contact info - northwestern health sciences …...1/9/2015 1 foot levelers proudly presents: dr....

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Foot Levelers Proudly Presents:

Dr. K.S.J. Murkowski

Northwestern Health Sciences UniversityDiagnosis, Documentation, Medicare compliance,

ICD 9 & ICD 10, DC Program

Contact Info:

Address: 645 St. Clair Avenue Jackson, MI 49202

Office: (517) 784-9123

Fax: (517) 784-9150

Email: [email protected]

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Know Your Zones“Knowledge is Power”

Should Attorneys, Insurance Companies, and IME’s tell you how to play the game?

Who’s game is it anyhow?

Know your “ZONES” to cover and BILL

CORRECTLY to “SCORE” (Document)

And WIN!!!

Are You Held Hostage?Do you know why business is down 31% for Chiropractors across the country? It is because the game has changed.

Are any of the following happening to you…

� Not getting the referrals from attorneys you deserve?

� Forced to deal with insurance capping and IME cutoffs?

�Angry with the way this game is sometimes played and unable to change it?

�Fed up that not enough people realize that you are the #1 expert for whiplash cases

Learn the rules and you can be the New Sheriff in town!!!!

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I think I know what the problem is…

Let’s Discuss It

The FutureThe Doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet, and in the cause and prevention of disease.

- Thomas Edison

No matter how thin you make a pancake, it still has two sides.

- Ben Veniste, Attorney Former Watergate Prosecutor

One or more vertebrae may not go out of place very much, and if they do, they are likely to produce serious complication and even death, if (they are) not properly adjusted…

- Hippocrates

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S W E A RS – Success

W – With

E – Education

A – And

R – Reason

“TURN THE MAGIC PRISM”

What is Chiropractic? P A L SP - Philosophy

A - Art

L - Legal (State Law)

S - Science

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What is DC/CA Malpractice?D - Duty

B-D – Breach of Duty

I - Injury

F – Financial Loss

L – Law (Legal – Standards of Care/Practice)

IC (6) - Informed Consent(s)

HIPPA

Chart/SOAP NOTES – 12 Office Visits – Standards of Care/Practice

Affordable Care ActAlabama: $600 per year Kentucky: 12 Visits per year New Mexico: $1500 per year West Virgina: No Limits

Alaska: 12 Visits per year Louisiana: 12 Visits per year New York: No Limit Wyoming: 15 Visits per year

Arizona: 20 Visits per year Maine: 40 Visits per year North Carolina: 30 Visits per year

Arkansas: 30 Visits per year Massachusetts: 12 Visits per year Ohio: 12 Visits per year

Connecticut: 20 Visits per year Michigan: 30 Visits per year Oklahoma: 25 Visits per year

Delaware: 30 Visits per year Mississippi: 20 Visits per year Pennsylvania: 20 Visits per year

Florida: 26 Visits per year Missouri: 26 Visits per year Rhode Island: 12 Visits per year

Georgia: 20 Visits per year Montana: $600 Per year Tennessee: 20 Visits per year

Idaho: $800 per year Nebraska: 20 Visits per year Texas: 35 Visits per year

Illinois: $1,000 per year Nevada: 12 Visits per year Vermont: 12 Visits per year

Indiana: 12 Visits per year New Hampshire: 12 Visits per year Virginia: 30 Visits per year

Kansas: No Limit New Jersey: 30 Visits per year Washington: 10 Visits per year

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Affordable Care Act2014 - Non-discrimination in health care: No health plan or insurer may discriminate against any health provider acting within the scope of that provider’s license or certification under applicable State Law.

This will ensure that insurance companies cannot unfairly exclude Doctors of Chiropractic or acupuncturists from practicing under the capacity of their training and licensure on a Federal level.

Provision is a federal protection applicable to ERISA and other plans established or regulated under the bill. Just as the HIPPA protections now apply across the board, the non-discrimination provision will be applicable to all health benefit plans both insured and self-insured.

Affordable Care Act“Sec. 2706. NON-DISCRIMINATION IN HEALTH CARE.,

“(a). PROVIDERS. – A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law.” This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.

“(b) INDIVIDUALS. – The provision of section 1558 of the Patient Protection and Affordable Care Act (relating to non-discrimination) shall apply with respect to a group health plan or health insurance issuer offering group or individual health insurance coverage.”

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Affordable Care ActAn official state legal counsel was asked the following 3 questions about the provider non-discrimination provision, section 2706, in the health reform law will impact his state’s health care reform activates:

Question 1:

If providing an essential health benefit/service is within the scope of a Chiropractic Physician’s or acupuncturists license e.g., primary care treatment of illness/injury, home health care, in patient rehab, X-rays, other imaging/diagnostics (MRI, CT, PET) wellness services/chronic disease management, smoking cessation, diabetes education, allergy testing, screening pap tests, prostrate cancer screening, pediatric service etc., can an insurer deny payment to a participating Chiropractic Physician who provided one of these essential health benefits/services based solely on that provider’s license or discipline?

ANSWER: NO

Affordable Care ActQuestion 2:

Put another way, would an isurer violate federal law if that insurer refuses to pay for an essential health benefit/service provided by a participating Chiropractic Physician or Acupuncturist when providing that service is within that provider’s scope of practice to deliver because he or she is not a medical/osteopathic physician?

ANSWER: YES

Question 3:

If a particular essential health benefit/service is within the scope of practice of a participating health care provider (e.g. Chiropractic Physicians, Naturopathic Physicians, nurse practitioners, acupuncturists, etc.) would an issuer violate Section 2706 of the PPACA federal law if an insurer refused payment for that service because the participating provider was not considered a “primary care physician/provider?”

ANSWER: YES

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Affordable Care ActRecent information from United Health Care and Optum health is they will as of 2014 pay for services within scope with no discrimination.

Additionally, the United States Office of Personnel Management found that multi-state health plans being considered for state insurance exchanges must comply with the provider non-discrimination protection provided by Section 2706 of the Patient Protection and Affordable Care Act (PPACA). This is truly remarkable and ground breaking, as it lays the foundation for 2015 when the exchanges will be implemented.

Given that in some states almost 70% of insurance enrollees are covered under ERISA (which will no be Section 2706 compliant), the two opinions above will change the access to and coverage of CHIROPRACTIC and acupuncture for millions of patients.

Fraud Definition: The intentional deception or misrepresentation that could result in unnecessary costs to health care contract/programs.

Examples:

1. Misrepresenting the service provider – Specialty

2. Misrepresenting patient service provided – Using 99204/99205 for new patients without documentation

3. Same as #3 – Using 99214/99215 on all established patients without documentation

4. Billing for substandard/unnecessary services

5. Billing for services or supplies not rendered

6. Misrepresenting the patient’s diagnosis (ICD Codes)

7. Unbundling (Exams, X-rays, Care, etc.)

8. Upcoding of regions and diagnosis (Using 98942 on all claims without necessary documentation)

9. Down Coding (Using 98940 on all claims to avoid audits) THAT HURTS ALL OF US!!!!!!!!

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Fraud10. Alteration of Claims to obtain higher payment

11. Duplicate submission of claims

12. Breach of contracts/agreements

13. Over-Utilization of health care services and rehabilitation

14. Signing blank certificates of medical necessity

15. Giving off work slips – Without documentation

16. Not sending patient back to work when ready (Monday Syndrome)

17. Advertising free services

18. Offering large gifts or cash for referrals

19. excessive referrals to one facility (Attorneys, X-rays, Testing Centers, Etc.)

20. Kickback – pay offs for referrals

21. Not having full disclosure to patients

12 Reasons for a visit from the Fraud Squad

1. Failing to effectively deal with employee/patient complaints

2. Free services – Advertised – Given

3. MD-DC Practice (Purpose to avoid DC reimbursement – Cuts/Limitations)

4. Failing to follow third party payor rules

5. Failing to properly code, document diagnosis (ICD) Services (CPT)

6. Failing to properly document clinic services – Rehabilitation

7. Advertising – Implied – Contracts – Misleading

8. Use of outside billing and/or collection companies with monitoring

9. Failing to properly establish medical necessity

10. Failing to properly respond to 3rd party questions of medical necessity and treatment plans

11. Maintaining on-going relationships (Attorneys, Consultants, Mobile Labs, Etc.)

12. Failing to repay any misbilled services or overpayments

These include acting in:

a) Deliberate Ignoranceb) Reckless disregard of

anything listed

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Federal ComplianceAnti-Kickback

Marketing/Advertising

Stark Rules – Review

Advertising – Fraud Safety Checks -Disclaimer

1. Do NOT advertise a free service and then bill the patient or their insurance, it’s FRAUD!

2. Be sure that you put a disclaimer on all advertising for those potential patients. It is illegal to solicit. Know state laws (prevent fraud)

3. On Auto Accidents or P.I. Injuries

4. REMUNERATION FOR REFERRALS IS ILLEGAL. It can distort Health Care decision making, cause overutilization of Clinical Services or Supplies (Durable Medical Codes 97___) increase costs to Federal Health Care Programs. Violates Federal Insurance (Medicare) results in unfair competition by shutting out competitors, Doctors who are willing to do FMLA.

5. Be Careful – Beware – of companies who want to come to your office and pay you to refer your patients, for special testing and/or procedures specifically with no out of pocket expense.

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Advertising – Fraud Safety Checks -Disclaimer

6. Developing office policies to address arrangements with other Health Care Providers and Suppliers. Doctors should implement measures to avoid offering inappropriate inducements to patients. Examples of suck inducements include routinely waiving coinsurance or deductibles without a Good Faith determination that the patient is in financial need or failing to make reasonable efforts to collect cost-sharing amount.

7. Soliciting, accepting, or offering ANY gift or gratuity of more than a nominal value to or from those who may benefit from a physician practice’s referral of Federal Health Care Programs business.

8. Posted and/or sign fee schedule for all clinical services. Verify fee’s with National Publication (PFR)

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Modern Malpractice Protection�Why will your Chiropractic philosophy, science and are get 1 out of 6 D.C.’s accused of malpractice.

�Why do cash practice D.C.’s get sued more than insurance practice D.C.’s?

�The new malpractice traps – HIPAA – Sexual Harassment – Deviation Standards of Care/Standards of Practice

�Protect yourself – Protect your Staff – Protect Chiropractic: Learn the New “Modern Malpractice Protection” Techniques

�Dr. Murkowski will share all from actual malpractice cases he has worked on!

Unhelpful Phrases in Advertising� Immediate Relief

�Painless

�Chiropractic care can bring relief from pain without drugs or surgery

�The complete health care center

�Relief is just minutes away

�Knowing, skilled, and gentle Chiropractic care

�To relieve pain and restore health

�Specializing in difficult and chronic cases

�Ruptured, herniated, or slipped discs

�Pain relief specialists who can help

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Please fill this in, Doctor…..

Arterial circulation at the base of the Brain

Upper Thoracic segment of the Spinal Cord

12 Cranial Nerves

Define: Sprain

Strain

Subluxation

HIP DEEP IN H.I.P.A.AWere you compliant on 9/23/13?

HIPAA Changes

�Business Associates

�Breach Reporting

�Encrypt Data at Rest

�Individual Rights�Electronic Copies

�Limit Access of Insurers for Cash Patients

�Marketing

�E-Mails Through Patient Portals

H.I.P.A.A. = OFFICE SUBLUXATIONH.I.P.A.A. = OFFICE SUBLUXATION

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HIPAA 13 Point Checklist for you…Be Ready!�Choose a Compliance Officer

�Choose a Compliance Officer Consultant

�Read your HIPAA Compliance Manual

�Train your employers (weekly-monthly)

�File employee signatures on HIPAA Documents

�Have an employee training log book

�Post the HIPAA Notice of Health Information

�Have patient Notice of Privacy Practice for patient to sign

�Obtain a baseline audit of Privacy Rules

�Have Disclosure ready of PHI

�Have Business Associate Letters

�Have Business Associate Agreement

�Have Fax and E-Mail Disclosures

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Dr. Murkowski’s 13 Office “Adjustments”To correct “HIPAA”Subluxations in the

Office1. Understand HIPAA is a Law

2. Understand HIPAA is a government program.

3. Accept the fact that you MUST comply.

4. Accept the fact that you MUST work the program.

5. Take the “Action Steps” for you and your staff.

6. Take the “Action Steps” for your patients.

7. Protect your office and patient files.

8. Protect your office, business associates & vendors.

9. HIPAA train yourself, staff and patients.

10. Take precautions and security steps.

11. Pick HIPAA consultants wisely.

12. Know government programs and penalties (Knowledge is Power).

13. Practice 2002 Chiropractic HIPAA & Patient respect.

Eight Kinds of Patients1.

2.

3.

4.

5.

6.

7.

8.

DOCUMENT DOCUMENT DOCUMENT DOCUMENTDOCUMENT DOCUMENT DOCUMENT DOCUMENT

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Screening High Risk PatientsBUSINESS

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12..

CLINICAL

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

What the new patient brings in…1.

2.

3.

4.

5.

6.

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Sectional Review of Signs, Tests, Maneuvers

George’s Cerebrovascular Craniocervical Functional (Test for Ischemia)

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Radiographic StudiesDavis Series should be routine procedure and includes the following

projections:

Antero-Postero Open Mouth which Reveals-Atlanto-Occipital Articulations-Atlas Lateral Masses-Atlanto-Axial Articulations-The body of axis-The odontoid process

[email protected] Closed Mouth-The lower 5 cervical bodies-Corresponding intervertebral spaces-Transverse processes-Covertebral articulations

Neutral Lateral View-Symmetry of the cervical curve-Cervical bodies-Apopyseal articulations-Spinous processes-Hypo-hypedordosis

Flexion View-Symmetry of the cervical curve-Range of motion-Areas of greatest stress and strain

Extension View-Symmetry of the cervical curve-Range of motion-Areas of greatest stress and strain

Two Oblique Views-Intervertebral foreman-Oblique study of vertebral bodies-Osteoarthritis of the covertebral joints

Osseous Manifestations of Vertebral Subluxations (VS) That May Produce Nerve Interference (NI)

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DIAGNOSIS�This is essentially what the carrier knows about out patient and level of care is determined from the current ICD codes

�Uncomplicated diagnosis = less care

�Greater severity = increased necessity of services

Vertebral Subluxation

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The Vertebral Subluxation ComplexThe Chiropractic Subluxation Complex is any alteration of the biochemical and neuro-physiological dynamics of contignous spinal and paraspinal structures which can cause neuronal disturbances and interrupt the body’s inherent recuperative power. (Allopathic subluxation maybe other, multiple and/or illdefined dislocations or partial dislocations.)

The Vertebral Subluxation Complex�VSC 8 Physical Components

�Osseous

�Connective Tissue

� Muscles

� Ligaments – Fascia

�Disc

�Neurological

�Altered Biochemical

� I.E. Kyphosis Scoliosis

�Lymphatic

�Circulatory

�Visceral

�VSC 8 Chemical Componants

�Nociceptive Irritants

� Traumatism

� Chemical

� Lactic Acid

� Potassium Ions

� Prostaglandin E-2

� Leukotriene B-4

� Glycosaminglycans

� Histamine

� 5-Hydroxytryptamine

� Bradylcinin

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ConceptsDiagnosis Care I – Emergency

Diagnosis II Care II – Managed (Rehabilitation Support Systems

Diagnosis III Care IV – Co-ordinated

a) Final Diagnosis Certified Impairment Rating

b) Dismissal Diagnosis (3rd Party Intervention)

M.M.I.

Pre-Accident Status

Care IIICare III

Medical Necessity VS Clinical Appropriateness

Billing a Wall of Protection

NECESSARY PATIENT DOCUMENTATION

1. MPC-101 5. MPC-105 9. MPC-1 MIN SOAP 13. MPC-113A

2. MPC-104 6. MPC-107 10. MPC-110 14. MPC-114A

3.MPC-104 7. MPC-107 11. MPC-111 15. MPC-115A

4. MPC-105 8. MPC-108 12. MPC-112 16. MPC-116A

Reinforcing Walls of Protection17. MPC-117 EM 19. MPC-199 Ouch 21. MPC-121 23. MPC-B2 PA

PT Update Exam

18. MPC- 20. MPC-120 22. MPC-B1 24. HIPAA

Informed Consent CH Update Office Policy

Bonus Review

Soap VS Chart – P.A.R.T. VS HER - EMR

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ICD-9 Diagnosis For Medicare Billing739-Non-Allopathic Lesions, Not

elsewhere Classified Includes: Segmenial

dysfunction, somatic dysfunction

739.0-Head Region

739.1-Cervical Region – Cervicothoracic

region

739.2-Thoracic Region – Thoracolumbar

region

739.3-Lumbar Region – Lumbosacral

region

739.4-Sacral Region – Sacrococcygeal

region, Sacroiliac region

739.5-Pelvic Region – Hip region, Pubic

region

839-Other, Multiple, Ill-defined dislocations

839.0-Cervical Vertebra, Closed (Cervical

Spine, Neck)

839.00-Cervical Vertebra, Unspecified

839.01-First Cervical Vertebra

839.02-Second Cervical Vertebra

839.03-Third Cervical Vertebra

839.04-Fourth Cervical Vertebra

839.05-Fifth Cervical Vertebra

839.06-Sixth Cervical Vertebra

839.07-Seventh Cervical Vertebra

839.08-Multiple Cervical Vertebra

839.2-Thoracic and Lumbar Vertebra,

Closed

839.20-Lumbar Vertebra

839.21-Thoracic Vertebra

Dorsal (Thoracic) Vertebra

839.4-Other Vertebra, Closed

839.40-Vertebra, Unspecified Unit (Spine

NOS)

839.41-Coccyx

839.42-Sacrum (Sacroiliac joint)

839.49-Other

839.6-Other Location, Closed

839.61-Sternum (Sternoclavicular joint)

839.69-Other (Pelvis)

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Common Diagnosis Codes

Common Diagnosis Codes Cont…

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Sample Diagnosis---DX BANK-Go To BankPrimary

839.05 Sublaxation of C-5 Vertebra

722.4 Degeneration Cervical Disc

729.2 Radiculitis

737.1 Kyphosis (Acquired)

723.1 Neck Pain

723.5 Torticollis

353.0 Irritation Brachial Plexus

Secondary

839.20 Sublaxation of L-5 Vertebra

722.1 Displacement Lumbar Disc

782.0 Parasthesia

737.3 Scoliosis

724.4 Neuritis

724.3 Sciatica

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Physical Medicine and RehabilitationPhysical medicine is the diagnosis, treatment and prevention of disease with the aid of physical agents such as light, heat, cold, water, or electricity or with mechanical devices. Physical medicine services may be provided by physicians or physical therapists. Physical medicine and rehabilitation codes are divided into three sections; Modalities, Procedures, and Tests and Measurements. Other services performed by medical professionals specializing in physical medicine and/or physical therapy include; muscle testing, range of joint motion, electromyography, biofeedback training EMG, and transcutaneous nerve stimulation (TNS).

Physical Medicine and RehabilitationCoding Rules

1) The physician or therapist is required to be in constant attendance when reporting codes for modalities and procedures.2) The physical medicine procedure codes specify treatment to one area, for the initial 30 minutes, and provide codes to report each additional 15 minutes of treatment.

Special Physical Medicine Coding Issues

Many worker’s compensation and casualty health insurance companies use pre-CPT coding systems, such as CRVs, and do not use any form of diagnostic coding, relying instead on special reports to justify the procedures performed and services provided. As the majority of physical medicine services are performed for accidents and injuries, many that are work-related, the medical professionals performing these services must be informed of the specific reporting requirements in the areas that they practice.

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Physical Medicine and RehabilitationCorrect Coding Guidelines

1) With one exception providers should not report more than on physical medicine and rehabilitation therapy service for the same 15 minute time period. (The only exception involves a “supervised modality” defined by CPT codes 97010-97028 which may be reported for the same 15 minute time period as other therapy services). Some CPT codes for physical medicine and rehabilitation services include an amount of time in their code descriptors. Some NCCI edits pair a “timed” CPT code with another “timed” CPT code or a non-timed CPT code. These edits may be bypassed with modifier 59 if the two procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter. NCCI does not include all edits pairing two physical medicine and rehabilitation services (excepting “supervised modality” services) even though they should never be reported for the same 15 minute time period.

2) NCCI contains edits with column one codes of the physical medicine and rehabilitation therapy services and column two codes of the physical therapy and occupational therapy re-evaluation CPT codes of 97002 and 97004 respectively. The re-evaluation services should not be routinely reported during a planned course of physical or occupational therapy. However, if the patients status should change and a re-evaluation is medically reasonable and necessary, it may be reported with modifier 59 appended to CPT code 97002 or 97004 as appropriate.

Physical Medicine and Rehabilitation3) The procedure coded as CPT code 97755 (assistive technology assessment…direct one-on-one contact by provider, with written report, each 15 minutes) is intended for use on severely impaired patients requiring adaptive technology. For example, a patient with the use of only one or no limbs might require the use of high level adaptive technology.

4) The NCCI edit with column one CPT code 97140 (Manual therapy techniques, one & more regions, each 15 minutes) and column two CPT code 97530 (Therapeutic activities, direct patient contact, each 15 minutes) is often bypassed by utilizing modifier 59. Use of modifier 59 with the column two CPT code 97530 of this NCCI edit is appropriate only if the two procedures are performed in distinctly different 15 minute intervals. The two codes cannot be reported together if performed during the same 15 minute time interval.

5)Based on CPT coding system instructions selective debridement (CPT codes 97597, 97598) should not be reported in conjunction with surgical debridement (CPT codes 11040-11044). Physicians cannot report these codes separately on the same date of service. However, under OPPS a facility may report these codes separately if the selective debridement and surgical debridement are performed on two separate and distinct wounds. The two procedures may be performed by the same practitioner or two separate practitioners and may be performed at the same or separate patient encounters on the same date of service.

The same principle applies to CPT code 97602 which is payable under OPPS.

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97001 Physical Therapy Evaluation715.15 Osteoarthrosis localized primary

involving pelvic region

716.90 Unspecified arthropathy site

unspecified

716.96 Unspecified arthropathy

involving lower leg

719.41 Pain in joint involving shoulder

region

721.3 Lumbosacral spondylosis without

myelopathy

722.10 Displacement of lumbar

intervertebral disc without myelopathy

722.52 Degeneration of lumbar or

lumobosacral intervertebral disc

RVUs: Transitioned NonFacility Total 1.96 Transitioned Facility Total 1.96

Medicare Policies: No payment adjustment rules for multiple procedures apply, 150% payment adjustment for bilateral

procedures does not apply, payment for assistant surgeon subject to documentation of medical necessity.

PLEASE SEE DXPLEASE SEE DX

GOLD BOOKSGOLD BOOKS

FOR MORE FOR MORE

ICD CODESICD CODES

97002 Physical Therapy Re-Evaluation715.15 Osteoarthritis localized primary involving pelvic region and thigh

716.90 Unspecified arthropathy site unspecified

719.41 Pain in joint involving shoulder region

723.4 Brachial neuritis or radiculitis nos

724.1 Pain in thoracic spine

724.2 Lumbago

RVUs: Trasitioned NonFacility Total 1.06 Transitioned Facility Total 1.06

Medicare Policies: No payment adjustment rules for multiple procedures apply, 150% payment adjustment for

bilateral procedures does not apply, payment for assistant surgeon subject to documentation of medical necessity.



FOR MORE FOR MORE

ICD CODESICD CODES

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97010 Application of a modality to one or more areas; hot or cold packs353.1 Lumbosacral plexus lesions

353.4 Lumbosacral root lesions not elsewhere

classified

715.00 Osteoarthrosis generalized involving

unspecified site

720.2 Sacroiliitis not elsewhere classified

721.0 Cervical spondylosis without myelopathy

721.3 Lumbosacral spondylosis without myelopathy

722.0 Displacement of cervical intervertebral disc

without myelopathy

722.10 Displacement of lumbar intervertebral disc

site unspecified without myelopathy

722.2 Degeneration of cervical intervertebral disc

722.51 Degeneration of thoracic or thoracolumbar

intervertebral disc

722.52 Degeneration of lumbar or lumbosacral

intervertebral disc

722.73 Intervertebral disc disorder with myelopathy

lumbar region

723.1 Cervicalgia

723.2 Cervicocranial syndrome


Medicare Policies: Bundled code-no separate payment made.



FOR MORE FOR MORE

ICD CODESICD CODES

97012 Application of a modality to one or more areas; traction, mechanical 353.1 Lumbosacral plexus lesions

353.2 Cervical root lesions not elsewhere classified

715.00 Osteoarthrosis generalized involving unspecified site



722.0 Displacement of cervical intervertebral disc without

myelopathy

722.10 Displacement of lumbar intervertebral disc without

myelopathy

722.2 Displacement of intervertebral disc site unspecified without

myelopathy


722.51 Degeneration of thoracic or thoracolumbar intervertebral

disc

722.52 Degeneration of lumbar or lumbosacral intervertebral disc


Medicare Policies: No payment adjustment rules for multiple prodecures apply, 150% payment adjustment for bilateral

procedures does not apply, payment for assistant surgeon subject to documentation of medical necessity.



FOR MORE FOR MORE

ICD CODESICD CODES

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97014 Application of a modality to one or more areas; electrical stimulation (unattended) 353.1 Lumbosacral plexus lesions

353.4 Lumbosacral root lesions not elsewhere specified

715.00 Oseteoarthrosis generalized involving specified site

720.2 Sacroilitis not elsewhere specified



722.0 Displacement of cervical intervertebral disc without

myelopathy

722.10 Displacement of lumbar intervertebral disc without

myelopathy


722.51 Degeneration of thoracic or thoracolumbar intervertebral

disc

722.52 Degeneration of lumbar or lumbosacral intervertebral disc

722.73 Intervertebral disc disorder with myelopathy lumbar region


Medicare Policies: No valid for Medicare



FOR MORE FOR MORE

ICD CODESICD CODES

The Dangers of Pre-Paid Care PlansDoctors should be aware that patient prepayment plans could expose them to criminal or civil liability. At this time, opinions of numerous state insurance commissioners and a recent bulletin from the National Association of Insurance Commissioners (NAIC) have held these plans to be illegal.

The basis of these rulings is that the operation of a prepayment plan constitutes the business of insurance. As such, anyone engaged in this business must be licensed either as an insurance company, a health maintenance organization, or a similar entity. Offering some of these plans without a license may be illegal.

Insurance is defined as an activity that shifts the risk of loss from an insurer, and distributes that loss potential among a larger group through the payment of a lesser amount. In patient prepayment plans, the doctor assumes the risk that the actual cost of care will exceed the amount charged. He/she also assumes that there will be a number of patients who over-utilize the benefits, but that they will be balanced by those who under-utilize. Patients rely on the fact that they will be able to obtain all needed care for a set fee. .

Recently, the National Council for Chiropractic Attorneys reported that suits against chiropractors, by patients in prepayment plans, has been one of the top five causes for malpractice actions since 1988. Further, the NAIC has predicted these plans to be an increasing enforcement priority by state insurance departments.

To avoid risk, doctors should cease the usage of any unlicensed prepayment plans.

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2012 Poverty Guidelines for the 48 Contiguous States and the District of Columbia

Application and Affidavit ofApplication and Affidavit of

Financial HardshipFinancial Hardship

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Financial PolicFinancial Policy Statementy Statement

Individual Consideration Contract (I.C.C)Individual Consideration Contract (I.C.C)

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NCLC Case Evaluation/ClinicalNCLC Case Evaluation/Clinical

Procedure Break DownProcedure Break Down

Chiropractic Advanced Chiropractic Advanced

Beneficiary NoticeBeneficiary Notice

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HHS.gov For Immediate

Release 01/17/13

U.S. Department of Health & Human ServicesNew rule protects patient privacy, secures health informationThe U.S. Department of Health and Human Services (HHS) moved forward today to strengthen the privacy and security protections for health information established under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The final omnibus rule greatly enhances a patient’s privacy protections, provides individuals new rights to their health information, and strengthens the government’s ability to enforce the law.

“Much has changed in health care since HIPAA was enacted over fifteen years ago,” said HHS Secretary Kathleen Sebelius. “The new rule will help protect patient privacy and safeguard patients’ health information in an ever expanding digital age.”

The changes in the final rulemaking provide the public with increased protection and control of personal health information. The HIPAA Privacy and Security Rules have focused on health care providers, health plans and other entities that process health insurance claims. The changes announced today expand many of the requirements to business associates of these entities that receive protected health information, such as contractors and subcontractors. Some of the largest breaches reported to HHS have involved business associates. Penalties are increased for noncompliance based on the level of negligence with a maximum penalty of $1.5 million per violation. The changes also strengthen the Health Information Technology for Economic and Clinical Health (HITECH) Breach Notification requirements by clarifying when breaches of unsecured health information must be reported to HHS.

Individual rights are expanded in important ways. Patients can ask for a copy of their electronic medical record in an electronic form. When individuals pay by cash they can instruct their provider not to share information about their treatment with their health plan. The final omnibus rule sets new limits on how information is used and disclosed for marketing and fundraising purposes and prohibits the sale of an individuals’ health information without their permission.

“This final omnibus rule marks the most sweeping changes to the HIPAA Privacy and Security Rules since they were first implemented,” said HHS Office for Civil Rights Director Leon Rodriguez. “These changes not only greatly enhance a patient’s privacy rights and protections, but also strengthen the ability of my office to vigorously enforce the HIPAA privacy and security protections, regardless of whether the information is being held by a health plan, a health care provider, or one of their business associates.”

The final rule also reduces burden by streamlining individuals’ ability to authorize the use of their health information for research purposes. The rule makes it easier for parents and others to give permission to share proof of a child’s immunization with a school and gives covered entities and business associates up to one year after the 180-day compliance date to modify contracts to comply with the rule.

The final omnibus rule is based on statutory changes under the HITECH Act, enacted as part of the American Recovery and Reinvestment Act of 2009, and the Genetic Information Nondiscrimination Act of 2008 (GINA) which clarifies that genetic information is protected under the HIPAA Privacy Rule and prohibits most health plans from using or disclosing genetic information for underwriting purposes.

The Rulemaking announced today may be viewed in the Federal Register at https://www.federalregister.gov/public-inspection.

Contact: HHS Press OfficeContact: HHS Press Office

202202--690690--63436343

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The check really is in the mail!Very few things in life are more frustrating than waiting around for money that someone owes you.

Particularly if that someone is an insurance company.

Unfortunately, its by no means unusual to wait months on end for an insurance company to pay up.

At Aetna, we think that’s unconscionable.

So at our Employee Benefits Division, we've reduced the entire health insurance claims process to a mere nine days. Despite the fact that we receive nearly a quarter million claims a day.

Of course, you don’t get results like this by waiving a wand. At Aetna, it takes a national on-claims network, three mainframe computers, 32 automatic collating machines, five zip code pre-sorters, and 225 dedicated people dedicated solely to getting those checks in the mail.

Still, we find the extra effort pays. We like to think that such unusual promptness is why so many companies are so quick to employ us for their employee benefit programs.

And why they're so slow to leave us.

AETNA. WE GIVE NEW MEANING TO THE WORD DILIGENT.

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Understanding ICD – 10 10/01/15Will there be a grace period for converting to ICD-10?No

If I transition early to ICD-10, will my claims be processed?No. CMS and other payers will not be able to process claims using ICD-10 until October 1,2014.

Providers – Develop an implementation strategy that includes an assessment of the impact on your organization, a detailed timeline, and budget.

Billing Service

Clearing house

Practice Management Software

Providers who handle billing and software development internally should plan for medical records/coding, clinical, IT, and staff to coordinate on ICD-10 transition efforts.

�Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed.

�For accurate reporting of ICD-10-CM diagnosis codes, the documentation should describe the patient’s condition, using terminology which includes specific diagnoses as well as symptoms, problems, or reasons for the encounter. There are ICD-10-CM codes to describe all of these.

�Do not code diagnoses documented as “probable”, “suspected”, “questionable”, “rule out”, or “working diagnosis” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit.

�Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist.

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Format and Structure:The ICD-10-CM Tabular List contains categories, subcategories and codes. Characters for categories, subcategories and codes may be either a letter or a number. All categories are 3 characters. A 3-character category that has no further subdivision is equivalent to a code. Subcategories are either 4 or 5 characters. Codes may be 3,4,5,6 or 7 characters. That is, each level of subdivision after a category is a subcategory. The final level of subdivision is a code. Codes that have applicable 7th

characters are still referred to as codes, not subcategories. A code that has an applicable 7th

character is considered invalid without the 7th character.

Diagnosis codes are to be used and reported at their highest number of characters available. ICD-10-CM diagnosis codes are composed of codes with 3,4,5,6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth and /or fifth characters and/or sixth characters, which provide greater detail.

A three-character code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if possible.

Anatomy of ICD-10-CM “Knowing the bones” is a good idea in almost any Chiropractic endeavor. It is the same when you are trying to wrap your arms around a new coding system. Much of what you will find in ICD-10-CM will see familiar – the codes represent disorders to the body, the numbers describe the codes, and picking the right one is often half the science and half art.

This book will now explore the anatomy of ICD-10-CM codes at a level beyond the pre-cursory depth presented so far. If further information is needed, you can look at the “Official Guidelines” presented in the Appendix, or peruse some of the Additional Resources listed also in the appendix. To simplify learning, we will usually contrast ICD-10-CM with ICD-9-CM. Refer to the chart on page 18.

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ICD-9-vs-ICD-10 Comparison

There are at least 3 ways There are at least 3 ways

In which ICDIn which ICD--99--CM and ICDCM and ICD--1010--CMCM

are different!are different!

Differences between ICDDifferences between ICD--99--CM and ICDCM and ICD--1010--CMCM

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Comparison of ICD-9-CM and ICD-10-CM Chapter Numbers and TitlesCHP ICD-9-CM ICD-10-CM

1 Infections and Parasitic Diseases (001-139) Certain Infections and Parasitic Diseases (A00-B99)

2 Neoplasms (140-239) Neoplasms (C00-D49)

3 Endocrine, Nutritional and Metabolic Diseases, and Immunity

Disorders (240-279)

Diseases of the blood and blood-forming organs and certain

disorders involving the immune mechanism (D50-D89)

4 Diseases of the Blood and Blood-Forming Organs (280-289) Endocrine, Nutritional and Metabolic Diseases (E00-E89)

5 Mental Disorders (290-319) Mental and Behavioral Disorders (F01-F99)

6 Diseases of the Nervous System and Sense Organs (320-389) Diseases of the Nervous System (G00-G99)

7 Diseases of the Circulatory System (390-459) Diseases of the eye and adnexa (H00-H59)

8 Diseases of the Respiratory System (460-519) Diseases of the ear and Mastoid Process (H60-H95)

9 Diseases of the Digestive System (520-579) Diseases of the Circulatory System (I00-I99)

10 Diseases of the Genitourinary System (580-629) Diseases of the Respiratory System (J00-J99)

Comparison of ICD-9-CM and ICD-10-CM Chapter Numbers and Titles cont…11 Complications of Pregnancy, Childbirth and the Puerperium (630-

677)

Diseases of the Digestive System (K00-K94)

12 Diseases of the Skin and Subcutaneous Tissue (680-709) Diseases of the Skin and Subcutaneous Tissue (L00-L99)

13 Diseases of the Musculoskeletal System and Connective Tissue

(710-739)

Diseases of the Musculoskeletal System and Connective Tissue (M00-

M99)

14 Congenital Anomalies (740-759) Diseases of the genitourinary system (N00-N99)

15 Certain Conditions Originating in the Perinatal Period (760-779) Pregnancy, childbirth and the puerperium (O00-O99)

16 Symptoms, Signs and Ill-Defined Conditions (780-799) Certain conditions originating in the perinatal period (P00-P96)

17 Injury and Poisoning (800-999) Congenital malformations, deformations and chromosomal

abnormalities (Q00-Q99)

18 N/A Symptoms, Signs and abnormal clinical and laboratory findings, not

elsewhere classified (R00-R99)

19 N/A Injury, poisoning and certain other consequences of external causes

(S00-T88)

20 N/A External causes of morbidity (V00-Y99)

21 N/A Factors influencing health status and contact with health services (Z00-

Z99)

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How are ICD-9 and ICD-10 Different?

CategoryCategory Etiology, Anatomic SiteEtiology, Anatomic Site

SeveritySeverityExtensionExtension

ICDICD--1010

ICDICD--99

CategoryCategoryEtiology, Anatomic SiteEtiology, Anatomic Site

SeveritySeverity

Numeric or AlphaNumeric or Alpha

Numeric or AlphaNumeric or Alpha

NumericNumeric

NumericNumericAlphaAlpha

How do I know which codes to use?Diagnosis code hierarchy:◦ Neurological

◦ Structural

◦ Functional

◦ Soft Tissue

◦ For example, sciatica (724.3) will carry more weight than DDD (722.4) or other structural diagnoses

◦ Soft tissue such as spasm (728.85) or myalgia (729.1) are the least significant when establishing medical necessity

◦ Rumor has it that some software only looks at the first diagnosis when adjudicating a claim

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ICD-10 Chapter Specifics

�A = Initial encounter and evaluation and treatment by a new physician

�D = Healing or recovery phase (ongoing treatment)

�S = Complications or conditions that are a result of injury

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Chiropractic Diagnosis Coding Rules ICD-9 and ICD-10:Code to the highest level of specificity – meaning be sure you have the correct number of digits required for the reported diagnosis.

In ICD-9 codes have about 13,000 codes and are numerical. They can range from 3 digits to 4 or 5 digits in length. Any billing with a code having the improper number of digits will cause the claim to be rejected.

ICD-10 codes have approximately 68,000 codes may be from 3-7 characters in length and all codes begin with an alpha character but contain letters and numbers.

Which code is correct?ICD-9

◦ Headache 784.0 784.00

◦ Migraine 346.0 346.00

◦ Shoulder Pain 719.4 719.41

◦ Adhesive Capsulitis of shoulder (frozen) 726.0 726.00

◦ Sciatica 724.3 724.30

ICD-10 (ICD10 Codes are all correct)

◦ R51 Headache

◦ G44.1 Vascular Headache

◦ G46.109 Migraine with aura

◦ M25.519 Pain unspecified shoulder

◦ M25.511 Pain in right shoulder

◦ M25.512 Pain in left shoulder

◦ M75.00 Adhesive capsulitis of unspecified shoulder

◦ M75.01 Adhesive capsulitis of right shoulder

◦ M75.02 Adhesive capsulitis of left shoulder

◦ M54.40 Lumbago w/ sciatica, unspecified side

◦ M54.41 Lumbago w/ sciatica, right side

◦ M54.42 Lumbago w/ sciatica, left side

◦ M54.30 Sciatica unspecified

◦ M54.31 Sciatica right side

◦ M54.32 Sciatica left side

Remember: Use ZeroRemember: Use Zero

Not The Letter “O”!Not The Letter “O”!

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Chiropractic Coding�All codes begin with alpha character in ICD-10

�R51 Headache

�M54.2 Cervicalgia

�M54.12 Radiculopathy cervical region

�M25.511 Pain in right shoulder

�S13.4XXA Sprain cervical spine

Placeholder CharacterThe ICD-10-CM utilizes a placeholder character “X”. The “X” is used as a placeholder at certain codes to allow for future expansion.

Where a placeholder exists, the X must be used in order for the code to be considered a valid code.

• Some characters act as a place holder and will be indicated with “x”.

• S33.5 is lumbar sprain but must also indicate if initial, subsequent, or sequelae.

• This indicator of initial, subsequent or sequelae is done by A, D, or S as the 7th character of the code.• For Example:

• S33.5XXA Initial Visit and treatment

• S33.5XXD Subsequent Visit

• S33.5XXS Sequelea

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Signs and SymptomsCodes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, not elsewhere classified (codes R00.0 – R99) contains many, but not all codes for symptoms.

Conditions that are an integral part of a disease process

Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

� There is no need to indicate pain with a sprain or strain code, for instance.

Conditions that are not an integral part of a disease process

Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.

� Spasm should be indicated as it is not necessarily integral to a strain or sprain, which would be give indication for need of services to reduce or eliminate spasm.

Acute and Chronic Conditions If the same condition is described as both acute (sub acute) and chronic, and separate subentries exist in the Alphabetic Index at the same indentation level, code both and sequence the acute (subacute) code first.

Late Effects (Sequela)

A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Coding of late effects generally requires two codes sequenced in the following order: The condition or nature of the late effect is sequenced first. The late effect code is sequenced second.

◦ ICD-10

◦ G89.29 Chronic pain due to trauma

◦ S33.5XXS Sequela of sprain lumbar

◦ ICD-9

◦ 338.29 Chronic pain due to trauma

◦ 847.2 Sprain and strain lumbosacral

◦ 905.7 Late effects strain and sprain

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Reporting Same Diagnosis Code More than OnceEach unique ICD-10-CM diagnosis code may be reported only once for an encounter. This applies to bilateral conditions when there are no distinct codes identifying laterality or two different conditions classified to the same ICD-10-CM diagnosis code.

Laterality

For bilateral sites, the final character of the codes in the ICD-10-CM indicates laterality. An unspecified side code is also provided should the side not be identified in the medical record. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.

◦ If there is a condition on both extremities codes for each side (left and right) would be used.

How do I know which code to use?Short term (6-12 treatments)

◦ 721s Spondylosis

◦ 723-724s Back Pain

Moderate term (12-24 treatments)

◦ 353s Root lesions

◦ 722.9s Unspecified disc disorders

◦ 724s Stenosis

◦ 846-7s Sprains

Long term (more than 24 treatments)

◦ 722s Degeneration, displaced discs

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Cervical/Head DiagnosesSUBLAXATION AND DISLOCATION

M99.10 Subluxation complex (vertebral) of head region S13.141 Dislocation of C3/C4 cervical vertebrae

M99.11 Subluxation complex (vertebral) of cervical region S13.150 Subluxation of C4/C5 cervical vertebrae

S03.0XX Dislocation of jaw S13.151 Dislocation of C4/C5 cervical vertebrae

S13.100 Subluxation of unspecified cervical vertebrae S13.160 Subluxation of C5/C6 cervical vertebrae

S13.101 Dislocation of unspecified cervical vertebrae S13.161 Dislocation of C5/C6 cervical vertebrae

S13.110 Subluxation of C0/C1 cervical vertebrae S13.170 Subluxation of C6/C7 cervical vertebrae

S13.111 Dislocation of C0/C1 cervical vertebrae S13.171 Dislocation of C6/C7 cervical vertebrae

S13.120 Subluxation of C1/C2 cervical vertebrae S13.180 Subluxation of C7/T1 cervical vertebrae

S13.121 Dislocation of C1/C2 cervical vertebrae S13.181 Dislocation of C7/T1 cervical vertebrae

S13.130 Subluxation of C2/C3 cervical vertebrae S13.4xx Sprain of ligaments of cervical spine

S13.131 Dislocation of C2/C3 cervical vertebrae S13.8xx Sprain of joints & ligaments of other parts of neck

S13.140 Subluxation of C3/C4 cervical vertebrae

How do I code for a subluxation?Fifth Character gives the specific vertebral level:

◦ S13.10 - Subluxation and dislocation of unspecified cervical vertebrae

◦ S13.11 - Subluxation and dislocation of C0/C1 cervical vertebrae







◦ S13.18 - Subluxation and dislocation of C7/T1 cervical vertebrae

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How do I code for subluxation?

Sixth character differentiates between a sublaxtion and a dislocation:

0 = Sublaxation 1 = Dislocation

S13.110 – Subluxation of C0/C1 cervical vertebrae

S13.111 – Dislocation of C0/C1 cervical vertebrae

How do I code for subluxation?Seventh character identifies the encounter:

S13.110A Subluxation of C0/C1 cervical vertebrae, initial encounter

S13.110D Subluxation of C0/C1 cervical vertebrae, subsequent encounter

S13.110S Subluxation of C0/C1 cervical vertebrae, sequel

Seventh charactersA = initial encounter (great for E/M visits)D = subsequent encounter (aftercare or follow-up)S = sequel (complications as a result of an injury)

(ex. Scar due to burns)

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HeadHead (face & eyes)

ICD-9 ICD-10 Description

784.0 G44.1 Vascular headache, not elsewhere classified

784.0 R51 Headache

307.81 G44.209 Tension-type headache, unspecified

339.20 G44.309 Post traumatic headache, unspecified

339.21 G44.319 Acute post traumatic headache

339.22 G44.321 Chronic post traumatic headache

346.00 G43.109 Migraine headache, with aura

Thoracic DiagnosesSubluxation and Dislocation

M99.12 Subluxation complex (vertebral) of thoracic region S23.142 Subluxation of T7/T8 thoracic vertebra

S23.100 Subluxation of unspecified thoracic vertebra S23.143 Dislocation of T7/T8 thoracic vertebra

S23.101 Dislocation of unspecified thoracic vertebra S23.150 Subluxation of T8/T9 thoracic vertebra

S23.110 Subluxation of T1/T2 thoracic vertebra S23.151 Dislocation of T8/T9 thoracic vertebra

S23.111 Dislocation of T1/T2 thoracic vertebra S23.152 Subluxation of T9/T10 thoracic vertebra






S23.131 Dislocation of T4/T5 thoracic vertebra S23.170 Subluxation of T12/L1 thoracic vertebra

S23.132 Subluxation of T5/T6 thoracic vertebra S23.171 Dislocation of T12/L1 thoracic vertebra

S23.133 Dislocation of T5/T6 thoracic vertebra S23.20x Dislocation of unspecified part of thorax

S23.140 Subluxation of T6/T7 thoracic vertebra S23.29x Dislocation of other parts of thorax

S23.141 Dislocation of T6/T7 thoracic vertebra

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Lumbar DiagnosesSubluxation and Dislocation

M99.13 Subluxation Complex (vertebral) of lumbar region S33.130 Subluxation of L3/L4 lumbar vertebra

S33.100 Subluxation of unspecified lumbar vertebra S33.131 Dislocation of L3/L4 lumbar vertebra

S33.101 Dislocation of unspecified lumbar vertebra S33.140 Subluxation of L4/L5 lumbar vertebra

S33.110 Subluxation of L1/L2 lumbar vertebra S33.141 Dislocation of L4/L5 of lumbar vertebra

S33.111 Dislocation of L1/L2 lumbar vertebra S33.30x Dislocation of unspecified parts of lumbar spine and pelvis

S33.120 Subluxation of L2/L3 vertebra S33.39x Dislocation of other parts of lumbar spine and pelvis

S33.121 Dislocation of L2/L3 lumbar vertebra

Lower BackICD-9 ICD-10

724.2 M54.5 Low back pain (lumbago)

724.3 M54.40 Lumbago with sciatica, unspecified side

724.3 M54.41 Lumbago with sciatica, right side

724.3 M54.42 Lumbago with sciatica, left side

724.3 M54.30 Sciatica, unspecified

724.3 M54.31 Sciatica, right side

724.3 M54.32 Sciatica, left side

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ICD-10◦M54.40 Lumbago with sciatica, unspecified side

◦M54.41 Lumbago with sciatica, right side

◦M54.42 Lumbago with sciatica, left side

◦M54.30 Sciatica unspecified

◦M54.31 Sciatica right side

◦M54.32 Sciatica left side

Subluxation ICD-9 ICD-10

739.1 Cervical segmental dysfunction M99.01 Cervical segmental dysfunction

739.2 Thoracic M99.02 Thoracic

739.3 Lumbar M99.03 Lumbar

739.4 Sacrum M99.04 Sacrum

739.5 Pelvis M99.05 Pelvis

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Enthesopathy◦ Like many diseases and disorders, enthesopathy has a variety of possible causes. Very commonly the

disorder is caused by some activity or position (posture in spine) that creates repetitive or continual stress.

◦ Common enthesopathies are tennis elbow, planter fasciitis and iliotibial band syndrome. Noting this patients postural abnormalities and the indication of pain being worse when working on a computer and the resultant postural stress of this activity this would be indicative of spinal enthesopathy.

◦ This is further evidenced on x-ray where there was exostoses on the spinous processes indicative of stress and inflammation reaction where the muscle and tendon intsert to the bone (spinous).

◦ There was also greater tenderness over the spinous process.

Enthesopathy◦ M46.02 Spinal enthesopathy cervical region (720.1 ICD-9)

◦ M46.03 Spinal enthesopathy cervicothoracic region (720.1 ICD-9)

◦ M46.04 Spinal enthesopathy thoracic region (720.1 ICD-9)

◦ These codes are also condisdered a category II or moderate term diagnosis but give much more specificity than muscle pain as it relates specifically vertebral sections.

M46.00 Spinal enthesopathy site unspecified M46.05 Spinal enthesopathy thoracolumbar region

M46.01 Spinal enthesopathy occipito-atlanto-axial region M46.06 Spinal enthesopathy lumbar region

M46.02 Spinal enthesopathy cervical region M46.07 Spin enthesopathy lumbosacral region

M46.03 Spinal enthesopathy cervicothoracic region M46.08 Spinal enthesopathy sacral and sacrocccygeal region

M46.04 Spinal enthesopathy thoracic region M46.09 Spinal enthesopathy multiple sites in spine

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Complicating Factors◦ There are some additional diagnosis for this patient that were evidenced on x-

ray that at the very least would be considered complications and demonstrate a greater necessity of care whether by intensity and or length.

◦ The spinal degenerative and arthritic changes would be indicated by.

◦ M47.812 Cervical spondylosis (721.0 ICD-9)

◦ M47.813 Cervicothoracic region spondylosis (721.0 and 721.2 ICD-9 but non specifically to identify cervicothoracic)

◦ M47.814 Thoracic spondylosis (721.2 ICD-9)

◦ The acquired kyphosis noted in the cervical and thoracic region.

◦ Postural kyphosis cervicothoracic region M40.03 (737.10 ICD-9)

Taping and StrappingStrapping refers to the application of overlapping strips of adhesive plaster or tape to a body part to exert pressure and hold a structure in place. Strapping may be used to treat strains, sprains, dislocations, and some fractures. The strappingcodes are intended to be used when the desired effect is to provide total immobilization or restriction of movement. These services are typically performed outside a therapy plan of care.

◦ 29200 Strapping; thorax

◦ 29799 Unlisted (Includes lower back)

◦ 29240 Strapping of shoulder (e.g. Velpeau

◦ 29260 Strapping of elbow or wrist

◦ 29280 Strapping of hand or finger

◦ 29505 Application of long leg splint (thigh to ankle or toes)

◦ 29520 Strapping; hip

◦ 29230 Strapping; knee

◦ 29540 Strapping; ankle

◦ 29550 Strapping; toes

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KinesiotapingAMA CPT Assistant in March 2012. They state, “Because Kinesiotape tape is a supply, its application is included in the time spent in direct contact with a patient to provide either reeducation of a muscle and movement or to stabilize a body are to enable improved strength or range of motion. The application of tape is usually performed in conjunction with education the patient on various functional movement patters. The tape is applied based on the patients specific patters of weakness or strength. The tape is left in place after instruction related to movements designed for improving strength, range, and coordination is provided and documented.

“However, if the purpose of the taping is to immobilize the joint then strapping codes may be appropriate as those codes describe the use of a strap or other reinforced material applied post fracture or other injury to immobilize a joint. If the taping is used to facilitate movement by providing support, and the tape is applied specifically to enable a less painful use of the joint and greater function (i.e. restricting in some movement, facilitating others) application of tape in this manner is typically part of neuromuscular reeducation (97112) or therapeutic exercise (97110), dependent on intent or outcome desired.”

HCPCS CodesHCPCS (pronounced “hick-picks”) is a uniform coding system designed for health care providers to report supplies and other professional services. Many health insurance companies are now requiring the use of these codes to identify supports and or other supplies provided to your patients. The following list are the most commonly used supplies in chiropractic offices. A complete list of codes is available in the HCPCS code book which can be purchased from AMA 800 621-8335.

Vitamins and Non Rx

◦ A9150 Nonprescription drug or similar substance

◦ A9152 Single Vitamin/mineral/trace element, per dose

◦ A9153 Multiple vitamins, with or without minerals, per dose

Tens and Supplies

◦ E0720 TENS Unit (two lead)

◦ E0730 TENS Unit (four lead)

◦ A4595 Electrodes (per pair) TENS or similar

◦ A4558 Conductive paste or gen Tens, NMES device

◦ A4559 Conductive paste or gel Ultrasound device

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Evaluation & Management Service GuidelinesLevels of E/M Services

Within each category or subcategory of E/M service, there are three to five levels of E/M services available for reporting purposes. Levels of E/M services are not interchangeable among the different categories of service. For example, the first level of E/M services in the subcategory of office visit, new patient, does not have the same definition as the first level of E/M services in the subcategory of office visit, established patient.

The levels of E/M services include examinations, evaluations, treatments, conferences with or concerning patients, preventive pediatric and adult health supervision, and similar medical services. The levels of E/M services encompass the wide variations in skill, effort, time, responsibility and medical knowledge required for the prevention or diagnosis and treatment of illness or injury and the promotion of optimal health. Each level of E/M services may be used by all physicians.

The descriptors for the levels of E/M services recognize seven componants, six of which are used in defining the levels of E/M services. These componants are:

◦ History

◦ Examination

◦ Medical decision Making

◦ Counseling

◦ Coordination of care

◦ Nature of presenting problem

◦ Time

Evaluation & Management Service GuidelinesLevels of E/M Services

Within each category or subcategory of E/M service, there are three to five levels of E/M services available for reporting purposes. Levels of E/M services are not interchangeable among the different categories of service. For example, the first level of E/M services in the subcategory of office visit, new patient, does not have the same definition as the first level of E/M services in the subcategory of office visit, established patient.

The levels of E/M services include examinations, evaluations, treatments, conferences with or concerning patients, preventive pediatric and adult health supervision, and similar medical services. The levels of E/M services encompass the wide variations in skill, effort, time, responsibility and medical knowledge required for the prevention or diagnosis and treatment of illness or injury and the promotion of optimal health. Each level of E/M services may be used by all physicians.

The descriptors for the levels of E/M services recognize seven componants, six of which are used in defining the levels of E/M services. These componants are:

◦ History

◦ Examination

◦ Medical decision Making

◦ Counseling

◦ Coordination of care

◦ Nature of presenting problem

◦ Time

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Levels of E/M Services Cont…The first three of these components (history, examination and medical decision making) are considered the key components in selecting a level of E/M services.

The next three components (counseling, coordination of care, and the nature of the presenting problem) are considered contributory factors in the majority of encounters. Although the first two of these contributory factors are important E/M services, it is not required that they be provided at every patient encounter.

Coordination of care with other providers or agencies without a patient encounter on that day is reported using the case management codes.

The final component, time, is included only to assist physicians in selecting the most appropriate level of E/M services. It should be recognized that the specific times expressed in the visit code descriptions are averages, and therefore represent a range of time which may be higher or lower depending on actual clinical circumstances.

The actual performance of diagnostic tests/studies for which specific CPT codes are available is not included in the levels of E/M services. Physician performance of diagnostic tests/studies for which specific CPT codes are available should be reported separately, in addition to the appropriate E/M code.

Evaluation & Management Service GuidelinesNature of Presenting Problem

A presenting problem is a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for

encounter, with or without a diagnosis being established at the time of the encounter. The E/M codes recognize five

types of presenting problems that are defined as follows:

Minimal: A problem that may not require the presence of the physician, but service is provided under the physicians

supervision.

Self-Limited or Minor: A problem that runs a definite and prescribed course, is transient in nature, and is not likely to

permanently alter health status OR has a good prognosis with management/compliance.

Low Severity: A problem where the risk of morbidity without treatment is low; there is little risk of mortality, without

treatment; full recovery, without functional impairment is expected.

Moderate Severity: A problem where the risk of morbidity without treatment is moderate; there is moderate risk of

mortality without treatment uncertain prognosis OR increased probability of prolonged functional impairment.

High Severity: A problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high

risk of mortality without treatment OR high probability of severe, prolonged functional impairment.

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Evaluation & Management Service GuidelinesHistory of Present Illness

A chronological description of the development of the patient’s present illness from the first sign and/or symptom to the present. This includes a description of location, quality, severity, timing, context, modifying factors and associated signsand symptoms significantly related to the presenting problem(s).

The extent of the history is dependent upon clinical judgment and on the nature of the presenting problem(s). The levels of E/M services recognize four types of history that are defined as follows:

Problem Focused: Chief complaint; brief history of present illness or problem.

Expanded Problem Focused: Chief complaint; brief history of present illness; problem pertinent system review.

Detailed: Chief complaint; extended history of present illness; problem pertinent system review extended to include a review of a limited number of additional systems; pertinent past, family and/or social history directly related to the patients problems.

Comprehensive: Chief complaint; extended history of present illness; review of systems which is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems; complete past, family and social history.

CODES/ICD CPTOffice Management and Billing Tips (Are you HIPAA Compliant-Do you have HIPAA office forms?)

New Patient

1.

2.

3.

4.

5.

Established Patient

1.

2.

3.

4.

5.

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Revision 02/12

• Changed to match electronic format

(5010) and ICD-10 codes

• Adds space for eight more diagnosis

codes in box 21

• January 6th, 2014 – Health plans and

clearinghouses must accept the form

• April 1st, 2014 – Providers must use new

form

Seminar Summary NotesS - E - X -

_________________________________________________

A - I - D - S -

_________________________________________________

D - I - E –

_________________________________________________

MPC Forms will ensure that the documentation will meet the Standards of Care and the Standards of Practice. This works with EHR/EMR.

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Units� 1 Unit 8-22 Minutes

� 2 Units 23-37 Minutes



� Multiple timed procedures are billed in units based on cumulative time.

10 Worst Insurance Companies(D.C. Magazine – Vol.27, #17 – Aug. 12, 2009)

1. Allstate – 3 Ds (Dent, Delay, Defend) Note: 4.6 Billion in 2007

2. UNUM – Disability Insurance Company

3. AIG

4. State Farm – Forged IME Doctors Signatures

5. Conseco

6. Wellpoint

7. Farmers

8. United Health

9. Torch Mark

10. Liberty Mutual

www.justice.org/docs/tenworstinsurancecompanies.pdf

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Office of the Inspector General Compliance GuidelinesThe Office of Inspector General has issues Voluntary Compliance Guidelines for Individual and Small Group Physician Practices to help physicians identify both erroneous and fraudulent claims and to help ensure that submitted claims are true and accurate.

The compliance guidelines contain seven standards components that provide a solid basis upon which a physician practice can create a voluntary compliance program:

◦ Conducting internal monitoring and auditing

◦ Implementing compliance and practice standards

◦ Designating a compliance officer or contact

◦ Conducting appropriate training and education

◦ Responding appropriately to detected offenses and developing corrective action

◦ Developing open lines of communication

◦ Enforcing disciplinary standards through well-publicized guidelines

A copy of the guidelines can be found on the OIG website at :

http://oig.hhs.gov/authorities/docs/physician.pdf

Office of the Inspector General Compliance GuidelinesSimilar components have been contained in previous guidance's issued by the OIG. However, unlike other guidance's issued by OIG, this guidance for physicians does not suggest that physician practices implement all seven components of a full scale compliance program. Instead, the guidance emphasized a step-by-step approach to follow in developing and implementing a voluntary compliance program. This change is in recognition of the financial and staffing resource constraints faced by physician practices. The guidance should not be viewed as mandatory or as an all inclusive discussion of the advisable components of a compliance program. Rather, the document is intended to present guidance to assist physician practices that voluntarily choose to develop a compliance program.

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2251.3 Necessity for TreatmentA. The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patients condition and provide reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam, as described above.

Most spinal joint problems may be categorized as follows:

◦ Acute subluxation – A patients condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in arrest or retardation of the patients condition.

◦ Chronic subluxation – A patients condition is considered chronic when it is not expected to completely resolve (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the functional status has remained stable for a given condition, further manipulative treatment is considered maintenance therapy and is not covered.

2251.3 Necessity for TreatmentD. Documentation Requirements: Subsequent Visits – The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:

1. History

◦ Review of chief complaint

◦ Chances since last visit

◦ System review if relevant

2. Physical Exam

◦ Exam of area of spine involved in diagnosis

◦ Assessment of change in patient condition since last visit

◦ Evaluation of treatment effectiveness

3. Documentation of treatment give on day of visit

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Medicare Change 1996Levels of Subluxation no longer required on Medicare Claim FormHistorically in the past on the Medicare Claim Form HCFA-1500, you had to enter the levels of subluxation. However, recently, according to Medicare, Chiropractic offices “No Longer” have o show the levels of subluxation on the Medicare Claim Forms. X-rays, however, under Federal Section 2250, etc., etc., must be available for review in the providers office upon request. This special Chiropractic requirement is still in effect, along with; #14 for chiropractic servicer enter the date of the initiation of the course of the treatment, #19 enter the x-ray date for Chiropractic vices. By entering the “x-ray” date in item #19 and the “initiation” date for the course of treatment in item #14 you are now certifying that all relevant clerical information is on file along with the appropriate x-rays and all are available for review upon request. These new changes are part of the revision of the HCFA 1500 requirements. Please check with your local carrier and/or administrators for changes in items #4,#9, and #11. This creates a standards national policy for collecting Medicare information on the HCFA Form 1500 in as much as this was not available in the past. If your Medicare carrier is not following these instructions, Federal HCFA wants to be made aware of this situation. Please call the Medicare office in Washington or contact your Washington Rep or Senator. Also, please not that instead of using the word subluxation, according to Federal Section 2251.4, you are allowed to also use the following safer, legal words which are:

1. Off centered 5. Incomplete dislocation

2. Misalignment 6. Rotation

3. Malposition 7. Listhesis

4. Spacing - antero

- Abnormal - postero

- Altered - setro

- Decreased - lateral

- Increased - spondylo

8. Motion-limited lost restricted flexion/extension

X-Rays Ordered/Referred by a ChiropractorCoverage of chiropractic services is specifically limited to treatment of the spine by means of manual manipulation. No other diagnostic or therapeutic service furnished by a chiropractic or under his order is covered. The x-ray may be used for documentation, but Medicare will make no payment to the MD or DO if the chiropractor orders the x-ray.

This clarifies the current policy regarding payment of diagnostic x-rays either ordered by or referred by a chiropractor. If a chiropractor directs or refers the patient to the radiologist to obtain an x-ray to demonstrate a subluxation prior to beginning treatment, and the radiologist performs the x-ray based upon the chiropractors evaluation of the patient, the radiologist should report the chiropractor as the ordering provider in item 17 of the CMS-1500 claim form. Medicare will deny the service as non-covered, the beneficiary will be responsible for payment, the Advance Beneficiary Notice (ABN) will not apply, advance written notice will not be required.

If the patient is referred by the chiropractor to the radiologist, and the radiologist then determines that an x-ray is appropriate, the radiologist assumes responsibility for ordering the x-ray, and enters his name and ID number in items 17 and 17a of the CMS-1500 claim form; Medicare will not deny the claim. The radiologist is not precluded from ordering a diagnostic x-ray. However, in this case, we would expect the radiologist to maintain adequate documentation to substantiate the medical necessity of the services that he has ordered, based upon his evaluation of the patient. In the event of a post payment review of claims, we would request this documentation to validate payments made to the radiologist.

Per the Balanced Budget Act (BBA) of 1997, the subluxation no longer has to be demonstrated by an x-ray (ie, the x-ray is no longer mandated, for dates of service on or after Jan. 1, 2000). However, effective for claims with dates of service on or after Oct. 1, 2000, when the x-ray is used to demonstrate subluxation, the date of the x-ray must be entered in Item 19 of the CMS-1500 claim form.

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Medicare ContraindicationsDynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement.

The following are relative contraindications to dynamic thrust: A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust, but does not rule out the use of dynamic thrust. The chiropractic physician should discuss this risk with the patient and record this in the chart.

◦ Articular hypermobility and circumstances where the stability of the joint is uncertain

◦ Severe demineralization of bone

◦ Benign bone tumors (spine)

◦ Bleeding disorders and anticoagulant therapy

◦ Radiculopathy with progressive neurological signs

Medicare Contraindications Cont…Dynamic thrust is absolutely contraindicated near the site of demonstrated subluxation and proposed manipulation in the following:

◦ Acute arthropathis characterized by acute inflammation and ligamentous laxity and anatomic subluxation or dislocation including acute rheumatoid arthritis and ankylosing spondylitis

◦ Acute fractures and dislocations or healed fractures and dislocations with signs of instability

◦ An unstable os odontoideum

◦ Malignancies that involve the vertebral column

◦ Infection of bones or joints of the vertebral column

◦ Signs and symptoms of myelopathy or cauda aquina syndrome

◦ For cervical spinal manipulations, vertebrobasilar insufficiency syndrome

◦ A significant major artery aneurysm near the proposed manipulation

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Beware of Offering Gifts and Other Incentives to PatientsProhibited Inducements in Medicare & Medicaid Draw Growing Attention

The US Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) continue to rigidly enforce federal rules that strictly prohibit Medicare and Medicaid providers from giving beneficiaries any sort of goods or services that might be interpreted as “prohibited inducements” to select on provider over another for covered health care services. The HHS Office of the Inspector General (OIG), the body charged with enforcement of this provision, interprets the prohibition to apply to any gift offered or provided to program beneficiaries that has a retail value of more then $10 individually, or a cumulative value of more than $50 in a calendar year.

According to section 1128A(a)(5) of the Social Security Act (thereafter “The Act), “…a person who offers or transfers to a Medicare of Medicaid beneficiary any remuneration that the person knows or should know is likely to influence the beneficiary's selection of a particular provider, practitioner or supplier of Medicare or Medicaid payable items or services may be liable for civil monetary penalties (CMPs) of up to $10,000 for each wrongful act.” The statutes defines “remuneration” to include, without limitation, waivers of copayments and deductible amounts (or any part thereof) and transfers of items or services for free or for other than free market value.

“This prohibitioner has serious implications for the chiropractic practitioner, since even the provision of transportation toand from chiropractic appointment as a courtesy to the Medicare patient becomes a violation of this rule if the value of that transportation exceeds $10”, said International Chiropractors Association (ICA) Medicare Committee Chair Dr. Michael Hulsebus. “This prohibition applies to both participating and non-participating Medicare providers and all providers, suppliers, etc., in the joint state-federal Medicaid program”.

Beware of Offering Gifts and Other Incentives to PatientsProhibited Inducements in Medicare & Medicaid Draw Growing AttentionThe OIG applies the prohibition against inducements according to the following principles:

◦ First, the OIG has interpreted the prohibition to permit Medicare or Medicaid providers to offer beneficiaries inexpensive gifts (other than cash or cash equivalents) or services without violating the statute. For enforcement purposes, inexpensive gits or services are those that have a retail value of no more than $10 individually, and no more than $50 in the aggregate annually per patient.

◦ Second, providers may offer beneficiaries more expensive items or services that fit within one of the five statutory exceptions:

◦ Waivers of cost sharing amounts based on financial need

◦ Properly disclosed copayment differentials in health plans

◦ Incentives to promote the delivery of certain preventive care services

◦ Any practice permitted under the federal anti kickback pursuant to 42 CFR 1001.952

◦ Waivers of hospital outpatient copayments in excess of the minimum copayment amounts

◦ Third, the OIG is considering several additional regulatory exceptions. The OIG may solicit public comments on additional exceptions for complimentary local transportation and for free goods in connection with participation in certain clinical studies.

◦ Fourth, the OIG will continue to entertain requests for advisory opinions related to the prohibition on inducements to beneficiaries. However, given the difficulty in drawing distinctions between categories of beneficiaries or types of inducements, favorable opinions have been, and are expected to be, limited to situations involving conduct that is very close to an existing statutory or regulatory exception.

In sum, unless a providers practices fit within an exception (as implemented by regulations) or are the subject of a favorable advisory opinion covering a providers own activity, any gifts or free services to beneficiaries should not exceed the $10 per item and $50 annual limits. (Note: The OIG will review these limits periodically and may adjust them for inflation if appropriate).

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OIG Continued� 83% insufficient treatment plan

�72% no treatment plan

�77% of treatment plans had no goals or objective measures of progress

�66% did not check for contraindications

�2009 OIG Report

�Medicare inappropriately paid 178 million out of 466 million for Chiropractic claims in 2006

�Efforts to stop payments for maintenance therapy have largely been effected

�Claims data lack information to identify maintenance therapy

�Chiropractors often do not comply with Medicare documentation requirements

Necessity of TreatmentThe patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patients condition and provide reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam.

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Acute Subluxation

A patients condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical exam. The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression, of the patients condition.

Chronic SubluxationA patients condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment, but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.

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MaintenanceUnder the Medicare program, chiropractic maintenance therapy is not considered to be medically reasonable or necessary, and is therefore not payable. Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.

P.A.R.T - Guidelines for DocumentationPain – Asymmetry – R.O.M. – Tissue Medicare Carriers Manual (MCM)/Part 3 – Claims Process Section 2251.2 Utilization Guidelines

�Subluxation – Subluxation is defined as a motion segment, in which alignment, movement integrity and/or physiological function of the spine are altered although

�Documentation of Subluxation – A subluxation may be demonstrated by an x-ray or by physical examination, as described below.

� Demonstrated by X-ray – An x-ray may be used to document subluxation. The x-ray must have been taken a time reasonably proximate to the initiation of a course of treatment. Unless

more specific x-ray evidence is warranted, an x-ray is considered reasonably proximate if it was taken not more than 12 months prior to or 3 months following the initiation of a course of

chiropractic treatment. In certain cases of chronic subluxation (e.g., scoliosis), an older x-ray may be accepted provided the beneficiary's health record indicates the condition has existed

longer than 12 months and there is a reasonable basis for concluding that the condition is permanent. A previous CT scan and/or MRI is acceptable evidence if a subluxation of the spine is

demonstrated.

� Demonstrated by physical examination – evaluation of musculoskeletal/nervous system to identify:

� Pain/tenderness evaluated in terms of location, quality, and intensity

� Asymmetry/misalignment identified on a sectional or segmental level

� Range of Motion abnormality (changes in active, passive, and accessory join movements resulting in an increase or a decrease of sectional or segmental mobility)

� Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament.

To demonstrate a subluxation based on physical examination, two of the four criteria mentioned under “physical examination” are required, one of which must be asymmetry/misalignment

or Range of Motion abnormality.

The history recorded in the patient record should include the following:

� Symptoms causing patient to seek treatment

� Family history, if relevant

� Past health history (general health, prior illness, injuries, or hospitalizations; medication, surgical history)

� Mechanism of trauma

� Quality and character of symptoms/problem

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

� Aggravating or relieving factors

� Prior interventions, treatments, medications, secondary complaints

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� Documentation Requirements: Initial Visit – the following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical exam:

� History as stated above

� Description of present illness including

� Mechanism of trauma

� Quality and character of symptoms/problem

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

� Aggravating or relieving factors

� Prior interventions, treatments, medications, secondary complaints

� Symptoms causing patient to seek treatment

� These symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine (spondylo or vertebral), muscle (myo), bone (osseo or osteo),

rib (costa or costal), and joint (arthro) and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause

headaches, arm, shoulder, and hand problems as well as leg and foot pain and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must

relate to the spine as such. The subluxation must be cansal, i.e. the symptoms must be related to the level of subluxation that has been cited. A statement on a claim that there is

“pain” is insufficient. The location of the pain must be described and whether the particular vertebra listed is capable of producing pain in the are determined.

� Evaluation of the musculoskeletal/nervous system through physical examination.

� Diagnosis: The primary diagnosis must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer

either to the condition of the spinal joints involved or to the direction of position assumed by the particular bone name.

� 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

� Documentation requirements: Subsequent Visits – the following documentation requirements apply whether the subluxation is demonstrated by x-ray or physical exam:

� History

� Review of chief complaint

� Changes since last visit

� System Review of relevant

� Physical Exam

� Exam of area of spine involved in diagnosis

� Assessment of change in patient condition since last visit

� Evaluation of treatment effectiveness

� Documentation of treatment given on day of visit

Medicare Audits�Different types of audits performed; Probe, CERT, OIG, RAC and Medicare Advantage

�Include all information relevant to date of treatment; exams, history, tx plans…

�Go through the appeals process, at this time most DC’s win the majority of cases on appeal

�Contact MAC

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Audit Tips�Pretend you are the reviewer: Are you more likely to approve a claim that is easily readable and understandable or one that requires an hour to decipher.

�Read the letter carefully and include everything it requests

�Consider attaching a brief note/cover letter to explain the patients history. This is not a substitute for the actual documentation.

2005 OIG Report�94% missing required elements

�34% missing evaluation

�26% no evaluation

�8% improper evaluation

�33% improper diagnosis

�29% no diagnosis

�4% diagnosis not subluxation

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This article from “Medicare B News”, Issue 203 dates April 21, 2003, is being updated and reprinted to ensure that the NAS provider and supplier community has access to recent publications that contain the most current accurate, and effective information available.

NAS has noticed an increase in the use of software – generate documentation for chiropractic services. On this subject , CMS states: “Documentation should detail the specific elements of the chiropractic service for this particular patient on this day of service. It should be clear from the documentation why the service was necessary that day. Services supported by repetitive entries, lacking encounter specific information, will be denied.”

In general, most computerized documentation, regardless of the software used, fails to provide individualized information necessary for reimbursement.

Software – generated documentation is commonly identical to the letter, comma and space for different patients, with only minor word changes; therefore, it does not reflect medical necessary. Services supported by repetitive entries lacking encounter specific information will be denied.

Daily notes need to be encounter specific for each date of service and contain both qualitative and quantitative elements evident for the subjective and objective portions of the documentation. Without this information, it is difficult for a reviewer to assess the true clinical picture of the patient, in regard to the severity of his/her condition. What may be appropriate for one patient, may not be enough or required on another patient or visit.

Factors that must be taken into consideration when treating and documenting: age, severity of condition, past response to treatment, frequency of treatment, and complicating factors.

Software-generated documentation often repeats the same phrases and sentences by simply rearranging the words to make it appear as if new information is being disseminated, but when compared to prior days notes, reflects the same or similar concepts.

Medicare Medicare

Part BPart B

DC SoftwareDC Software

DocumentationDocumentation

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Examples below illustrate poorly software-generated documentationA patient is seen and adjusted by the Chiropractor. See the following subjective findings.

Patient Visit Subjective Documentation

Day One She is afflicted by a moderate degree of intermittent dull pain with her stiffness and soreness in both sides of her neck.

Day Two In her neck bilaterally, the patient is feeling a moderate degree of dull pain with stiffness and soreness which occurs intermittently.

Day Three She is experiencing in her neck on both sides, an intermittent dull pain with stiffness and soreness of a moderate degree.

Another patient is seen and adjusted by the same Chiropractor. See the following subjective findings.

Patient Visit Subjective documentation

Day One The patient is troubled by a moderate grade of intermittent dull pain with both stiffness and soreness in her head on both sides.

Day Two In both sides of her head she is afflicted by a moderate grade of dull pain with stiffness and soreness which occurs intermittently.

Day Three The patient is afflicted by an intermittent dull pain with stiffness and soreness of a moderate degree in her head bilaterally.

The objective findings for both patients are as follows:

Patient Visit Objective Documentation

Day One Evidence of subluxation is detected coupled with tender deep paraspinal musculatires located at the middle and lower cervical regions on both sides.

Day Two Joint dysfunction is noted coupled with tenderness located in the middle and lower cervical areas on both sides.

Day Three The presence of subluxation is apparent, plus tender deep paraspinal musculatures overlying the lower and middle cervical regions on both sides.

Examples below illustrate poorly software-generated documentation Cont…Documentation should detail the specific elements of the manipulative service for a particular patient on each day of service. It should be clear from the documentation why the service was necessary that day.

The specific goals of treatment plans should be referred to in the contents of the progress notes. Using identical vague terminology for each visit is equivalent to using the word “ditto” or “same as” which is not appropriate and will lead to a claim denial. Coverage will also be denied for lack of reasonable expectation that the continuation of treatment would result in significant improvement of the patients condition.

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CMS CMS –– Audit NoticeAudit Notice

Advance Beneficiary NoticeAdvance Beneficiary Notice

Of Of NonCoverageNonCoverage (ABN)(ABN)

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Trending Now�Case Management

�Scrutiny of services including type, intensity and length

�24 visit plans do not necessarily = automatic 24 visits but up to 24 if medically necessary

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CMT Rules�CMT Includes Routine E/M Services:

�Pre-Service

�Intra-Service

�Post Service

�ADD’L E/M Services Reimbursable:

�Only if the patients condition requires separately identifiable service

�Modifier-25 added to indicate a separate and identifiable service was performed

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Chiropractic Manipulative TreatmentChiropractic manipulative treatment (CMT) is a form of manual treatment to influence joint and neurophysiological function. This treatment may be accomplished using a variety of techniques. The chiropractic manipulative treatment codes include a pre-manipulation patient assessment. Additional evaluation and management services may be reported separately using the modifier 25. If and only if the patients condition requires a significant separately identifiable E/M service, above and beyond the usual pre-service and post-service work associated with the procedure. For purposes of CMT, the five spinal regions referred to are: cervical region (includes atlanto-occipital joint); thoracic region (includes costo-vertebral and costotransverse joint); lumbar region; sacral region; and pelvic (sacro-iliac joint) region. The five extraspinal regions referred to are: head (including temperament, dibular joint, excluding atlanto-occipital) region; lower extremities; upper extremities; rib cage (excluding costotranverse and costovertebral joints) and abdomen.

98940 – Chiropractic manipulative treatment (CMT); spinal, one to two regions

98941 – Spinal, three to four regions

98942 – Spinal, five regions

98943 – Extraspinal, one or more regions

-25 Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service: the physician may need to indicate that one the day a procedure or service identified by a CPT code was performed, the patients condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. This circumstance may be reported by adding the modifier ‘-25’ to the appropriate level of E/M service, or the separate live digit modifier 09925 may be used. Note: this modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier ‘-57’.

Chiropractic Manipulative Treatment (CMT)

Code Description

98940 CMT; Spinal, one to two regions

98941 CMT; Spinal, three to four regions

98942 CMT; Spinal, five regions

98943 CMT; Extra spinal, one or more regions (not for Medicare purposes

Chriopractic Manipulative Treatment (CMT) is a form of manual treatment to influence joint and neurophysiological function. This treatment may be accomplished using a variety of techniques.

Spinal Regions – 98940 (98925 OMT) – 98941 (98926 OMT) – 98942 (98927 OMT)

For purposes of CMT, the five spinal regions referred to are:

�Cervical region (includes antio-occipital joint)

�Thoracic region (includes costobertebral and costotransverse joints)

�Lumbar Region

�Sacral Region

�Pelvic Region

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Chiropractic Manipulative Treatment (CMT)Extraspinal Regions – 98943 (98928 – 98929 – OMT)

The five extraspinal regions referred to are:

�Head Region (including temporomandibular joint, excluding atlanto-occipital)

�Lower Extremities

�Upper Extremities

�Rib Cage (excluding costotransverse and costovertebral joints)

�Abdomen

Extraspinal manipulation billed with spinal manipulation

United Health Care is a requirement modifier 51 on the extraspinal manipulation code when billed the same date of service as spinal manipulation: 98940, 98943-52

Flexion Distraction – 97140-59 --- Never bill with a 98942 – Document separate regions!

Flexion distraction is considered part of the manipulation service and not separately billable as traction.

Osteopathic Manipulative TreatmentOsteopathic manipulative treatment is a form of manual treatment applied by a physician to eliminate or alleviate somatic dysfunction and related disorders. This treatment may be accomplished by a variety techniques. Evaluation and Management services may be reported separately if, and only if, the patients condition requires a significant separately identifiable E/M service, above and beyond the usual pre-service and post service work associated with the procedure. Body regions referred to are: head region, cervical region, thoracic region, lumbar region, sacral region, pelvic region, lower extremities, upper extremities, rib cage region, abdomen and viscera region.

◦ 98925 Osteopathic manipulative treatment (OMT); one to two body regions involved

◦ 98926 Three to four body regions involved

◦ 98927 Five to six body regions involved

◦ 98928 Seven to eight body regions involved

◦ 98929 Nine to ten body regions involved

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Physical Medicine and Rehabilitation�Not Physical Therapy

�These services are viable for any provider that they are within their scope of practice – (Check Your State Law)

Active Care Documentation & Protocols

RRR – FLI

-Backsys

-FootWheel

-Rock & Roller

-Intracell Stick

-Necksys

-Thera-Ciser

-Swiss Ball

-Stationary Bike

-Treadmill

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ICD Bank – Use CPT Diagnostic Corollaries

Complicating conditions demonstrate a greater need for

carePer- Medicare, Blue Cross, Blue Shield, ASHN, Optum Health, United Health Care, et al

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Obama-Care Section 2706 – RE Weight Loss Program

�For eligible health plan members with obesity, defined as Body Mass Index (BMI) equal to or greater than 30 kg/m2, Optum will align reimbursement with Medicare including

�BMI = weight/height squared * 703

�Height in inches squared 72*72 = 5184

�Weight in pounds divided by that number 250/5184 = .0482253

�That sum * 703 = 33.90 BMI

�One face-to-face visit every week for the first month

�One face-to-face visit every other week for months 2-6

�One face-to-face visit every month for months 7-12 (if the member meets the 3kg(6.6lbs) weight loss requirement during the first 6 months

�For members who do not achieve a weight loss of at least 3kg (6.6lbs) during the first 6 months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional 6 month period

�CPT codes for obesity screening and counseling are:

�99401 – preventative medicine counseling and/or risk factor interventions provided to an individual (separate procedure); approximately 15 minutes

�99402 – preventative medicine counseling and/or risk factor interventions provided to an individual (separate procedure); approximately 30 minutes

Aetna – Danger Policies For DCs/PatientsAetna Policy Bulletin Chiropractic 0107Aetna considers chiropractic services medically necessary when all of the following criteria are met:◦ The member has a neuromusculoskeletal disorder; and

◦ The medical necessity for treatment is clearly documented; and

◦ Improvement is documented within the initial 2 weeks of chiropractic care

If no improvement is documented within the initial 2 weeks, additional chiropractic treatment is considered not medically necessary unless the chiropractic treatment is modified.

If not improvement is documented within 30 days despite modification of chiropractic treatment, continued chiropractic treatment is considered not medically necessary.

Once the maximum therapeutic benefit has been achieved, continuing chiropractic care is considered not medically necessary.

Chiropractic manipulation in asymptomatic persons or in persons without an identifiable clinical condition is considered not medically necessary.

Chiropractic care in persons, whose condition is neither regressing nor improving, is considered not medically necessary.

Manipulation is considered experimental and investigational when it is rendered for non-neuromusculoskeletal conditions (e.g., attention-deficit hyperactivity disorder, dysmenorrhea, and epilepsy; not an all inclusive list) because its effectiveness for these indications is unproven.

Manipulation of infants is considered experimental and investigational for non-neuromuculoskeletal indications.

Chiropractic manipulation has no proven value for treatment of idiopathic scoliosis or for treatment of scoliosis beyond early adolescence, unless the member is exhibiting pain or spasm, or some other medically necessary indications for chiropractic manipulation are present.

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Aetna -- Danger Policies For DCs/Patients Aetna Policy Bulletin Chiropractic 0107The primary focus of the profession is the vertebral column; however, all other peripheral articular structures and adjacent tissues may be treated, depending on state chiropractic scope of practice laws.

Neuromusculoskeletal conditions commonly treated by chiropractic physicians include: Contractures, degenerative conditions of joints, fibrositis, headaches, myalgia, myofibrositis, neuralgias, noninfectious inflammatory disorders of the joints muscles and ligaments of the spine and extremeties, osteoarthritis, peripheral joint trauma, radiculopathies, repetitive motion injuries, spinal facet syndromes, spondylolisthesis, spondylosis, and sprains and strains.

The chiropractor may treat multiple neuromusculoskeletal conditions during a single visit.

In addition to manipulation, chiropractors may employ adjunctive nutritional, hygienic, and environmental modalities, physiotherapeutic modalities, rehabilitation, and therapeutic massage for the treatment of subluxation and related conditions. The use of adjunctive modalities must be appropriate for the diagnosis and must augment or enhance the manipulative treatment. The type of therapy used should be be consistent with status of the patients condition. (e.g., acute, subacute, rehabilitative or chronic)

Examples of adjunctive physiotherapeutic measures that have been used in chiropractic include:◦ Acute phase: thermal (cold) therapy, electrotherapy, trigger point therapy

◦ Rehabilitative phase: exercise

◦ Subacute phase: thermal (heat), electrotherapy, ultrasound

Danger Policies for DCs/PatientsDanger Policies for DCs/Patients

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Danger PoliciesDanger Policies

For For

DCs/PatientsDCs/Patients

15 Patient Points to Remember in all Practices

�The PATIENT is the most imporatant person in our profession who will fight for us.

�The PATIENT is the most important person in the office.

�The PATIENT is not dependant upon us, we are dependant on him or her.

�The PATIENTS do us a favor when they call. We are not doing them a favor when we “serve” them.

�The PATIENTS are not a cold statistic. They are flesh and blood, spines and bones, and brain and spinal cord. A human being with feelings and emotions like our own.

�The PATIENTS are not an interruption of our work. They are the purpose of our existence.

�The PATIENT is not a name, face or patient number. He or she is a real person, with opinions, questions, and experience.

�The PATIENT is not someone with whom to argue or match wits.

�The PATIENT is a person who brings us his or her spinal and personal problems. It is our job to help and serve him or her.

�The PATIENT is the person who pays for time, knowledge, our services, and provides our income.

�The PATIENT should always be treated with the same courtesy and respect, as you would expect for your own mother or father.

�The PATIENT deserves the most courteous and attentive attitude that we can provide. The best quality services and products we can produce.

�The PATIENT should always get PTC – Present Time Consciousness.

�The PATIENT should always receive the best spinal adjustments to address his or her VSC (vertebral subluxation complex) with its 8 physical and 8 chemical components.

�We should always ask the patient for referrals of their family and friends.

Remember love and service is primary – all rewards are by produces!

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Dr. Murkowski’s MPCDr. Murkowski’s MPC

Seminar Product ListSeminar Product List

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