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Responding To The Coronavirus

By | Compliance, COVID-19 | No Comments

Although the CDC has released new safety guidelines for individuals who have been fully vaccinated, doctors offices should note that the recent changes do not apply to healthcare personnel while at work and all patients while they are being cared for in a healthcare setting.

With some states reopening and COVID mandates being lifted, what are the latest CDC requirements for keeping patients and staff safe while in your office setting?

Masking Protocols:

Some patients refuse to wear masks and may not understand that the CDC’s lifting of masking protocols for fully vaccinated patients does not apply to healthcare settings.

Thus, when making appointments for in-office visits, practice staff should continue to set office expectations prior to coming into the office regarding established infection control protocol set by the CDC.

Additionally, a sign posted on the front door and in the reception area will help to alert patients that the masking protocols are still in effect.

If a patient is uncooperative upon arrival, healthcare providers should ask the patient to step aside to a private area where are you can address the patient’s concerns.

If the patient gets angry, let them know that you are obligated to follow guidelines set forth by the CDC as well as other government agencies, to ensure everyone’s safety.

If the patient becomes hostile or uncooperative, you always have the right to suggest that the patient seek care elsewhere. But remember, that if you decide to terminate the doctor patient relationship over this issue, it is critical that you end the relationship in a manner that will not lead to claims of discrimination or patient abandonment.

Social Distancing:

The CDC still recommends physical distancing within your facility and requires that patients sit at least six feet or more apart. If it is practical, you could ask patients to wait in their car and text them when you’re ready to see them.

Ask anyone accompanying the patient to wait in the car during the appointment if possible.

Do not allow staff members who are sick, have been sick or have sick family members to come to the office.

Environmental Infection Control Protocol:

  • Routinely clean and disinfect frequently touched surfaces, treatment tables or objects. Cleaning guidelines vary based on devices and surfaces being cleaned.
  • Remove magazines and toys from the waiting room.
  • Routinely disinfect the waiting room and bathrooms throughout the day.
  • Develop a cleaning schedule and checklist for your facility, and document compliance in your administrative files that the cleaning schedule is followed.
  • Provide approved face masks to patients and all caregivers and staff to use.
  • Have alcohol-based hand rub available in the reception area, waiting room, patient care and restroom areas.

Patient Screening Protocol:

Screen patients calling to schedule an appointment by asking them:

  1. If they or anyone in their family has a fever or has had one in the last two weeks.
  2. Have they or family members had any symptoms of a cold or flu?
  3. Have they traveled abroad in the last two weeks?
  4. Have they been near anyone who has potentially had the virus through their
    family or work?

For individuals entering your facility, query all patients about symptoms of coronavirus, whether in written form or verbally by your staff, take their temperature, and then document findings in the soap note on each visit.

For example:

  • “The patient was questioned with regards to recent travel and exposure to illness including COVID-19.
  • The patient denies any close contact with individuals who have confirmed cases of coronavirus and recent travel to high-risk areas within the last 14 days.
  • The patient denies the following symptoms: fever or chills, cough, shortness of breath,
    fatigue, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting or diarrhea.
  • Temp: 98.6″

Office Preparedness Protocol:

  • Design a COVID-19 office management plan.
  • Educate staff about coronavirus and why it is important to contain the outbreak.
  • Educate staff on facility policies and practices to minimize chance of exposure.
  • Train staff on how to advise patients about changes in office procedures (e.g., calling prior to arrival if the patient has any signs of a respiratory infection and taking appropriate preventive actions.
  • Prepare for office staff illness, absences, and/or quarantine by cross-training staff for all essential office and patient care functions.
  • Implement mechanisms and policies that promptly alert key facility staff about known suspected COVID-19 patients.
  • Keep updated lists of staff and patients to identify those at risk in the event of an exposure.


OSHA released its new Emergency Temporary Standard (ETS) for COVID on June 10, 2021, with an effective date of June 15. Impacted healthcare employers are expected to comply with most requirements within 14 days of publication and within 30 days for the remainder of the requirements (e.g., employee training).

OSHA’s COVID-19 Healthcare Emergency Temporary Standard (ETS),29 CFR 1910.502 paragraph (c), requires employers to develop and implement a COVID-19 plan for each workplace to protect workers from COVID-19.

Additionally, if an employer has more than 10 employees, the plan must be written.

Fortunately, most offices will not be affected by OSHA’s COVID-19 Healthcare ETS requirements.

To determine if the new mandate applies to your workplace or portions of your workplace, answer the following questions.

  1. Is the workplace a setting where any employee provides healthcare services or healthcare support services?
  2. Does the workplace meet all the following conditions?
  3. It is a non-hospital ambulatory care setting?
  4. Are all non-employees are screened prior to entry?
  5. People with suspected or confirmed COVID-19 are not permitted to enter?

If you answered yes to all of the above than the ETS does not apply to your workplace?

In conclusion, make sure that both staff and patients are aware of your offices policies regarding the SARS-CoV-2 virus.

1. Advise them of the precautions you are taking to provide a safe workplace and give them the opportunity to voice any concerns.

2. Document your compliance with the CDC protocols and employee training on COVID office policies and procedures.

3. Develop a cleaning schedule and checklist for your facility, and document compliance with CDC requirements that the cleaning schedule is followed.

4. Make sure that your office staff is following patient screening protocol and document patient screening procedures in your S.O.A.P notes.

Remember that the Occupational Safety and Health Act (“OSHA”) requires employers to provide employees with a workplace free from recognized hazards that are causing or are likely to cause death or serious physical harm.

Failure to comply with applicable laws, including reporting and investigative demands, is grounds for revoking not only your license to practice but also your office’s operating license.

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

The Use and Understanding Of X{EPSU} Modifiers

By | 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

Preparing For Significant Revisions To E/M Office Visits 2021

By | Compliance, Insurance Coding | No Comments

In part one of this article we learned that starting January 1st, the American Medical Association implemented major changes to the 2021 Current Procedural Terminology (CPT) code for outpatient evaluation and management (E/M) services.

The stated reason for the need to change the Evaluation and Management (E/M) guidelines was that the guidelines did little to support patient care and that the old E/M guidelines consume too much of the physician’s time and didn’t reflect the actual work done by the physician.

While the current E/M code set guidelines use the 3 key elements of history, examination and medical decision-making to determine the correct E/M code level to bill, The new guidelines will allow practitioners to document office and outpatient E/M level codes 99202—99215 based on the total time spent on the date of the encounter or medical decision making (MDM).

Additionally, because of the new change, it was necessary that the descriptions and guidelines surrounding MDM and time be redefined for better clarity.

For example, when time is used to select the appropriate level for E/M services codes, the following are the time codes used as a determining factor for each category:

New patient codes:

 Established patient codes:

99202: 15-29 minutes 99212: 10-19 minutes
99203: 30-44 minutes 99213: 20-29 minutes
99204: 45-59 minutes 99214: 30-39 minutes

The E/M services for which these guidelines apply require a face-to-face encounter with the physician and remember to count only the practitioner time on the calendar day the patient was seen. Do not include time on any other day, and don’t include staff time.

With that said, in the first part of this article we reviewed the descriptors and guidelines that support the use of time to select the appropriate level for E/M services in depth.

If you didn’t read part one of this article, regarding the use of time, read the last newsletter HERE. Knowing this information and the differences should help you in deciding which method would be best for your office.

The purpose of this article is to learn the descriptors and guidelines that support the use of a Medical Decision Making (MDM) E/M code set.

In general, MDM is related to the process of establishing a diagnosis, assessing the status of a condition, and selecting a management option. MDM is defined by the following three elements:

  • The number and complexity of problem(s) addressed during the encounter.
  • The amount and/or complexity of data to be reviewed and analyzed. This data includes medical records, tests, and/or other information reviewed and considered for the date of the encounter and not a subsequent encounter.
  • The risk of complications, morbidity, and/ or mortality of patient management decisions made that are associated with the patient’s problem, diagnostic procedures, treatment and treatment alternatives at the time of the visit.

This includes the possible management options selected after sharing medical decision making and explaining both the risks and benefits of each management option with the patient, family and/or legal representative.

It’s also important to know the four levels of MDM recognized as part of the new 2021 E/M guidelines: straightforward, low, moderate, and high.

To determine the most appropriate level of MDM to report, the physician would review and meet the qualifications for each of the three elements of MDM.

To aid physicians in selecting the level of MDM for reporting the correct E/M service code, the AMA developed a guideline to assist in selecting the acceptable level of MDM.

The following guideline includes the four levels of medical decision making and the three elements of medical decision making.

Note that to qualify for a particular level of medical decision making, at least two of the three elements for that level of medical decision making must be met or exceeded.

Three Element Qualification Guide:

Level of MDM: Straightforward  (99202/99212)

  1. The number and complexity of problem(s) addressed during the encounter.
    • Minimal
      – 1 self-limited or minor problem
  1. Amount and/or Complexity of Data to be Reviewed and Analyzed.
    • Minimal or none
  1. Risk of Complications and/or Morbidity or Mortality of Patient Management.
    • Minimal risk of morbidity from additional diagnostic testing or treatment

Level of MDM: Low  (99203/99213)

  1. The number and complexity of problem(s) addressed during the encounter.
    • Low
      2 or more self-limited or minor problems or one or more of the following:

      • 1 stable chronic illness
      • 2 acute, uncomplicated illness or injury
  1. Amount and/or Complexity of Data to be Reviewed and Analyzed.
    • Limited (Must meet the requirements of at least 1 of the 2 categories)

Category 1: Tests and documents

  • Any combination of 2 from the following:
  • Review of prior external note(s) from each unique source*
  • Review of the result(s) of each unique test*
  • Ordering of each unique test*

Category 2: Assessment requiring an independent historian(s)
( An Independent historian is any individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history or because a confirmatory history is judged to be necessary.)

  1. Risk of Complications and/or Morbidity or Mortality of Patient Management.
    • Low risk of morbidity from additional diagnostic testing or treatment

Level of MDM: Moderate  (99204/99214)

  1. The number and complexity of problem(s) addressed during the encounter.
    • Moderate
      • 1 or more chronic illnesses with exacerbation progression, or side effects of treatment or one or more of the following:
        • 2 or more stable chronic illnesses
        • 1 undiagnosed new problem with uncertain prognosis
        • 1 acute illness with systemic symptoms
        • 1 acute complicated injury
  1. Amount and/or Complexity of Data to be Reviewed and Analyzed.
    • (Must meet the requirements of at least 1 out of 3 categories)

Category 1: Tests, documents, or independent historian(s)

  • Any combination of 3 from the following:
  • Review of prior external note(s) from each unique source
  • Review of the result(s) of each unique test and ordering of each unique test
  • Assessment requiring an independent historian(s)

Category 2: Independent interpretation of tests

  • Independent interpretation of a test performed by another physician/other qualified healthcare professional (not separately reported)

Category 3: Discussion of management or test interpretation

  • Discussion of management or test interpretation with external physician/other qualified health care professional or appropriate source (not separately reported)
  1. Risk of Complications and/or Morbidity or Mortality of Patient Management.
    • Moderate risk of morbidity from additional diagnostic testing or treatment

Examples only:

  • Prescription drug management
  • Decision regarding minor surgery with identified patient or procedure risk factors
  • Decision regarding elective major surgery without identified patient or procedure risk factors
  • Diagnosis or treatment significantly limited by social determinants of health

In review, history exam is no longer a defining element when choosing the appropriate level of medical decision making. But it is important to understand that even though the nature and extent of the history and/or physical examination is determined by the treating physician, the guidelines still require that all E/M services include a medically appropriate history and or physical examination.

Remember that billing for outpatient evaluation and management (E/M) services is based on complexity as documented, and not based on implied or undocumented complexity.

All the Best,

Dr. John Davenport
Chief Compliance Officer

Compliance & Auditing Services

(800) 509-0538

Preparing For Significant Revisions To E/M Office Visits 2021

By | Compliance, Insurance Coding | No Comments

Starting January 1st, the American Medical Association (AMA) implemented major changes to the 2021 Current Procedural Terminology (CPT) code for outpatient evaluation and management (E/M) services.

The stated reason for the need to change the Evaluation and Management (E/M) guidelines, was that the guidelines do little to support patient care. Simply put, adherence to the old E/M guidelines consume a significant amount of the physician’s time and don’t necessarily reflect the actual work by the physician.

So, in accordance with President Trump’s executive order, directing federal agencies to cut red tape, CMS proposed revisions to the E/M rules to decrease administrative burden and make code level selection more intuitive. CMS feels this will improve payment accuracy and minimize the amount of note bloating from EHR copy and pasting of the same problem list day after day.

The current E/M code set includes guidelines on using the 3 key elements of history, examination and medical decision-making to determine the correct E/M code level to bill.

With that said, starting on January 1st, 2021 practitioners will now document office and outpatient E/M level codes 99202—99215 based on total time on medical decision making (MDM) or the total time on the date of the encounter.

Additionally, because of the new change, it was necessary that the descriptions and guidelines surrounding MDM and time be redefined for better clarity.

Starting with time, except for 99211, time alone may be used to select the appropriate code level for the office or other outpatient E/M services codes 99202 – 99215 whether or not counseling and/or coordination of care dominates the service.

When time is used to select the appropriate level for E/M services codes, time is defined by the service descriptors in each category.

The E/M services for which these guidelines apply require a face-to-face encounter with the physician.

Here are the major points from the 2021 guidelines for Time:

  • You will be able to use time alone to select the correct code from 99202-99205 and 99212-99215. Note that 99211 is not in that list because no time is listed in that descriptor.
  • The 2021 Time guidelines explain that for 99202-99205 and 99212-99215, total time on the encounter date includes both face-to-face and non-face-to-face time spent by the provider on the same day as the visit.
  • When you start counting time for the 2021 codes, you should not include time spent on services you report separately. For instance, if you report care coordination or x-rays using a separate code, you should not include that in the time for the E/M code.

This is because the performance and/or interpretation of diagnostic tests/studies during a patient encounter are bundled together under a separate billing code and not included in determining the levels of E/M services. Even so, it should be documented in your records.

  • The total time also will not include time for activities the clinical staff normally perform such as taking vitals.

Physician professional time includes the following activities, when performed:

  • Preparing to see the patient (eg, intake forms and studies from other providers)
  • Obtaining and/or reviewing separately obtained history
  • Performing a medically appropriate examination and/or evaluation
  • Counseling and educating the patient/family/caregiver
  • Ordering tests or other procedures
  • Referring and communicating with other healthcare professionals (when not separately reported)
  • Documenting clinical information in the patient’s health record
  • Care coordination (not separately reported)
  • Typically, because a chiropractor cannot justify the use of the 99205/99215 codes they will not be used.
  • If coding using the 99204/99214 codes, make sure that your documentation supports its use.

The following are the time codes used as a determining factor for each category:

New patient codes:

  • 99202: 15-29 minutes
  • 99203: 30-44 minutes
  • 99204: 45-59 minutes

Established patient codes:

  • 99212: 10-19 minutes
  • 99213: 20-29 minutes
  • 99214: 30-39 minutes


Remember to count only the practitioner time on the calendar day the patient was seen. Do not include time on any other day, and don’t include staff time.

Additionally, It isn’t necessary to note how much time was spent in each activity but the total time for the encounter.

Describe what was done, and document time in a single statement as in the example below.

“I spent 30 minutes reviewing the patient’s intake form, examining the patient, and documenting my diagnosis and findings in the record. I also discussed treatment with the patient, including the possible risk associated with treatment and alternatives to care. The patient stated that they understood the risk and requested that treatment be performed.”

  • Though a medically appropriate history and/or examination will not be part of the basis for code selection, history and exam findings that are pertinent to the visit should still be documented.
  • Physician documentation must accurately depict what occurred during the encounter, as you still need to be covered in the event of a lawsuit or post-payment audit.
  • It’s crucial to understand that your E/M documentation must support the medical necessity of the diagnosis and treatment provided.
  • When using time as a coding factor, if a physician reviews medical records or special studies from another source on the day of the encounter, they should document what specific records or studies and their origin.

Also, the physician should sign the document with their full name and credentials (eg, DC) to show that they reviewed them.

  • Keep in mind, the AMA does not process or pay claims and as such, they are not the final word on billing policies or payment guidelines. This means that though CMS is accepting the new E/M guidelines for 2021, single payers and commercial Insurance plans may not.

So, it is your responsibility to contact the individual commercial insurance providers and make sure that they are accepting the new guidelines.

Because starting in 2021 practitioners will document office and outpatient E/M level codes 99202—99215 based on time or medical decision making (MDM), part two of this article will review the requirements for medical decision making (MDM) and the different categories associated with each E/M level code.

Knowing this information and the differences should help you in deciding which method would be best for your office.

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

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:


Spanish Version:


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.