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Dr. John Davenport

Compliance Consultant

Compliance Consultant Explains Active Treatment

By | Compliance, Compliance Consultant | No Comments

As a compliance consultant,I find that a high percentage of chiropractors are guilty of providing only passive therapies to their patients.

In fact, third-party payers have coined the phrase M.U.S.H. for chiropractic treatment. This is an acronym for manipulation, ultrasound, stem, and heat.

Due to the increasing amount of evidence-based research and increased scrutiny on the chiropractic profession by insurance carriers, prolonged use of passive therapies is frowned upon and could be a red flag for doctors.

Insurance carriers require providers to prove medical necessity of the treatment they provide and show a direct therapeutic relationship to the services rendered.

 

Based on research, carriers feel that prolonged passive therapy leads to dependence by the patient for symptom relief, and do nothing to improve the patient’s complaints in the long run.

Since passive therapies are typically used in the initial, acute phase of care to reduce pain and swelling, their clinical effectiveness tends to decline after one to two weeks of treatment.

In fact, the Council on Chiropractic Guidelines & Practice Parameters, stated, “Although passive care methods for pain or discomfort may be initially emphasized, “active” (ie, exercise) care should be increasingly integrated to increase function and return the patient to regular activities.”

It recommended that physicians limit the use of therapeutic modalities only to, “facilitate the shift from passive-to-active care and not dependency on passive modalities with limited evidence of efficacy.”

 As a compliance consultant, I tell my clients that when moving to active care, the goal of treatment is to improve functional deficits, increase the strength and endurance of a given area, and minimize the potential for re-injury or exacerbation of the patient’s chief complaint.

Therefore, Insurance carriers not only encourage active rehabilitative care, they see it as the natural progression of treatment and feel it justifies the medical necessity of longer treatment.

Additionally, encouraging patient participation in treatment incentivizes the patient to continue treatment once their pain has improved in an effort to prevent future problems.

It’s a win-win for everyone involved because improving the patient’s functional weakness is the best thing for your patients, and insurance companies pay more for active therapies than passive care.

Having taught human performance and sports rehabilitation on the college level, I know there are many different ways to approach active care besides having a full-size gym in your office or employing physical therapists or athletic trainers.

With a little knowledge, you can develop a viable rehab program in your office for less than $200.00. In addition, you make more money while minimizing denials, request for more information to justify treatment, and being flagged for an audit.

If you have any questions or would like additional information, don’t hesitate to contact one of our compliance consultants at 800-509-0538

Changes To the Advance Beneficiary Notice of Non-Coverage

By | 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 | 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

Locum Tenens and Compliance

By | 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.

 

 

Medicare Access and CHIP Reauthorization Act of 2015

By | Department of Health and Human Services, Medicare | No Comments

girl-studying-stressed-istock_000022144730smallStarting with the reporting year 2017, the current fee for service method of reimbursing physicians is going to evolve into a value-based methodology. Ignoring these changes can have a profound effect on your cash flow and profitability.

In the past, physicians were paid based on volume or utilization. The reimbursement rates were governed by something known as the SGR (Sustainable Growth Rate).

The government is replacing SGR with MACRA, which stands for the Medicare Access and CHIP Reauthorization Act of 2015. MACRA will reimburse physicians based no value rather than volume.

The reason for the change is that the government needed to replace the Sustainable Growth Rate formula because it became too difficult to manage, and wanted to combine all existing quality reporting programs into one system.

The government also wanted to develop a framework for rewarding providers for giving better care, not just more care.

There are essentially two different pathways in MACRA, but the one that most physicians will engage in is known as the Merit Based Incentive Payment System known as MIPS.

The MIPS program simply wraps up PQRS, the Value Based Modifier and the Medicare Electronic Health Record Incentive Program or meaningful use into one single program.

There are four components to MIPS:

50% of the component is based upon quality. The definition of quality is simply related to how well you comply with the current PQRS program.

25% of the net component is based upon what’s known as advancing care information. For all practical purposes this is our current Meaningful Use program.

15% is based upon clinical practice improvement activities. Here providers will have to choose some activities which improve their clinical care. This really hasn’t been well defined yet for chiropractic.

10% of the component will be based upon resource use, which means cost. This means that your cost per diagnosis will be benchmarked against your peers.

In the end, the MIPS program ultimately defines the financial impact for clinicians by creating a composite score for each provider.

In an attempt to motivate providers, by having an effect on their reputation, the providers composite score is also going to be placed on the CMS new public website known as, “Physician Compare.”

Without getting into too much detail, the end financial result of the MIPS program is fairly straightforward, the maximum penalty that can be levied is 9% for each provider and is going to be determined by
competing with your peers.

Remember that the 2019 reimbursement year is a reflection of what happens in 2017. That’s why it’s urgent that you prepare yourself since we’re rapidly approaching that starting date.

Dr. John Davenport DC, CCSP, FIAMA, MCSP

Compliance & Auditing Services

Immediate Action Required: Health Care Providers MUST Comply!

By | Department of Health and Human Services, Medicare | No Comments

Immediate Action Required by Health Care Providers to Comply With Section 1557 of the Affordable Care Act

On May 18, 2016, the U.S. Department of Health and Human Services (“HHS”) Office of Civil Rights (“OCR”) issued the Final Rule implementing the prohibition of discrimination under Section 1557 of the Affordable Care Act (ACA) of 2010.

Under Section 1557, individuals are protected from discrimination in health care on the basis of race, color, national origin, age, disability, and sex, including discrimination based on pregnancy, gender identity, and sex stereotyping.

Though Section 1557 has been in effect since the enactment of the ACA in 2010 and the HHS Office for Civil Rights (OCR) has been enforcing the provision since it was enacted, the Final Rule explains consumer rights under the law and provides additional clarification on enforcement and administrative remedies. In addition, it further defined who is considered a covered entity and their obligations.

The Final Rule applies to those who provide or administer health-related services or insurance coverage and receive “federal financial assistance,” which includes Medicare (except for Part B), Medicare Advantage Plans, Medicaid, Children’s Health Insurance Fund (CHIP) and receive meaningful use payments.

Under the Final Rule, all covered practices are required to “take reasonable steps to provide meaningful access to each individual with limited English proficiency eligible to be served.”

Section 1557 also states that “access services must be provided free of charge” and health care providers are expected to treat the costs of providing auxiliary aids and services as part of the annual overhead costs of operating a business.

Though doctors can claim a tax credit of up to 50 percent for eligible access expenditures over $250, but less than $10,250, the total amount is limited to $5,000 per tax year.

Eligible access expenditures include the costs of:

  1. Qualified interpreters (Meaning an interpreter who is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary)
  2. Note takers
  3. Transcription services
  4. Written materials
  5. Telephone handset amplifiers
  6. Assistive listening devices and listening systems
  7. Telephones compatible with hearing aids closed caption decoders, open and closed captioning
  8. Text telephones (TTYs)
  9. Videotext displays, or other effective methods of making aurally delivered materials available to the deaf or hard of hearing.

No one disagrees that there should be effective communication, but it seems unfair that physicians have to bear the total cost, which is estimated at $120 to $200 per visit, when reimbursement doesn’t come close to covering it.

Among other things, the Final Rule requires effected health care providers to include a non-discrimination notice and taglines in “significant publications” or “significant communications” targeted at patients or the public.

Though HHS does not specify which communications are considered significant, HHS does provide some examples such as patient handbooks, consent and complaint forms, initial patient paperwork, outreach publications, marketing materials and any notice “requiring a response from an individual” – which could include patient bills or notices to contact the practice to schedule an appointment. The notice/taglines can be part of the publication or a separate insert.

Additionally, taglines must be in at least the top 15 non-English languages spoken in the State in which the entity does business. For small sized communications such as postcards; the final rule requires entities to post a nondiscrimination statement and taglines in at least the top two non-English languages spoken by individuals with limited English proficiency in the State.

The provisions of the final rule became effective on July 18, 2016. In addition, the rule’s notice requirements, specifically the posting of a nondiscrimination notice and taglines are effective within 90 days of the effective date.

The Office for Civil Rights (OCR) is responsible for enforcing civil rights laws and complaints to OCR can result in investigations by HHS and the Department of Justice. In addition, an individual can sue you in civil court for a Section 1557 violation.

The director for the Office for Civil Rights, Jocelyn Samuels, sent a memorandum out to the U.S. Department of Health and Human Services stating, “I wanted to take this opportunity, as we reflect on the critical importance and impact of Federal civil rights laws and our role as public servants, in their vigorous enforcement, to underscore our authority and important responsibility to enforce Section 1557.”

Discrimination claims are not covered under traditional medical liability insurance and any judgments will come out of the doctors’ own pocket.

Steps Providers Should Take Immediately To Protect Themselves:

  1. Prepare and post all required “notice” communications and make sure websites are updated accordingly.
  2. Establish a means of providing required language support. This may require contracting with an outside vendor and/or addressing other forms of access to language support within the practice.
  3. Review all existing entity policies and/or create new policies, procedures addressing non-discrimination (including gender identity and gender transition) in health services, auxiliary aid, and language access requirements.
  4. Educate and train employees and staff. 
  5. Create and document a grievance procedure. 
  6. Submit an assurance of compliance form to OCR.

 

Again, remember that this applies only to practices which accept Medicare Advantage plans (Medicare Part A), Medicaid, Childrens Health Insurance Plans (CHIP), or have received Meaningful Use dollars.  This does not apply to Medicare Part B.

Post Payment Audits

By | Audits | No Comments

Screen-Shot-2013-12-03-at-1.13.23-PMAudits are big business for insurance carriers. For every 2 dollars that insurance companies spend on investigations, they profit $17 dollars in recoveries. In fact, audit and investigation divisions are one of the most profitable divisions for insurance companies.

Even though this doesn’t mean insurance carriers are out to get you, studies show that chiropractors have one of, if not the highest error rate when it comes to documentation.

In other words, insurance companies know chiropractors are bad at documentation and it’s easier to get money from them.

In general, chiropractors assume that as long as insurance carriers and Medicare are paying, they must be billing correctly. This is a very dangerous assumption to make.

Both insurance companies and Medicare collect information on all providers to identify those who fall outside the accepted parameters.

If your claims are coded improperly, you will be held responsible and required to pay back all the payments you received and possibly an additional fine.

The average payout by a practice seeing an average of 70 patient visits per week is $40,000.00 and $800,000.00 in an office seeing an average of 350 patients visits per week.

Because audits can be conducted on any provider that receives payments, and that includes cash practices as well, you can be audited. It’s not a question of if you’ll get audited; it’s a question of when you’ll get audited.

What Triggers an Audit?

Audits can be triggered in several ways, but the two most common are complaints and profiling.

As an example, a doctor contacted me recently for consulting services because a patient submitted a complaint to the board of chiropractic. The board requested the patient’s record for review. Because his documentation was so poor, the board requested five more files to be reviewed by the Department of Healthcare Quality Assurance.

Concerned, he called my office to review the files before submitting them to the board. Unfortunately, his documentation did not support his billing and without going into detail because I’m now working with his attorney, he is facing fines up to $10,000 dollars, the loss of his license, and possible referral for criminal prosecution.

With profiling, insurance companies gather information from claims submissions and then use the information to profile your billing patterns. If your office falls outside accepted parameters, then you get picked out for an audit.

Usually it starts with a request to review a certain number of patient files. Then the auditor reviews the files to determine if your records support the services that you received payment for.

If the records can’t prove the medical necessity of your treatment or support the billing codes, then the auditor will calculate a “percent deficiency,” and then extrapolate that over all the claims paid to you for the past five years.

That will then determine your payback amount and the insurance company sends you a letter demanding you pay them back.

As an example, a doctor called Compliance & Auditing Services for help when he received a request for $400,000 dollars.

Medicare audits can be triggered by a complaint, profiling or even randomly.     Medicare has a policy requiring them to randomly audit doctors’ offices.

The worst-case scenario is to have criminal charges filed against you.

Specific triggers include:

  1. Billing for maintenance care
  2. Overusing CMT code 98941(3-4 regions) or 98942 (5 regions).

   *Payers consider the correct percentage of utilization by chiropractors for CMT codes is:

                                   98940–25%, 98941–60%, 98942–15%*

  1. Excessive use of the E/M codes 99204 and 99205.
  1. Billing massage therapy (97124) with a CMT 98941 or 98942.
  1. Billing manual therapy (97140) with a CMT 98941 or 98942.
  1. Repeatedly billing neuromuscular re-education (97112).
  1. Billing passive therapies beyond the first 12 visits of care.

Being audited doesn’t mean you are guilty, it means you have to prove that you are innocent. So be able to justify your treatment with accurate documentation and evidence-based research.

Take the first steps now, before you get audited, by taking the time to improve your documentation and billing polices.

Start implementing active rehabilitation directed at the improvement of function rather than symptom relief. Most importantly, take compliance seriously.

Though there’s no way to completely avoid an audit, performing internal audits and having a comprehensive compliance program in your office can flag potential problems in billing or coding and avoid costly mistakes.

In fact, federal regulation requires you to do regular audits and to have a documented compliance program in your office.

Signed into law by the Health Care and Education Reconciliation Act of 2010, having an active office compliance program is mandatory. So you don’t have a choice, it’s the law.

Compliance programs must be updated regularly and followed to the letter.

If you haven’t completed an internal audit or developed a comprehensive compliance program, now is the time. Both can be done by outside consultants, or done in-house.

For example, all Compliance & Auditing Services consultants are certified as medical compliance specialists, insurance consultants and certified peer reviewers. Our company can design a compliance program that meets all federal and state regulations for you from scratch and conduct the required internal audits.

So why struggle to be compliant alone when there’s a team of qualified experts ready to give you the personal support you need to protect your office from losing 1000s of dollars to audits.

These are trying times for all doctors and ignoring the new regulations is no longer an option.

 

Dr. John Davenport DCM, CCSP, FIAMA, MCSP, ICI

Chief Compliance Officer Compliance & Auditing Services

CMS Targeting Against Payments for Chiropractic Services?

By | 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:

  1. 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).
  2. 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.
  3. 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:

  1. Establish a more reliable control for identifying Active Treatment
  2. Develop and use measures to identify questionable payments for chiropractic services.
  3. Collect overpayments based on inappropriately paid claims.
  4. Ensure that claims are paid only for Medicare-covered diagnoses.
  5. 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:

  1. Recouping inappropriate payments.
  2. Educating providers on proper billing.
  3. Making referrals to law enforcement.
  4. Imposing payment suspensions.
  5. Revoking billing privileges.
  6. Taking no action, if the payment is determined to be appropriate.
  7. “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.

Common Sense PQRS For Chiropractic Offices

By | 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:

  1. Patient is in an emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status.
  2. 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:

  1. 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.
  2. The patient is unable to complete the questionnaire.
  3. 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 1st 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 | Insurance Coding | No Comments

X Modifier PictureI’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.

If you have any questions or concerns don’t hesitate to call or email Compliance & Auditing Services (complianceandauditingservices.com) . We’re here to help you.

All The Best,

Dr. John Davenport
Chief Compliance Officer
Compliance & Auditing Services