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TRANSCRIPT
7 Mistakes DC’s Can’t Afford to MakeWith Billing, Coding, Documentation, Compliance & Your Business
Presented by Tom Necela, DC, CPC, CPMA, CCP-P
www.StrategicDC.com
Mistake 1: ICD-10 Procrastination
Mistake #1: ICD-10 Procrastination
Realizations
1. Deadline is set -
October 2014
� ICD-9 & ICD-10
Closed for revision!
Mistake #1: ICD-10 Procrastination
2. All Dx Codes Change…
PLUS the 7th Character Extenders
� Initial Encounter = A
� Subsequent = D
� Sequela = S
Mistake #1: ICD-10 Procrastination
Hip Spr/Str(843.8) ���� Becomes 19 codes!
� S73.191A
(right hip spr, initial)
� S73.192A
(left hip spr, initial)
� S76.111A
(right quad spr, initial)
� S76.112A
(left quad spr, initial)
� S76.119A
� (unspecified quad, initial)
Mistake #1: ICD-10 Procrastination
Realizations
3. More specificity for Dx and Documentation
4. Doctors & Staff BOTH Affected
5. No Exceptions
Mistake #1: ICD-10 Procrastination
Preparation
1. Estimate 3-6 mos
2. Start Feb-Apr 2014
3. Train DC & staff
4. Train by June to practice
5. Ready to be “live” in October 2014
Mistake 2: Billing Metrics
Metrics to Monitor Your Money
Collections Performance as % of Services
• Gold Standard goal = 100%
• Acceptable = 80-85%
• Below Avg = less than 75%
Metrics to Monitor Your Money
Healthy A/R
• <1.5x gross services
• 2x is danger zone
• >2x = problem
% of Cash, Ins, PI can vary
Know When to Fold ‘Em
� Outsourcing
• Timely Claims Pd – 80% < 45 days
• Low % of duplicates
• Insurance balances vs Pt balances
• Billing cost – Norm = 4-15%, avg = 8%
� Collections Agency
� Forgiveness
Mistake 3: Ignoring Audit Patterns
Mistake #2: Ignoring Audit Patterns
1. Random Audit
• Target = your license
• Trigger = none
• Defense = Correct coding & documentation
• Offense = Prompt response and appeals
<9 % Appeal, >64% Appeals Win
Mistake #2: Ignoring Audit Patterns
2. Specialty Audit
• Target = rehab, radiology, etc
• Trigger = high usage patterns
• Defense = understand payer policies, coding
& documentation
• Offense = Appeals (more $, tougher to win)
Mistake #2: Ignoring Audit Patterns
3. Outlier
• Target = anyone outside the curve
• Trigger = high usage patterns
• Defense = understand parameters
• Offense = Appeals (more $$, tougher)
Mistake 4: Medicare Mess Mgmt
� Mandatory Reporting
Par and Non-Par
� Pain & Function
Each Visit
� 30 Day Episodes
G8539 Initial FOA
G8942 FOA <30 days
The Impact of Meaningful Use
� DOI
• Box 14
� Update Dx Codes
• Box 21 Claim
• Documentation
� Exacerbations
• Temporary Worsening
• (Date in Box 19)
The Impact of Meaningful Use
Mistake 5: Documentation Denial
CERT Documentation
Checklist
� History
• Mech of Trauma
AT = Active Tx
Acute or Chronic
Noridian Medicare CERT Checklist
� PART Exam OR Xray
• Pain
• Asymmetry
• ROM
• Tenderness
Xray
• Box 19 date
Noridian Medicare CERT Checklist
� Tx Plan
• Duration
• Frequency
• Objective Goals
• Measures
Noridian Medicare CERT Checklist
� Encounter specific
Daily doc
� All Spinal Levels
Documented
� No Ongoing Imp =
Maintenance
� Signatures
Noridian Medicare CERT Checklist
Mistake 6: Shelving Compliance
1. Manual ≠ Compliance
• Must be interactive
2. HIPAA
• Deadline Sept 23, 2013
• OCR or Dept of Justice
Mistake #6: Shelving Compliance
2. Fee Schedule
• Dual Fees / TOS Discount
• Payer Phone Snoop
• Website Woes
Mistake #6: Shelving Compliance Concerns
3. Coding
• Understanding Rules
Example: 97140 & 9894x
• Understanding time
CMS (8-22 min) vs CPT(15 min)
• Creative
Mistake #6: Shelving Compliance Concerns
Mistake 7: No Pre-Auth Strategies
2.0
Regence/CareCore Pre-Auth Program
Includes
• All Regence plans
• Medicare Advantage
• For In and Out of Network Providers
Excludes
� Uniform Medical Plan
� Federal Employee Plan
� If Regence is Secondary
� Medigap, BlueCard
Regence/CareCore Pre-Auth Program
Trial Date
• Trial period starts November 1, 2013
• Pre-authorizations in operations
• No denials issued
• Data tracked and education issued
Regence/CareCore Pre-Auth Program
“Live” Start
� Full program starts February 1, 2014
� Pre-auth requirements according to Tiers
� Denials issued
Regence/CareCore Pre-Auth Program
Tier A (approx 50%)
• Submit Notification w/in 7 days after Initial Exam
• May Tx for 30 days
• No info given for Tx beyond 30 days
Regence/CareCore Pre-Auth Program
Tier B (approx 25%)
• Submit Notification w/in 7 days after Initial Exam
• Receive approval for 6 visits (DC) / 4 for LMP/Lac
• Initial approval waiver good for up to 60 days
• Tx >60 days or 6 visits requires pre-auth
• Subsequent episodes require immed pre-auth
Regence/CareCore Pre-Auth Program
Tier C (approx 25%)
• Submit Treatment Request + Notification @ Exam
• Wait for Tx Request approval to continue care
• Approved # of visits given within 2 days
Regence/CareCore Pre-Auth Program
Pre-Authorization Denial Differences
Denial
INNo Tx
No Pay
OUT Pt Resp
Appeal
Regence / Care Core
Use of Member Consent Form
�Services requiring pre-authorization cannot be
billed to patient even if…
�Patient signs a waiver/consent/ABN form
Regence/CareCore Pre-Auth Program
7 Areas of Impact to Consider
1. Case Presentation / ROF modification
� 30 day tx plans will work best
� Re-submit 7 days prior to end to continue care
Regence/CareCore Pre-Auth Program
7 Areas of Impact to Consider
2. PRN patient paperwork hassles
� >30 lapse will force restart
3. Double Duty patients (chiro & massage)
� Visit approvals will not match
4. Secondary Slap
� Watch Double Denial
Regence/CareCore Pre-Auth Program
5. Staffing – do we have time?
� Consider outsourcing
� Consider “down-sourcing”
6. Documentation
� Prompt
� Detailed
7. Diagnosis Coding
� Hierarchy
� Updates
Regence/CareCore Pre-Auth Program
Participation Considerations
1. Demand to see how many DC’s in each tier
2. Appeal your Tier Level early
3. Use the Trial Period to test system
4. Examine 1099 to see impact
5. Opt Out Before Kicked Out or Downgraded
Regence/CareCore Pre-Auth Program
Navigating Pre-Authorization Programs DVD Tutorial
• Billing/Coding
• Documentation
• Staff Management
• Business Strategies
Specific to Regence/Care Core
The Future
� Do the Math & Take Action
� Develop Multiple Streams
� Monitor Money
� Educate to Excel
� Focus on patients,
not paper
� DC’s are still thriving!
Work Smarter, Not Harder
www.StrategicDC.com
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