tool examples include Oswestry Disability Index (ODI), Roland Morris Disability/Activity Questionnaire (RM), and the Neck Disability Index (NDI).

G-codes:

Each Measure contains several choices of quality data codes (G-codes) that correspond to the measure to be reported. On each visit, the provider should report one of the G-codes, from each of the two measures, on line 24 D of a paper claim or on service line 24 of an electronic claim.

Measure #131: Pain Assessment and Follow-Up

G8730 – Pain assessment documented as positive using a standardized tool and a follow-up plan is documented.
G8731 – Pain assessment using a standardized tool is documented as negative, no follow-up plan required.
G8442 – Pain assessment NOT documented as being performed, documentation the patient is not eligible for a pain assessment using a standardized tool.

*Note that patients are not eligible only if one or more of the following reason(s) are documented:

Patient is in an emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status.
A severe mental and/or physical disorder and patient is unable to express their self in an understandable way by others.

G8939 – Pain assessment documented as positive, follow-up plan not documented, documentation the patient is not eligible.
G8732 – No documentation of pain assessment reason not given.
G8509 – Pain assessment documented as positive using a standardized tool, follow-up plan not documented, reason not given.

Measure #182: Functional Outcome Assessment

G8539 – Functional outcome assessment documented as positive using a standardized tool and a care plan, based on identified deficiencies on the date of the functional outcome assessment, is documented.
G8542 – Functional outcome assessment using a standardized tool is documented; no functional deficiencies identified, care plan not required.
G8942 – Functional outcome assessment using a standardized tool is documented within the previous 30 days and care plan, based on identified deficiencies on the date of the functional outcome assessment, is documented.
G8540 – Functional Outcome Assessment not documented as being performed, documentation the patient is not eligible for a functional outcome assessment using a standardized tool.

Patients are not eligible only if one or more of the following reason(s) are documented:

Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status.
The patient is unable to complete the questionnaire.
The patient refuses to participate.

G8541 – Functional outcome assessment using a standardized tool not documented, reason not given.
G8543 – Documentation of a positive functional outcome assessment using a using a standardized tool; care plan not documented, reason not given.
G9227 – Functional outcome assessment documented, care plan not documented, documentation the patient is not eligible for a care plan.

(*See G8540 for non-eligibility reasons).

**Note that the use of a standardized tool assessing pain alone, such as the visual analog scale (VAS), does not meet the criteria of a functional outcome assessment standardized tool.

G-code Rules:

You should report Measures #131 and #182 on every visit, for every Medicare patient who is at least 18 years old and where you have reported a spinal CMT.

You must document the name of the standardized tools used to assess the patients in the medical record. The exception would be when a provider uses a fraction for the Numeric Rating Scale (ie.6/10) when assessing pain for intensity.

Providers should report, for each visit, whether they provided a standardized pain assessment on the patient, if pain was present or absent, and, if pain was present, documented a follow-up plan that includes a reassessment of the pain.

Common Sense PQRS For Chiropractors:

First understand that Medicare pays for medically necessary treatment. Basically, this means that the patient has pain that is interfering with their ability to perform their normal daily activities (Functional Deficits).

Once a patient’s pain and, more importantly, functional deficits have improved or they have reached a plateau in their care, Medicare is no longer responsible to pay for treatment.

Because of this, the reporting of these measures ( #131: Pain Assessment and Follow-Up and Measure #182: Functional Outcome Assessment ) are required to meet the PQRS reporting standards.

With this in mind, chiropractic offices will generally document only a handful of G- codes from each of the two measures, on line 24 D of a paper claim or on service line 24 of an electronic claim.

G-codes Common Sense:

During active care, the doctor has the patient fill out both pain and functional assessments on the Initial Visit and Re-exams.

G8730 – Pain assessment documented as positive using a standardized tool and a follow-up plan is documented.

This means a pain assessment was done using a standardized tool and documents the patients level of pain with a documented treatment plan that includes a planned reassessment of pain, a referral, or that the initial plan is still in effect.

In other words, chiropractors will use this code with every visit during active care and patient visits for initial exams and re-exams.

G8539 – Functional outcome assessment documented as positive using a standardized tool and a care plan, based on identified deficiencies on the date of the functional outcome assessment, is documented.

This means a functional outcomes assessment was done using a standardized tool and documents that it was preformed on the same date of service. This is typically coded only with the initial exam and re-exams during active care.

G8731 – Pain assessment using a standardized tool is documented as negative, no follow-up plan required.

This means a pain assessment was done using a standardized tool that documents the patient has no pain and no treatment plan is required.

G8942 – Functional outcome assessment using a standardized tool is documented within the previous 30 days and care plan, based on identified deficiencies on the date of the functional outcome assessment, is documented.
The G8942 code is typically used for office visits during active part of treatment, between the initial exam and re-exams.
G8542 – Functional outcome assessment using a standardized tool is documented; no functional deficiencies identified, care plan not required.

The G8542 code is typically used on the date of final re-exam once the patient has reached maximum medical improvement and patient is discharged from care.

The following are examples of how the G- codes are typically used.

Initial Exam And Re-exams:

G8730 – Pain assessment done, and a follow-up plan is documented.(CMT / Active / Tx / Exams)
G8539 – F0A done, care plan done (During 1^st CMT / Active Tx)

Daily office visits for routine treatment:

G8730- Pain assessment done, and a follow-up plan is documented.(CMT / Active / Tx / Exams)
G8942 –FOA done and care plan done within 30 days (CMT Visits between RE/Active Tx)

The final Re-exam once the patient has reached maximum medical improvement and patient is discharged.

G8731 – Pain assessment done, no pain using a standardized, no follow-up plan required. (Final RE/Discharge)
G8542 – FOA done, no deficit, no care plan needed (Final RE/Discharge)

Finally, always remember that your assessments, exams and treatment plans must be documented in your patient files. If your records are audited, you have reported that you have correctly documented these measures.

Dr. John Davenport DCM, MCS-P

Chief Compliance Office, Certified Insurance Consultant

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.

[/fusion_text]

It’s Time To Get Ready For ICD-10

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

The Boy Scout motto was to be prepared. Are you? It’s been my experience as a compliance consultant that when it comes to compliance the vast majority of doctors are completely unprepared for the increased regulation and scrutiny.

This may not surprise you, but according to recent surveys 80% of all providers will not be ready by October 2015, and the percentage is probably higher for chiropractors.

What is perhaps more shocking, is how few of the payers are ready or estimated they would have a finished product ready by the end this year. Only 40%.

I can understand the procrastination of most chiropractors in getting ready. They don’t have a lot of extra time and extra staff around to dedicate to the task.

It’s not time to “panic” yet, but to make a smooth transition
to the October, 2015 deadline, there are several things you can begin doing now.

Bear in mind that even though the number of codes will grow from 17,000 to 140,000, you only need to know the codes that relate directly to chiropractic.

You and your staff will need training in multiple formats. Compliance & Auditing Services’ members will get the codes with explanations and how to cross check for the appropriate codes. Members also have webinars and the training newsletter to make it easy, with unlimited email to get answers to any questions.

It will be too late to learn this new language once ICD -10 goes “live,” because you will be behind the curve.

First, identify how ICD -10 will effect your practice.

1. How will ICD-10 effect your people and processes? To find out, review how and where staff and doctors use ICD-9.

2. Ask your payers and vendors (software systems, clearinghouses, billing services) about ICD-10 readiness. Ask when they will start testing, how long they will need, and how you and other clients will be involved.

3. Develop a plan for communicating with staff and business partners about ICD-10.

4. Estimate and secure budget (potential costs include updates to practice management systems and government payment delays.

5. Ideally, have a cash reserve of at least 3 months operating expenses so your office will be able to continue to function normally.

6. Work on your documentation. ICD-10 codes are much more specific and your documentation will need to improve to match them.

➢ This is important because if the insurance carriers ask for documentation to justify the codes, poor documentation will slow the process down or result in all out denials.

So for now, focus on these first steps in preparing your office for the ICD-10 transition and don’t sweat it.

Together we will make it easy to stay on track. After all, you have better things to do with your time than worry about the constant changes.

Dr. John Davenport
Chief Compliance Officer

Cart