making your practice well and excell through … · understanding hipaa and documenting compliance...

Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 1

MAKING YOUR PRACTICE

WELL AND EXCELL

THROUGH DOCUMENTATION

UP TO DATE INFORMATION ON

HIPAA MEDICARE CARE OPTIONS FRAUD

Benjamin M. Bartolotto, BS, DC, FACC


COURSE OBJECTIVES

1. Understanding HIPAA and documenting compliance through practical and

proportional action steps

2. Confidently and correctly navigating and fulfilling Medicare documentation

requirements

3. Through treatment goal planning and outcome studies selecting the appropriate

type of care

4. Identifying record keeping red flags, identifying fraudulent activity


HIPAA

The three components the Health Insurance Portability and Accountability Act are now in

force. The premise of HIPAA was the patient’s protection over the privacy of their

healthcare information, {PHI}, with its administration under the United States

Department of Health and Human Services, the enforcement through the Division of

Health and Human Services, {HHS}, Office for Civil Rights. You can explore the depth

of HIPAA to your interest and convenience at www.hhs.gov/ocr/hipaa. 1

The original intent of HIPAA was to protect a patient’s PHI when the covered entity,

health plan, clearinghouse, and healthcare providers would transmit their health

information electronically. One of the missions of HIPAA was to standardize date

transmission, as well as electronic data interchange, {EDI}. This original concept was

then broadened to include all medical information communications. This evolving

process has brought the HIPAA to fruition. There are some simple and practical steps a

healthcare provider can take immediately to document their HIPAA compliance.

THE PRIVACY RULE - PART I

ACTION STEPS

Appoint a privacy officer/contact person in regard to office records; this can be a

healthcare provider or an office staff member. Dedicate a notebook or loose leaf binder

as the office HIPAA manual. The manual will record the name of privacy officer and

contact person, office policy and procedures, a copy of the privacy notice, signed by

1 United States Department of Health and Human Services; www.hhs.gov/ocr/hipaa

http://www.hhs.gov/ocr/hipaa


patients, as well as business agreements used for outside services such as for billing,

transcription, or collections stating that they are HIPAA compliant. Privacy notices come

in many forms but universally usually includes the following information for the patient

in regard to disclosing their health information;

Sharing of health information to receive payment, provide treatment, provide

health information to other providers, provide information to third party business

associates, {i.e. transcription services}

Share information for national security and public health reporting, disclose

information required by law, {i.e. valid court orders}

Share information for law enforcement purposes, in emergency medical situation,

appointment reminders, validate identity

May release information to coroner or medical examiner as authorized by law, for

research projects, a family or friend of your choice, governmental agencies

providing benefits and services

Share information for other reasons or sources with your written authorization

Name, address, and other contact information of the Privacy Officer

You have the right to look or receive a copy of your records at written request, if

you request copies a reasonable fee for copying and mailing may be charged

If you believe your information is incorrect or is missing you have the right to

request an amendment, that request made in writing

You have the right to have health information be shared in a confidential manner,

{i.e. sent to a different mailing address}

The patient should be provided with, and signed, an acknowledgement of receipt of

notice of privacy practices and this form inserted into the patient’s health record;

regardless if the patient retains a copy.


Include in the HIPAA office manual a signed statement by employees that they have been

informed and trained in HIPAA regulations and procedures. HIPAA training update

sessions should be recorded in the HIPAA manual, {i.e. quarterly, at regular staff

meetings, etc}. This would heighten the healthcare providers and staff’s appreciation and

sensitivity to the HIPAA environment.

General, physical safeguards of HIPAA; placement of computer screens or the use of

computer screen guards so they are not viewed by any one other than authorized office

personnel, a secure location for the fax machine, as well as file cabinets.

The sign in sheet secured at the front desk, an option, a sliding cover over the sign in

sheet only exposing a blank line for the next patient to sign in, with the signature of the

prior patient covered from view.

If open treatment areas are utilized, a private treatment area should be available if desired

by the patient.

SAMPLE OF PATIENT ACKNOWLEDGEMENT


RECEIPT OF NOTICE OF PRIVACY PRACTICES2

By signing below, I acknowledge receiving a copy of the sample

Privacy Practices, dated ________________________________

________________________ ________________ _________________

PATIENT NAME PATIENT’S DOB PATIENT SOC SEC #

______________________________________________ ______________

SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE DATE

*If signed by a Personal Representative, the following information must also be included:

_________________________________________

NAME OF PERSONAL REPRESENTATIVE

DESCRIPTION OF THE PERSONAL REPRESENTATIVE’S AUTHORITY TO ACT

ON BEHALF OF THE PATIENT

2 New York Chiropractic College Patient Acknowledgement Receipt of Notice of Privacy Practice


HIPAA SECURITY RULE - PART II

Effective April 2005 the Security Rule came into effect, in regard to healthcare plans,

healthcare clearinghouses, healthcare providers, anyone who transmits electronically

protected health information, {EPHI}. EPHI examples are submitting of claim forms

electronically, checking claim status and eligibility, electronic referrals, diagnostic testing

results, e-mails, etc. The HIPAA Security Rule does not apply to a healthcare provider’s

practice who does not submit/receive any information electronically. Considering the

software becoming available to healthcare providers and entities in regard to managing

their business, recording in the category of medical information and submitting the same,

and the growing interest and movement to electronic record management, the HIPAA

Security Rule will apply to the majority rather than the minority.

Covered entities are to implement safe guards to prevent improper access to patient

health information that is stored in an electronic form, including information contained in

e-mails or other electronic transmissions, electronic protected health information {EPHI}.

Measures taken must be reasonable for practice size, and each component of the rule

must be identified as required or addressable.

RISK MANAGEMENT CONSIDERATION; There are now programs that can detect,

“Metadata”, these programs which can detect the alteration or emission of electronic data.


ACTION STEPS

The HIPAA Security Rule consists of 3 safe guards; administration, physical, and

technical.

Everyday technology, which is used and taken for granted is now becoming a HIPAA

Security item. Take the following into consideration; PDA’s {Personal Digital

Assistants}, Blackberrys, are increasingly popular. As the, “information age”, marches

on the use of these devices are commonplace. If patient information is stored in these

devices, in the event that the PDA is lost or stolen the security of the patient’s

information may be breached.

Most people today would be lost without their cell phone, though the mobile cell phone

in itself has evolved into a multiple device for phone calls, text messaging, and for

transmitting pictures and videos manufactured in smaller and smaller packaging. When

returning a phone call to a patient, especially in a public atmosphere it would be advised

to acknowledge the patient’s concern and set up a time when you may call the patient in a

more private setting. It is reported that technology exists to monitor cell phone calls and

even some companies have attained a list of what cell phone numbers were called and

have sold such lists.

Many providers, of all disciplines, now communicate with patients through e-mail. On

some provider websites you can schedule appointments, download office information, as


well as download office forms, which can be printed out and completed before your

presentation to the office. Security here though is a concern, as patients may have e-mail

accessible by multiple individuals.

ACTION STEP

Have the patient sign a release allowing you to contact them through this medium, {e-

mail}. Keep a copy of any e-mail communication to patient, as this is a form of patient

contact documentation, {risk management consideration}.

NATIONAL PROVIDER IDENTIFIER {NPI}

PART III

In 1996 HIPAA mandated that the HHS adopt a standard unique health identifier for

healthcare providers consisting of 10 positions, which will eventually phase out providers

UPIN and other provider identifiers, this identifier was named the National Provider

Identifier, {NPI}. On 1-23-04 HHS published the final rule for the NPI with the effective

date of the rule 5-23-05. Providers can start applying for their NPI on 5-23-05, the

compliance date is 2 years later, on 5-23-07. As of 5-23-07 covered entities, {healthcare

providers}, will only use the NPI for all standard transactions, no other numbers will be

accepted after that date.


ACTION STEP

To obtain your NPI contact https://nppes.cms.hhs.gov3 or you may contact the NPI

Enumerator at

NPI Enumerator

PO Box 6059

Fargo, ND 58103-6059

1-800-465-3203

On March 16, 2006, the HIPAA Enforcement Rule became effective. This rule addresses

CMP, {Civil Monetary Penalties}, for covered entities/HIPAA violations. The

enforcement rule outlines the investigative process and applies to all HIPAA components.

The HIPAA Enforcement Rule mandates HHS to impose a CMP for HIPAA violations,

the increased number of violations, the increased CMP.

For information go to: www.hhs.gov/ocr/hipaa

Your HIPAA office manual should contain

Copy of Privacy Notice

Office policy/steps to ensure the security of patient’s PHI/EPHI

Copy of your NPI

Employee signed statements of HIPAA training/awareness

Notes of HIPAA meetings

3 NPPES; National Plan & Provider Enumeration System

https://nppes.cms.hhs.gov/

http://www.hhs.gov/ocr/hipaa


HEALTH INFORMATION TECHNOLOGY FOR

ECONOMIC AND CLINICAL HEALTH ACT {HITECH}

The HITECH Act has been passed as part of the American Recovery and Reinvestment

Act of 2009. This act will expand HIPAA privacy rule in regard to notifying patients

protected health information, {PHI} disclosures. The HITECH Act enables the

Department of Health and Human Services Office for Civil Rights, {OCR}, to require

HIPAA covered entities to notify individuals in respect to PHI disclosures through

electronic health records for the purpose of treatment, payment, and healthcare

operations. The disclosures must include the following components:

• Date of disclosure

• Name and address of the entity or person receiving the disclosure

• A description of the information disclosed

• A copy of the request for disclosure or a brief description of the reason for

disclosure

For more information: http://edocket.access.gpo.gov/2010/pdf/2010-10054.pdfto

RED FLAG RULE

The Federal Trade Commission, {FTC}, along with five other agencies on November 9,

2007 issues a final rule implementing Sections 114 and 3015 of the Fair and Accurate

http://edocket.access.gpo.gov/2010/pdf/2010-10054.pdfto


Credit Transactions Act of 2003. Regulations stated that financial institutions and

creditors are required to develop and execute a written identity theft prevention program;

it must provide for the identification, detection, and response to patterns, practices or

specific activities. These are known as, “Red Flags”. Enforcement of this regulation has

been delayed from May 1, 2009 to August 1, 2009 and now scheduled to go into effect on

January 1, 2011. Many healthcare professional organizations are in disagreement as if

this regulation applies to healthcare providers and/or facilities. The AMA instituted a

lawsuit against the FTC in that regard. Photocopying a patients’ drivers license or other

picture identification for verification is a simple and practical action step. For more

information and guidance go to www.acatoday.org/redflags .

THE HEALTH CARE RECORD

Check specific state local statutes for required retention of medical records and/or x-rays.

A healthcare record is the provider’s examination, selection of diagnostic testing,

diagnosis, prognosis, and therapeutic approach to the patient’s condition. This

information can be utilized in various venues; risk management, protecting the patient,

legal documentation, utilization review, establishing medical necessity, documenting

regulatory compliance, support asset recovery, {reimbursement for services rendered}, as

well as research. The submitted documentation should underscore why the patient is

being treated, diagnosis, and therapeutic approach, decision making for providing the

treatment, as well as the anticipated degree of the therapeutic outcome.

http://www.acatoday.org/redflags


Every page of the patient’s file should have recorded the patient’s name on it. It is

becoming more popular to see healthcare provides utilizing computer generated notes,

these notes should be specific for patient’s on an individual basis. The computer-

generated notes should reflect the customary, reasonable examinations and procedures

which would be found to be proportional to the patient’s presenting complaints/

condition. There is a tendency that certain providers who use generated computer notes

will embellish the patient encounter with more information than is reasonable due to the

ease of using a palm pilot. Computer generated notes are becoming more popular with

providers in regard to the ease of completeness of the documentation; however, the

computer generated notes are recommended to be organized in specificity for every

patient. Computer organized notes, length and content, should be proportional to the

events of the patient encounter consistent with the patient’s diagnosis and what would be

anticipated to be reasonably and customarily performed throughout the timeline of

treatment.

Many providers will use abbreviations, which is acceptable, as long as the abbreviations

are commonly accepted and standardized in the healthcare professions.

APPROPRIATE EVALUATION AND MANAGEMENT

CODE {E&M} SELECTION4

4 CPT Codes, descriptions, and other data only are copyright 2004 American Medical Association {or such other data of publication of CPT}. All Right Reserved


There are four categories of history; problem focused, expanded problem focused,

detailed, and comprehensive. Each category must have a chief complaint accurately

recorded, as well as a selected number of the following components of the history of

present illness, {HPI}, the components of the HPI;

• Location • Quality • Severity • Timing • Duration • Context • Modifying factors • Associated signs and symptoms

A review of systems, {ROS}, is also taken into consideration. The patient’s positive or

negative responses in regard to the system related problem should be documented. An

extended ROS requires an inquiry to the system directly related to the problem and a

limited inquiry into additional systems.

Samples of systems;

• Constitutional • Eyes • ENT • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary • Neurological • Psychiatric • Endocrine • Hematologic/Lymphatic • Allergic/Immunologic


Also taken into consideration is the past family and/or social history {PFSH}.

Past history {the patient’s past experience with illness, operations, injuries, and

treatments}

Family history {a review of medical events in the patient’s family, including

diseases which may be hereditary or place the patient at risk}

Social history {an age appropriate review of past and current activities}

A pertinent PFSH is a review of the history area{s} directly related to the problem{s}

identified in the HPI.

A complete PFSH is a review of two or all three history area{s}.

DETERMINING EXAMINATION LEVEL

Problem focused - one system

Expanded Problem Focused - affected area and additional systems up to seven

Detailed - seven or eight systems

Comprehensive - eight or more systems

{Most common examination levels in chiropractic practice; problem focused and

expanded problem focused}

COMPLEXITY OF DECISION MAKING

Two of the three elements must be met or exceeded;


# of Dx/Mgmt. Options Complexity of Data Complication

Straightforward Minimal Minimal or none Minimal

Low Complexity Limited Limited Low

Moderate Complexity Multiple Moderate Moderate

High Complexity Extensive Extensive High

E&M CODES

Evaluation and management codes are the key to tracking patient’s evaluation and

management in regard to examination procedures, diagnostic techniques, and therapeutic

avenues and services pursued. More importantly, these codes give you a reference to the

type of service to be rendered to the patient, as well as the anticipated timeline of the

therapeutic intervention.

The following is a description of evaluation and management CPT codes.

E&M NEW PATIENT

99201 – problem focused; 10 mins.

99202 – expanded problem; 20 mins.

99203 – detailed; 30 mins.

99204 – comprehensive; 45 mins.



ESTABLISHED PATIENT

99211 – presence of a physician is not required

For the following codes at least 2 of the 3 components must be present, {i.e. degree of

history, examination, and decision making}

99212 – problem focused; 10 mins.

99213 – expanded problem; 15 mins.

99214 – detailed; 25 mins.


THERAPEUTIC PROCEDURES

CMT REGIONS

98940 1-2

98941 3-4

98942 5

98943 {extra spinal} 1 or more


MEDICAL NECESSITY

The documentation, in fact, addresses a paramount issue in the healthcare world, the

documenting of medical necessity, which can be extrapolated into what is considered,

“reasonable and necessary”. This term, while being all-important and having common

core components, does not have a universal definition.

THERAPEUTIC NECESSITY:5 exists in the presence of an impairment,

{illness/injury}, evidenced by recognized signs and symptoms, and likely to respond

favorably to the treatment/care planned.

Universally excepted components of medical necessity are;

1. The services of the healthcare provider rendered and diagnostic testing was

necessary to arrive at a diagnosis to establish care.

2. The level of services provided is consistent and proportional to the diagnosis and

can be additionally supported by objective findings.

3. The therapeutic course of care was delivered in guidelines acceptable to a

particular professional discipline and anticipated to provide a positive therapeutic

outcome.

The timeline of a course of care ideally leads to maximum medical improvement.

MAXIMUM MEDICAL IMPROVEMENT

5 Guidelines for Chiropractic Quality Assurance and Practice Parameters; Published 1993


{MAXIMUM THERAPEUTIC BENEFIT}6

Maximum Medical or Chiropractic Improvement; return to pre-injury/illness status or

failure to improve beyond a certain level of symptomatology or disability, whatever the

treatment/care approach.

When no additional care and treatment will in all medical probability make the

patient substantially better than they are at the present time.

When the care and treatment is no longer a curative and therapeutic value. At this

point the care is then palliative.

CURATIVE AND THERAPEUTIC CARE7

Treatment/care dynamics-manual procedures

Threshold - the minimum rate and magnitude of joint load needed to bring about a

change

Dosage – the frequency of care necessary and sufficient to maintain effects while healing

occurs

Duration – the minimum treatment/care interval to obtain a stable response

6 Guidelines for Chiropractic Quality Assurance and Practice Parameters; published 1993 7 Guidelines for Chiropractic Quality Assurance and Practice Parameters; published 1993


Combination – the potentiation or competition of response by simultaneous

treatment/care applications

The treatment necessary to establish a stationary status of the patient at maximum

therapeutic benefit

o Curative care must demonstrate improvement

o Increased ROM and function

o Decreasing subjective and objective findings

PALLIATIVE AND SUPPORTIVE8

Treatment/care for patients having reached maximum therapeutic benefit, in whom

periodic trials of therapeutic withdrawal fail to sustain previous therapeutic gains that

would otherwise progressively deteriorate. Supportive care follows appropriate

application of active and passive care including lifestyle modifications. It is appropriate

when rehabilitative and/or functional restorative and alternative care options, including

home based self care and lifestyle medications, have been considered and attempted.

Supportive care may be inappropriate when it interferes with other appropriate primary

care, or when the risk of supportive care outweighs its benefits, {i.e. physician

dependence, somatization, illness behavior or secondary gain}.

8 Guidelines for Chiropractic Quality Assurance and Practice Parameters; published 1993


When a patient after a therapeutic withdrawal resumes therapeutic intervention

and there is no objective, even interim, improvement but rather a sustained plateau

of the patient’s condition, then the care would be maintenance.

PREVENTATIVE/MAINTENANCE CARE:9

Care given to reduce the incidence or prevalence of illness, impairment, and risk factors,

and to promote optimal function.

Active care10 is when the therapeutic course of care is shifted to patient participation and

responsibility, and especially into the home active care programs compliance.

Passive care11 is the intervention of a caregiver who applies a treatment, therapeutic

course of care which may include singular or a combination of modalities and procedures

to a patient.

The model of care today is being driven toward evidence-based practice.12 Evidence-

based clinical practice is defined as “the conscientious, explicit, and judicious use of the

current best evidence in making decisions about the care of individual patients…{it} is

not restricted to randomized trials and meta-analyses. It involves tracking down the best

external evidence with which to answer our clinical questions.”

9 Guidelines for Chiropractic Assurance and Practice Parameters; published 1993 10 Guidelines for Chiropractic Assurance and Practice Parameters; published 1993 11 Guidelines for Chiropractic Assurance and Practice Parameters; published 1993 12 Clinical Practice Guidelines; Number 1; Vertebral Subluxation in Chiropractic Practice 1998


Outcome studies; outcome studies track the ongoing therapeutic intervention, attaining

anticipated treatment goals. Based on the information obtained the course of therapeutic

intervention can be modified or deleted or referral to another discipline if necessary in an

attempt to obtain the best reasonable therapeutic outcome.

Some of the common outcome studies; the modified Oswestry Neck Pain and Lower

Back Pain Disability Questionnaire, the Neck Disability Index, Lower Back and

Disability Questionnaire, {Roland Morris}.

IMPAIRMENT

There can be many different scenarios at the conclusion of care. Although a resolution

outcome is obviously the conclusion of care of choice, there are undoubtedly conclusions

of less than a favorable therapeutic outcome resulting in impairment or disability.

Impairment is assessed by a medical means; therefore, is a medical issue, disability is an

administrative issue. Healthcare providers address impairment issues and the

administrative profession, {i.e. Administrative Law Judges}, address disability issues.

However, throughout the United States it is common for the medical/legal system to

ask the healthcare professional to assess disability to a reasonable degree of their

professional certainty.


The World Health Organization, {WHO}, defines impairment as, “any loss of

abnormality of psychological, physiological, or anatomical structure or function”. From

the AMA guides impairments are defined as, “conditions that interfere with individuals

activities of daily living”.

An impairment impacts as individual’s health; it is a healthcare issue and there is an

abnormal function or deviation from the baseline in an organ system. After a therapeutic

trial of care, with a consideration of a timeline of healing and recovery, a plateau has

been achieved; therefore, the impairment becomes of a permanent nature.

DISABILITY

The World Health Organization, {WHO}, defines disability as, “any restriction or lack,

{resulting from an impairment}, with the ability to perform an activity in the manner

within the range considered normal for a human being”. AMA guides define disability

as, “an alteration of an individual’s capacity to meet personal, social, or occupational

demands, or statutory or regulatory requirements because of impairment”.

HANDICAP

The AMA guide describes a handicap as, “when an impairment is associated with an

obstacle to useful activity, a handicap may exist. An impaired individual is handicapped

if there are obstacles accomplishing life’s basic activities that can be overcome only by

compensating in some way for the effects of the impairment”.


To deal with a handicap an individual usually requires a form of durable medical

equipment, {DME}, {i.e. walkers, canes, wheelchair, hearing aides, etc.}. Many

handicaps are temporary during a recovery, rehabilitation phase of care.

IMPAIRMENT

Impairment, {AMA guide}, “is the loss of, loss of use of, or derangement of any body

part, system, or function.” Permanent impairment has become static with or without

medication treatment, is not likely to remit despite medical treatment of the impairing

condition.

PERMANENT DISABILITY

According to the AMA guide permanent disability takes into consideration other issues

than medical. Permanent disability exists when an individual’s ability to participate in

gainful employment/activity is decreased or nonexistent because of impairment. A

permanent disability is not a stand-alone issue; there may be other contributing factors.

When a condition is considered to be permanent there is no anticipation of any significant

change in the future.

TREATMENT GOALS


Once medical necessity and a care plan have been established, the therapeutic

intervention plan should be constructed to include both short term and long term goals.

This is dependent on the patient’s classification on presentation, {i.e. acute, subacute,

chronic, exacerbation, remission}.

Impacting the patient’s presenting complaint is comorbidity. Comorbidity continues to

be a troublesome issue with an alarmingly increasing frequency in the general population,

{i.e. obesity, elevated cholesterol levels, acid reflux, {GERD}, Type I or Type II

Diabetes, etc.}. It is not unusual to find in the file appropriate consultations or referrals

to other healthcare specialists or disciplines in regard to this issue. Regardless of the

patient’s presenting complaints and past history with comorbidity; both short and long

term goals should be realistic for a progressive positive outcome, which can be

realistically anticipated.

Treatment goals should include the type of treatment and frequency to best decrease the

patient’s symptomatology, increase function so he/she may participate in his/her

activities of daily life or ergonomics. These similar indicators are also necessary for the

patient to attain a pre-accident status.

There is a movement in healthcare, especially in chronic conditions to involve and

educate not only the patient but also the family members. This team approach gives the

immediate impacted family an appreciation of the patient’s condition, the type and

frequency of care needed, the probable symptomatology and potential cycle of


exacerbations and remissions. There is a movement in the healthcare industry to, when

possible, to reduce dependency of a patient on a healthcare provider. This will shift

many passive treatments to a more active form, having the patient engage in self help

rehabilitative programs; home stretching, exercise to increase strength and endurance of

the involved musculature, life style modifications, {dietary regulations, weight loss,

cessation of smoking}. When appropriate the patient will have a proportionate

responsibility to restore their health to what degree is possible and to maintain and

stabilize their condition.

MEDICARE ELIGIBILITY

• Largest medical program in the United States

• Individuals or spouses of individuals are eligible

o Reach 65 years of age

o US resident or permanent legal resident for at least 5 years

o Have paid into Social Security for 10 years

Eligibility prior to age 65 if the following criteria are met

o End stage renal disease

o Disability for 24 months

OIG REPORT


The office of the Inspector General in June 2005 published the chiropractic services in

the Medicare program of Patient Vulnerability Analysis report and a follow-up report in

May 2009; Inappropriate Medicare Payments For Chiropractic services. The reports are

critical of chiropractic documentation and highlights areas of deficiencies and absence

of information that is required by the Medicare benefit policy manual. However, there

was some improvement in the May 2009 follow-up report, the chiropractic profession

still has many documentation issues in the Medicare system to be addressed and

improved upon.

Suggested web site for further information: http://oig.hhs.gov

On a positive note, on June 16, 2009, a report was published to congress on the

evaluation of the Demonstration of Coverage of Chiropractic Services Under Medicare.

The Medicare Demonstration project consisted of selected regions in the country where

chiropractic coverage was expanded to include a broad range of numerous

musculoskeletal diagnoses involving the spine, extremities, neurological system, and a

broad range of services which included extra-spinal manipulation, modalities, E&M

visits, ordering diagnostic testing such as blood, as well as radiographic plain films and

imaging studies. With the exception of the Chicago region, the report was positive in

regard to the efficacy of the chiropractic services provided and patient satisfaction.

NATIONAL GOVERNMENT SERVICES {NGS}

The Centers for Medicare/Medicaid Services, {CMS}, announced on March 18, 2008

award of the contract for Part A and Part B Medicare fee for service claims in Jurisdiction

13, {which includes the states of Connecticut and New York}, to National Government

Services, {NGS}. NGS is one of the largest Medicare contractors in the country, taking

over 280,000 providers and suppliers and 22.5 million people in 26 states and five US

territories.

http://oig.hhs.gov/


Please contact CMS for your regional Medicare contractor.

Here are some important e-mail addresses in regard to National Government Services

General information – www.NGSMedicare.com

Monthly Medical Review

www.NGSMedicare.com/ngsmedicare/PartB/NewsandPublications/MedicareMonthlyRe

view/IndexMedMonRev

LCD Policy search page – www.cms.hhs.gov/mcd/results_idsearch.asp

In ID search box put L28144

Click on any Part B chiropractic service for LCD policy

EDI enrollment

www.NGSMedicare.com/ngsmedicare/PartB/Resources/Forms/IndexFormsPartB.aspx

MEDICARE PROVIDER ENROLLMENT, CHAIN AND

OWNERSHIP SYSTEM {PECOS}

You should submit and/or update a record in the PECOS system, if you have not already

done so. It is imperative that the necessary enrollment information is in the PECOS

http://www.ngsmedicare.com/

http://www.ngsmedicare.com/ngsmedicare/PartB/NewsandPublications/MedicareMonthlyReview/IndexMedMonRev

http://www.ngsmedicare.com/ngsmedicare/PartB/NewsandPublications/MedicareMonthlyReview/IndexMedMonRev

http://www.cms.hhs.gov/mcd/results_idsearch.asp

http://www.ngsmedicare.com/ngsmedicare/PartB/Resources/Forms/IndexFormsPartB.aspx


system so that you maintain your opportunity for Medicare future initiatives and

incentives. You may not have enrollment in PECOS if your enrollment in Medicare was

prior to the initiation of PECOS approximately 6 years ago. PECOS enrollment is

especially important in respect to incentive payments for Medicare in regard to certified

electronic health records.

For more information on the American Recovery and Reinvestment Act of 2009,

{HITECH}, visit http://www.cms.gov/Recovery/11_HealthIT.asp

PECOS is internet based, you would complete and send your own application to your

local Medicare carrier or A/B MAC, {contractor}. The application process requires your

NPI, you must create a user ID and password in the National Plan and Provider

Enumeration System, {NPPES}. A NPPES user ID and password is required to access

internet based PECOS. If you have never created a NPPES user ID and password or

cannot remember them contact http://www.cms.gov/MedicareProviderSupEnroll

The enrollment applications are available from the CMS forms page on the CMS website

http://www.cms.gov/cmsforms/cmsforms/list.asp

The enrollment applications are CMS-855I and/or CMS-855R. Mail the application and

any required additional supplemental documentation to the Medicare carrier or A/B

MAC.

Some additional informative websites; CMS Proposed Rule for meaningful use of

certified electronic health records

http://edocket.access.gpo.gov/2010/pdf/E9-31217.pdf

http://www.cms.gov/Recovery/11_HealthIT.asp

The Medicare Learning Network Catalog detailing provider responsibilities in the

Medicare program per the enrollment process.


http://www.cms.gov/MedicareProviderSupEnroll

http://www.cms.gov/cmsforms/cmsforms/list.asp

http://edocket.access.gpo.gov/2010/pdf/E9-31217.pdf



http://www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf

RECOVERY AUDIT CONTRACTORS (RAC)

.

From 2005 to 2008 The Centers for Medicare and Medicaid conducted a program named

the Demonstration on the Use of Recovery Audit Contractors, {RAC}, to identify over

and under payment to all types of providers. The states involved in this pilot program

were New York, California, and Florida.

After CMS paid the contractor and additional overhead expenses; the result was CMSs

net return of $373 for every $1 spent on the audit process. CMS plans by the end of 2010

to make this program permanent and to extend to all 50 states based on its successful

outcome.

Please note that if you have a cash practice and a patient is given a receipt for your

services rendered and the patient self submits to an insurance carrier, that carrier has the

right to audit your documentation to determine if the services provided were medically

necessary based on their local coverage determination policy and if not can request a

refund from the provider.

http://www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf


Considering that claims generated presently will be eligible for potential RAC review

strategies to ensure appropriate documentation NOW are paramount.

MEDICARE LOCAL COVERAGE DETERMINATION {LCD}

The following is from the NGS Jurisdiction 13 LCD (New York, Connecticut). Although

most Medicare LCD’s are attempting to coordinate nationwide; in other states check with

the regional CMS office for the LCD.

1. Spine or spinal adjustments by manual means

2. Spine or spinal manipulation

3. Manual adjustment

4. Vertebral manipulation or adjustment

The above define manipulative services rendered must have a direct therapeutic

relationship to the patient’s condition and provide reasonable expectation of

recovery or improvement of function.

Axial spine aches, strains, sprains, nerve pains, and functional mechanical disabilities of

the spine are considered to be medically and necessary therapeutic grounds for

chiropractic manipulative treatment. Manual devices, {those devices that are hand held

with the thrust of the force of the device being controlled manually}, may be used by the

chiropractor performing manual manipulation of the spine; however, no additional

payment is allowed for the use of the device or for the device itself. The same or


different providers may bill only single manipulation, {98940, 98941, or 98942}, on any

one date of service.

LOCATION OF CHIROPRACTIC SERVICES RENDERED

Chiropractic services can be rendered in a variety of locations. The following is a list of

locations and their appropriate number of which is to be inserted in box B.

Chiropractic services may be performed in the office {11}, home {12}, assisted living

facility {13}, group home {14}, inpatient hospital {21}, outpatient hospital {22},

emergency room {23}, nursing facility for patient in a Part A stay {31}, nursing facility

for patient no longer in a Part A stay {32}, custodial care facility {33}, independent clinic

{49}, comprehensive outpatient rehabilitation facility {62}, and state and local public

health clinic {71}.

ABN {ADVANCE BENEFICIARY NOTICE}


As of March 1, 2009 the Advance Beneficiary Notice of Noncoverage {CMS-R-131}, is

to be used. The prior ABN notice, as well as the NEMB {Notice of Exclusion from

Medicare Benefits}, have sunsetted.

The ABN informs the patient that Medicare will most probably not pay for certain

services being performed. The patient has the option to either accept or reject these

services. The ABN is signed prior to the service rendered, bundled services are not

acceptable. Each ABN is specific for DOS and fee.


MODIFIERS

It should be noted that if a modifier is attached to a code it is noted that something different

occurred at that patient encounter but the event that occurred did not rise to the level to

inherently change the code.

GY

The GY modifier is used when an item or service{s}, is statutory excluded and does not

fulfill a definition of any Medicare benefit. The GY modifier does not need to be

accompanied with an ABN. The GY modifier will be used when you are of the opinion

that an item will likely be denied because it is not a Medicare benefit, you are submitting a

claim to obtain a Medicare denial for the secondary payor and the beneficiary who may be

liable for the charges.

GA

The GA modifier, “waiver of liability on file”. When you are of the opinion that a service

rendered will be expected to be denied as not reasonable or necessary and an ABN was

provided to the patient and signed. A GA modifier documents that the patient has signed

an ABN. NOTE: The GA modifier is used on assigned claims, even in the situation where

the beneficiary refused to sign the ABN. In this scenario have the refusal of the beneficiary

to sign the ABN witnessed. The most common use of the GA modifier is when you

anticipate Medicare denial for services rendered due to treatment exceeding frequent

parameters. Noted billing patterns where the GA modifier is used without the supporting

ABN may be construed as abusive billing practices.


GZ

The GZ modifier is utilized when an item or service is expected to be denied as not

reasonable and necessary but there is no signed ABN on file. The GZ modifier is never

appropriate to use if you anticipate Medicare to pay for the services rendered. The use of

the GZ modifier is not mandated; however, it is suggested when a provider provides a

service and forwards a claim to Medicare and the ABN was not signed. If a patient

refuses to sign an ABN this refusal should be documented by a witness, {i.e. office staff},

and noted in the patient record. This reduces the inference of fraudulent activity for

providing unnecessary medical services.

GX

A new modifier GX has been created with a definition of notice of liability issued

voluntary under payer policy. This should be used to report when a voluntary ABN was

issued for a service. The GX modifier is used to provide beneficiaries with voluntary

notice of liability regarding services excluded from Medicare coverage by statute. The

GX modifier must be submitted with noncovered charges only, {i.e.exams, modalities, x-

ray}.


MEDICARE FACTS

On March 3, 2008 chiropractors are no longer required to bill for services that are

considered to be maintenance. Medicare will not be billed; the beneficiary will sign a

ABN option 2. If you believe that Medicare may still pay for services; are able to

demonstrate that the patient is getting functionally better, the beneficiary will sign the

ABN, option 1; modifier AT and GA will be used.

In box 23d of the CMS form you can place up to 4 modifiers. However, the carrier/MAC

is required only to process the first two modifiers and they must be the most necessary

relevant to their care to ensure reimbursement.

CMS allows doctors and suppliers to charge Medicare beneficiaries for missed

appointments; however, the Medicare beneficiary must also be charged equal amounts for

missed appointments. This is a missed business opportunity; therefore, the appointment

charge is directly billed to the patient and not to CMS as no services were provided.

National policy {Pub 100-2, Medicare Benefit Policy, Chapter 15, Section 240}, limits

the coverage of chiropractic services to the “hands on” manual manipulation of the spine

for symptomatology associated with spinal subluxation. Accordingly, CPT code 98943,

CMT, extraspinal, one or more regions, is not a Medicare benefit.


Some chiropractors have been identified as using an “intensive care” concept of

treatment. Under this approach, multiple daily visits {as many as four or five in a single

day} are given in the office or clinic and so-called room or ward fees are charged, since

the patient is confined to bed usually for the day. The room or ward fees are not covered.

If using a paper HCFA form and you have diagnoses exceeding the 4 spaces available,

list the diagnoses in order of chief complaint, secondary, etc. The diagnoses that do not

fit on the HCFA form are recorded in the patient’s records. Note, if you use Medicare

Claims Express, {MCE}, software there are spaces for 8 diagnoses.

A chiropractor is prohibited from ordering physical or occupational therapy. Other than

the chiropractic spinal adjustment, no other therapeutic or diagnostic services furnished

by a chiropractor is covered, {i.e. laboratory tests, E&M services, modalities, supplies,

orthopedic devices, nutritional supplements}.

Be aware that there is also another system of coding called HCPCS, {Healthcare

Common Procedure Coding Systems}, used by Medicare, which addresses status of

codes and any addendums. Basically HCPCS is a guide to Medicare’s national Level II

codes used for DME, drugs, medical supplies, etc. and indicates whether a code was

added or changed. On occasion this may effect chiropractic practice, you can

periodically check any code changes that may pertain to you through your respective

regional CMS website.


According to CMS providers providing beneficiary gifts which exceed $10 at one time,

cumulative $500 in 1 year can be liable for CMP civil monetary penalties.

MEDICARE DOCUMENTATION

The following information must be documented in the patient’s medical record for the

Initial Visit, whether the subluxation is demonstrated by x-ray or by physical

examination.

HISTORY

o Chief complaint including the symptoms present that caused the patient to seek

chiropractic treatment

o Family history if relevant

o Past health history including; general health statement, prior illness{es}, surgical

history, prior injuries or trauma, past hospitalizations {as appropriate},

medications.

DESCRIPTION OF PRESENT ILLNESS INCLUDING

o Mechanism of trauma

o Quality and character of problem/symptoms

o Onset, duration, intensity, frequency, location and radiation of symptoms

o Aggravating or relieving factors

o Prior interventions, treatments, medications, secondary complaints

o Symptoms causing patient to seek treatment


The subluxation must be causal, i.e. the symptoms must be related to the level of the

subluxation that has been cited. A statement on a claim that there is “pain” is

insufficient. The location of pain must be described and whether the particular vertebra

listed is capable of producing pain in the area determined.

Evaluation of musculoskeletal/nervous system through physical examination

Diagnosis; the primary diagnosis must be subluxation, and must indicate the level

of the subluxation. The secondary diagnosis, must reflect the

neuromusculoskeletal condition necessitating the treatment.

Treatment plan; the treatment plan should include the following

Recommended level of care {duration and frequency of visits}

Specific treatment goals

Objective measures to evaluate treatment effectiveness

Date of initial treatment or date of exacerbation

THE FOLLOWING DOCUMENTATION IS REQUIRED FOR SUBSEQUENT

VISITS

History including

Review of chief complaint

Changes since last visit

System review if relevant

Physical examination including

Documentation of treatment given on day of visit

Exam of area of spine involved in diagnosis

Assessment of change in patient condition since last visit

Evaluation of treatment effectiveness


Important: Documentation must be legible and made available to Medicare

upon request.

DOCUMENTING SUBLUXATION VIA X-RAY

A radiologist or an authorized ordering practitioner may accept referral for an x-ray

by doctors of chiropractic; however, the attending chiropractor may not order the x-

ray. The authorized practitioner is required to enter his/her name in item 17 of the

CMS 1500 form, as well as his/her UPIN number in item 17A of the CMA 1500

form, or the electronic equivalent as the ordering physician.

In regard to diagnostic imaging any dates of service prior to January 1, 2000, a

documented x-ray or existing MRI or CT Scan must be taken at a time, “reasonably

proximate”, according to Medicare to the initial of the course of treatment. Care is

considered to reasonably proximate if the imaging was taken no more than 12

months prior to or 3 months following the initiation of the course of treatment.

There is a provision that an imaging older than the above boundaries may be

considered adequate if it is documented in the patient’s health record that the

condition lasted greater than 12 month and reasonable objective findings that the

condition is chronic

NOTE: Medicare does not except video fluoroscopy as a method for

the diagnosis of subluxation through imaging.


When the Doctor of Chiropractic reviews the patient’s imaging it should be

documented into the patient’s file; especially recording the level of subluxation. In

office films should be labeled with the facility, {name of doctor}, in which they were

taken, the patient’s name and date, and a right or left marker. If the imaging was

performed in a facility other than a chiropractor’s office a written report of the

reviewing physician must be included in the patient’s record.

Section 2250 of the Medicare Carrier’s Manual stipulates that judgments about the

reasonableness of chiropractic treatment must be based on the application of

chiropractic principles. Therefore, the Centers for Medicare and Medicaid has

determined that if the opinions of a radiologist and a chiropractor conflict as to the

existence of a subluxation {for a chiropractic patient}, then the opinion of the

chiropractor takes precedence.

For dates of service after January 1, 2000, an x-ray is not required to demonstrate the

subluxation. The subluxation may be established by physical examination via the

PART formula.


DOCUMENTING SUBLUXATION

VIA PART

The P.A.R.T. evaluation process is recommended as the examination alternative to

the previously mandated demonstration of subluxation by x-ray/MRI/CT for services.

The acronym P.A.R.T. identifies diagnostic criteria for spinal dysfunction

{subluxation}. For dates of service after January 1, 2000, an x-ray is not required to

demonstrate the subluxation. The subluxation may be established by physical

examination via the P.A.R.T. formula.

{P} PAIN

Pain may be evaluated on observation, percussion, palpation, orthopedic testing, etc.

Commonly pain is evaluated by visual analog scales, pain questionnaires, etc. A

standard in the healthcare industry is the rating of a pain scale of 0-10 with the patient

rating his symptomatology from 0 being none to 10 being excruciating, {worse ever

experienced}.

{A} ASYMMETRY/ALIGNMENT

Asymmetry at a segmental or sectional level is commonly arrived at through static or

motion palpatory methods and/or diagnostic imaging {subluxation level}.


{R} RANGE OF MOTION ABNORMALITY

ROM in regard to hyper or hypo mobility would be evaluated by motion palpation,

diagnostic imaging, ROM, observation, etc.

{T} TISSUE, TONE, TEXTURE ABNORMALITY

Tissue and tone/texture abnormality most commonly is evaluated through palpation

and strength testing.

TO ESTABLISH A SUBLUXATION DIAGNOSIS VIA P.A.R.T.

TWO OF THE FOUR COMPONENTS OF P.AR.T. MUST BE

DOCUMENTED, WITH ONE OF THOSE TWO COMPONENTS

BEING ASYMMETRY AND/OR ROM

MEDICARE DIAGNOSES

PRIMARY AND SECONDARY DIAGNOSES

{CENTERS FOR MEDICARE/MEDICAID SERVICES}


Accompanying the primary diagnosis, a secondary diagnosis must be recorded

which supports medical necessity. It is important to note that Medicare has

established secondary diagnoses, which are listed in their local medical review

policy.

It would behoove you to review these secondary diagnoses, any other secondary

diagnoses will result in the claim being denied as not medically necessary.

Truncated diagnoses are not acceptable, it is the provider’s responsibility to avoid

truncated diagnoses and select the highest code of specificity from the available ICD-9-

CM codes.

SECONDARY ICD-9-CM CODES

Remember, both the primary and secondary diagnoses, as well as applicable

tertiary diagnosis, must be listed on each claim to avoid denial.

NOTE: Use of any ICD-9-CM code, other than what is listed in the LCD will be

denied.

CPT codes routinely utilized in Medicare, in regard to chiropractic manipulative

treatment are;

98940 1-2 Regions

98941 3-4 Regions

98942 5 Regions


It is important to remember that regardless of what code you use to establish a

subluxation, either by x-ray or by the PART formula, the components required in

subsequent visits must document that the subluxation criteria is fulfilled for every region

reported to be adjusted. Failure to do this would result in down coding of your

reported CPT level of service.

Relative contraindications to a dynamic thrust, {the spinal adjustment is not ruled out but

risk should be discussed with the patient}, risk management issue; obtain an informed

consent.

• Joint hypermobility

• Bone demineralization

• Bone tumors

• Bleeding disorders, anticoagulant therapy

• Radiculopathy with progressive neurological deficit

Absolute contraindications

• Acute arthropathies, fractures, dislocations, healed fractures or dislocations with

signs of instability

• Vertebral column malignancies, infections of bones and joints, signs and

symptoms of myelopathy or cauda equine syndrome

• Vertebrobasilar insufficiency, significant major artery aneurysm near

manipulation site


Generally the local medical review policy, in regard to Medicare, defines subluxation as

intervertebral motor segment in which alignment movement integrity and/or

physiological function of the spine are altered although contact between intervertebral

joint surfaces remain intact.

Classification of subluxation for Medical falls into one of three categories.

Acute Subluxation: most commonly a new injury identified through x-ray or

physical exam, in which the chiropractic care is expected to be an improvement in

arrest retardation of the patient’s condition.

Chronic Subluxation: a chronic condition is not expected to clinically resolve,

but where continued therapy can be expected to result in some function

improvement. **Once functional status has remained stable for a given

condition, the condition would then be considered maintenance therapy and

not covered. Nerve root problems; such as a nerve entrapment were the causality

is an acute or chronic subluxation. Medicare considers manipulation/adjustment

of the spine be delivered by a manual means.

**When treating chronic subluxation your daily office notes should record the

increase in functional status of the patient, even if it is a short interval of

improvement, {i.e. patient performs more activities of daily life, increased ROM,

able to engage in exercise}. In accordance with the Centers for Medicare and

Medicaid Services {CMS} “Medicare Benefit Policy Manual” when further

improvement cannot reasonably be expected from continuing care, the services are


considered maintenance therapy, which is not medically necessary and therefore not

payable under Medicare.

Denial: the most common reasons for denial from Medicare in regard to your

services; the information does not support the need for the amount of visits, the

level of service rendered, the frequency of the service or need for care.

MEDICARE APPEALS

The Medicare appeals process is five levels; regardless of what level you wish to pursue,

the request must be filed within 6 months of the date of notice of a subsequent appeal,

hearing, ALG’s, administrative law judge’s decision, and appeals council determination.

Level I – telephone appeal

Level II – hearing request; the amount in controversy must be $100 or more

Level III – administrative law judge hearing; the amount in controversy must

be $500 or more

Level IV – appeals council hearing; the amount in controversy must be $500 or

more

Level V – judicial review; amount in controversy must be $1000 or more


At the involved levels II thru V may combine claims that were reviewed within the past 6

months in order to meet the amount threshold of that particular level. All the appeals

level requests can be submitted to.

National Government Services Inc.

Appeals

PO Box 711

Indianapolis, IN 46207-7111

Other than NGS, CONTACT YOUR LOCAL MEDICARE CONTRACTOR FOR

APPEALS CONTACT INFORMATION.

The majority of chiropractic appeals can be handled through the redetermination {Level

I} and reconsideration {Level II}. Level I is reviewed again through the carrier and Level

II through a QIC, {Qualified Independent Contractor}. An example of the forms for

Level I and II appeal are as follows, these forms can be obtained through the CMS

website.


Website addresses:

Center for Medicare/Medicaid Services CMS: www.cms.hhs.gov

Many Medicare patients, to occupy their time, supplement their income by returning to

part-time work. If a Medicare patient has a causal related work injury the workers’

compensation carrier would be liable for the consequential healthcare cost specific to that

event.

Many individuals today work full-time, well past the Medicare age eligibility and carry

an indemnity plan, {i.e. BCBS}, through their employer, as well as have Medicare.

Therefore; if a patient at age 70 were working full-time with health insurance benefits

through his employer, the employment health insurance would be primary and Medicare

secondary.

http://www.cms.hhs.gov/


TREATMENT OF FAMILY MEMBERS

CMS bars and requires the reimbursement for services rendered by a related physician or

supplier, even if an unrelated individual, partnership, or professional corporation submits

the claim.

The following are included in the definition of immediate relative

Husband and wife

Natural or adoptive parent, sibling

Stepparent, stepchild, stepbrother, or stepsister

Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law,

sister-in-law

Grandparent or grandchild

Spouse of grandparent or grandchild


PATIENT INTERACTION SCENARIO {1}

NOTE: FEES ARE EXAMPLES ONLY

A Medicare eligible patient, a male 72 years of age, is in good health, exercises regularly

and has a preventative mindset. He finds chiropractic care beneficial for his health and

well being and presents on a scheduled basis, approximately 1 time monthly for a full

spine adjustment; a maintenance care pattern, which you have discussed with the patient

and he understands that Medicare does not pay for chiropractic maintenance care.

ACTION STEP

Have the patient sign an ABN; option 2, Medicare is not billed.



A new patient presents to the office, the Medicare diagnoses are; primary 739.1 and

secondary 721.0. In this particular case you are treating one region, CPT 98940, as active

treatment so you would utilize CPT 98940 with the AT modifier. Also on the initial visit

you performed a limited new patient examination; CPT 99202, performed AP and lateral

plain film x-rays in your office; CPT 72040 and applied ultrasound as an adjunct to the

chiropractic spinal adjustment CPT 97035. Based on the local coverage determination,

{LCD}, the initial new patient exam CPT 99202, the plain films of the cervical spine

CPT 72040, and the ultrasound CPT 97035 are non-covered services.

ACTION STEP

The patient may have secondary coverage for these non-covered services, so for these

services you will code them using a GY and GX modifier. This will ensure that the

proper denial will be explained on the explanation of benefits, {EOB}, from Medicare.

The patient will sign an ABN; option 1



The current treatment of this patient is protracted due to spinal degenerative change and

significant co morbidity. The patient’s diagnosis is 739.3, 724.2, and 722.52. The

treatments to date have numbered 30, you believe that you have the appropriate

documentation for medical necessity to continue care but you are also aware that you are

reaching the upper parameters of care frequency and additional care has the potential to

be denied.

ACTION STEP

Discuss the situation with the patient, have the patient sign an ABN, option 1 and add a

GA modifier to the CPT code; i.e. 98940 AT, GA.



Taking into consideration the same patient interaction scenario; however, you did not

obtain a waiver liability from the beneficiary. Therefore; you would code the date of

service CPT 98940 AT, GZ. If the patient refused to sign the ABN, have the refusal

witnessed and documented in the patient’s record.


UTILIZATION GUIDELINE

Acute, uncomplicated pain up 3 times a week for 2 weeks, 1-3 times a week for 2 weeks.

If documented improvement continuation of care up to 4 weeks at 1-2 times per week,

treatment parameter 16-30.

Chronic pain/acute complicated pain patterns; 3 times a week for 4-6 weeks, then 2 times

a week for an additional 4-6 weeks with treatment being concluded usually less than 12-

16 weeks.

Exacerbations; episodes of care exceeding one per condition will be reimbursed only

if there is an exacerbation documented in the medical records.

RED FLAGS IN RECORDKEEPING

If a correction is needed, the correction should consist of a line drawn through the

mistake and initialed. Corrections should never be erased and the use of white out

avoided. Open spaces between entries should be avoided, as there is the potential to add

or embellish documentation after a patient encounter. Notations should be avoided being

jammed into entries, as this infers that they have been put into the entry as an

afterthought. Dark colored ink is preferred and should be consistently used throughout

the day. The provider should initial typed, transcribed notes or handwritten notes.


Legibility of a note, when handwritten, is the responsibility of the provider. What is

documented in the record reflects experiences of the patient’s encounter. If an entry is

illegible then it is considered that what was illegibly recorded did not in fact take place.

There are certain findings and patterns, which can be considered to be suspicious

and would warrant monitoring.

Upcoding; when billing for a code higher than what was actually performed, {i.e.

billing for CPT 98941; 3-4 regions when CPT 98940; 1-2 regions service was

performed}.

Miscoding; coding for a procedure other than what was performed, {i.e.

performed 97010 application of modalities of one or more areas hot or cold packs

and billing for 97022 application of modalities to one or more area whirlpool}.

False time claims; billing for a time procedure that was not performed or

exaggerated, {i.e. billing for E&M 99202 when a E&M 99201 was performed}.

Unbundling; when a global fee or an agreed upon fee is billed is broken down

and charged per item.

Truncated diagnoses; insurance carriers today require diagnoses to be as specific

as possible; therefore, truncated or shortened diagnoses avoided. Diagnoses

should be now coded out to the highest level of specificity, {i.e. instead of 839.0

cervical subluxation unspecified, 839.05 cervical subluxation C5 level}


WAVING COPAYS AND DEDUCTIBLES

At any time in any part of the country economic down turns can occur. It is

commonplace in the news to hear of corporations, companies, or service industries down

sizing. Subsequently, unemployment, loss or reduction of healthcare insurance coverage,

personal illness, or tragedy could result in devastating financial hardship. During these

times ones ability to pay for healthcare services, or even to meet a deductible or

copayment is impossible. As a provider you are committed to treating the patients who

require your services, at the same time you are expected to consistently charge for your

services rendered. A strategy to address this problem is to refer to the United States

Government Published Poverty Guidelines. Internet resource; Department of Health in

Human Services www.aspe.hhs.gov/poverty/05poverty.shtml.

FRAUD IN HEALTHCARE

The definition of fraud according to Encarta Dictionary;

1. Crime of cheating people; the crime of obtaining money or some other benefit by

deliberate deception

2. Somebody who deceives by pretending; somebody who deliberately deceives

people by imitation or impersonation

3. Something intended to deceive; something that is intended to deceive people – a

story that was subsequently exposed as a fraud

http://www.aspe.hhs.gov/poverty/05poverty.shtml


FRAUD FACTS

Statistics from the Center for Medicare and Medicaid Services show that Americans

spent more than $1.7 trillion on health care in 2003. Combined with the fact that industry

experts estimate that anywhere from 3% to 10% of this total is lost to health care fraud,

that would put the minimum amount spent on health care fraud at over $100 million per

day. {Taken from Employee Benefit News – September 15, 2004}

Fraud is not only making an untrue statement. It can also be committed by concealing a

material fact. Under most circumstances a provider who renders care and who knowingly

administers the care for services not medically necessary is committing a fraud.

In 1997 CAIF’s {Coalition against Insurance Fraud}, study entitled Four Faces: Why

Some Americans do – and do not – tolerate insurance fraud, reported that the public

tolerance of insurance fraud is increasing. The potential reasons listed for committing

insurance fraud include

1. To save money

2. To get expensive work done they could not afford

3. To get back at insurance companies

The reasons why people resist fraud included the sense of right and wrong and the fear of

being caught.

The Journal of the American Medical Association in 2000 reported the following, “nearly

one of three physicians say its necessary to game the health care system to provide high

quality medical care”, “more than one in three physicians say patients have asked


physicians to deceive third-party payers to help the patients obtain coverage for medical

services in the last year”, one of ten physicians have reported medical signs or symptoms

a patient did not have in order to help the patient secure coverage for needed treatment or

services in the last year.

In the journal of the American Medical Association 2000 reported the following; in

healthcare 80% is causal to provider fraud. Provider fraud routinely is categorized as

1. False claims

2. Billing claims

FALSE CLAIM EXAMPLE: You are treating a workers’ compensation case, biweekly

presentations, you bill the carrier for treatment over a 4 week period on the dates of the

2nd, 5th, 10th, 12th, 16th, 18th, 24th, and 26th. However, the patient cancelled on the 14th and

the 26th, in that regard the carrier was billed. However, no services are rendered.

The patient was diagnosed with cervicodorsal complaints, examination revealed objective

findings to the cervicodorsal spine documenting the medical necessity of treatment. The

appropriate CPT code in this clinical scenario is 98940 but the provider routinely bills

98941 for 3-4 regions, though only addressing and adjusting 2 regions of the spine.

THIS IS AN EXAMPLE OF UPCODING.

Though much is written in regard to upcoding, undercoding consistently occurs.

Undercoding is when a provided service to a patient is coded at a level of service less

than which was actually delivered. Professional services are expected to be provided

consistently in the patient population.


SCENARIOS

Take the following into consideration; a patient presents to the office historically as a

cash patient. Upon evaluating the patient you render a diagnosis of 847.0 LS Strain.

Your treatment selection is side posture adjustments with application of electrical muscle

stimulation to hypertonic lumbar musculature. Customarily you charge $40.00 for a

spinal adjustment, $20.00 per modality. The fee for this service rendered is $60.00;

however, with the prospects of the patient paying cash, a relief from filling out treatment

plans and insurance forms and waiting for reimbursement, you charge this patient $40.00

eliminating the fee and/or not recording the application of the modality.

Later in the day a patient presents with the same clinical scenario as our cash patient, the

same diagnosis is arrived at and a side posture adjustment, as well as electrical muscle

stimulation is selected and those services delivered. This patient has insurance; you face

the task of filling out a treatment plan, awaiting decision on the number of visits that

would be authorized, potential of filing subsequent treatment plans and insurance forms,

and waiting for reimbursement. This patient is charged $60.00 for the services rendered;

the modality is charged for and recorded. THIS IS AN EXAMPLE OF

DISCRIMINATORY UNDERCODING BILLING.


A Medicare patient presents for chiropractic care with a diagnosis of 1. 739.3 lumbar

subluxation, 2. 721.3 Lumbar Spondylosis w/o Myelopathy. The primary and secondary

diagnosis would indicate to Medicare that the condition requires a chronic treatment

parameter. You select a series of chiropractic spinal adjustments for the patient, as well

as ultrasound applications to address lumbo-sacral musculature involvement. The

modality is a non-covered Medicare service. The patient may have secondary coverage,

which may in part pay for the modality. Usually, the charges for the modality, in office

x-rays, or examinations would add to the out of pocket expense for the Medicare patient.

You are concerned about that any mounting of out of packet expense may discourage or

deter the Medicare patient from continuing to present for his/her chiropractic spinal

adjustments; therefore, you elect to not bill and/or report the modality service. This

decrease of lack of out of pocket expenses has the potential to influence the Medicare

patient to continue presenting for the covered Medicare service, the chiropractic spinal

adjustment. THIS IS AN EXAMPLE OF UNDERCODING BILLING.

These practices diminish all healthcare providers who maintain the standards of ethical

professional conduct. In the healthcare industry this fraudulent conduct will continue to

be aggressively monitored through pre and post audits, reviewing documentation and

seeking remedy for offenses through state licensing boards and the civil court system.


PEER REVIEW

The peer review process involves a non treating provider reviewing the provider’s

management of the case. Peer review is common in all healthcare disciplines.

Universally, the peer review process is implemented most commonly to address one or

more of the following issues;

History consistent with the mechanism of injury

Is the treatment rendered consistent with the diagnosis

Does the testing, current course of care, {imaging, laboratory} be reasonably

anticipated to be ordered based on the objective findings and mechanism of injury

In work related dates of loss, was the mechanism of the date of loss and the events

of consistent with the employee/employer

The patient presenting to multiple providers at times for the same discipline

Return to work; light duty, regular duty and/or limitations

Patient cannot return to any type of duty

Patient can return to full duty but the employer is not convinced that the patient

can return to his normal duty safely

Return to work dates are extended several times

Permanency is reported

The above issues are addressed at times with a, “file review”, and other times with a

hands on physical examination, the Independent Medical Examination or the IME.

The subject matter that you reviewed will assist you in documenting appropriate

regulatory compliance and supporting the necessity of your care. This is so you, the

Doctor of Chiropractic, can continue to provide and deliver to your patient’s the

“hands on” experience which has no peer; the chiropractic spinal adjustment.


QUESTIONS

1. Permanent disability is determined via objective findings

a. When the patient is receiving supportive care

b. When the patient is presenting for maintenance care

c. When the patient utilizes DME {i.e. crutches, cane}

d. Post therapeutic care

2. A Permanent Impairment Evaluation is an administrative issue with the evaluation

performed by a healthcare provider

a. True

b. False

3. Issues which initiate a Peer Review

a. Multiple extended return to work dates

b. Is treatment rendered consistent with diagnosis, testing, and course of care

c. Permanency reported

d. All the above


4. What statement is true

a. The notifier of the ABN must retain a copy of the notice

b. ABN required in urgent and emergency situations

c. The ABN must be delivered in advance to the beneficiary or their

representative so there is sufficient time to consider the options

d. Both A and C

5. A Medicare patient presents with an acute low back condition to an office staffed

by two DC’s. The patient presents to the office two times in one day; at 9 AM

and 3 PM respectively being seen by Dr. A at 9 AM and Dr. B at 3 PM. Services

rendered by each DC; 98940. Appropriate billing would be

a. Two HCFA forms; one for each provider billing 98940 for the same date

of service

b. One HCFA form signed by one provider billing 98940 two times on the

same date of service

c. One HCFA form signed by one provider for one 98940 for the date of

service

d. Two HCFA forms; one for each provider billing 98940 two times for the

same date of service


6. You have a cash practice and supply a receipt to your patient and your patient self

submits the charge for services to his/her insurance company. In order for your

services to be considered for reimbursement your documentation is required to

meet the insurer’s local coverage determination policy/health care policy bulletin

for necessity of care.

a. True

b. False

7. The services of a healthcare provider, diagnostic testing ordered, level of service

provided proportional to the diagnosis and supported by objective findings with

the care anticipated to produce a positive therapeutic outcome best describes

a. Therapeutic care

b. Medical necessity

c. Supportive care

d. Palliative care


8. When documenting a spinal subluxation for a Medicare patient through physical

examination via the PART formula; two of the four components must be present

with one of the two components being one of two specific components of PART.

What combination is correct

a. PT

b. C5 subluxation demonstrated by plain film cervical x-ray

c. AR, PA, AT, RT

d. TP, PT, C5 subluxation documented on cervical MRI study with

gadolinium

e. Both c and d

9. Examples of record keeping red flags

a. Upcoding, downcoding

b. Illegible handwriting, upcoding, truncated diagnosis

c. Downcoding, miscoding, inconsistent ink color

d. All the above

10. CMS utilizes what coding system to modify or add a code

a. HCPCS

b. CPT

c. ICP

d. Index Medicus


11. The most common examination levels in chiropractic practice

a. Detailed

b. Comprehensive

c. Problem Focused and Expanded Problem Focused

d. Problem Focused

12. The dosage of a therapeutic intervention is

a. Minimum rate and magnitude of joint load needed to bring about a change

b. Frequency of care necessary and sufficient to maintain effects while

healing occurs

c. Minimum treatment/care interval to obtain a stable response

d. Potentiation or competition of response by simultaneous treatment/care

application

13. A continuous disability for 24 months and/or end stage Renal Disease prior to age

65 are criteria for eligibility for Medicare

a. True

b. False


14. The following modifier has been created by CMS with the definition of a notice

of liability issued voluntary under payer policy. This modifier is used to provide

beneficiaries with voluntary notice of liability regarding services excluded from

Medicare coverage by statute

a. GA

b. GY

c. GX

d. GZ

15. Insurance carriers require diagnoses to be as specific as possible. The following

shortened diagnoses category should be avoided

a. Complex

b. Unbundled

c. Miscoded

d. Truncated

16. Someone who deceives by pretending, somebody who deliberately deceives

people by imitation or impersonation is a definition of

a. Fraud

b. Misrepresentation

c. Deception

d. Impersonation


17. The Coalition against Insurance Fraud study reports that the publics potential

reasons for committing insurance fraud

a. To save money

b. To get expensive work done they cannot afford

c. To save money and to get back at insurance companies

d. All of the above

18. The following codes are the key to tracking patient’s evaluation and management

in regard to examination procedures, diagnostic techniques, therapeutic avenues

and services pursued

a. Medicare modifiers

b. Classification of evaluation and management E/M services

c. PART formula

d. 98940

19. The majority of chiropractic Medicare appeals can be handled through

a. Level I redetermination

b. Level II reconsideration

c. Level III administration law judge

d. Both A & B


20. The Health Insurance Portability and Accountability Act, {HIPAA}, rule that

outlines electronically protected health information, {EPHI}

a. Privacy Rule

b. Security Rule

c. NPI Rule

d. Enforcement Rule

making your practice well and excell through … · understanding hipaa and documenting compliance...

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