P.A.R.T. Exam, X-ray, and the Demonstration of Subluxation

One of the requirements for the initial visit is the diagnosis of a subluxation that corresponds to the symptoms the patient demonstrates.  In other words, these symptoms must bare a direct relationship to the level of subluxation. The diagnosis of subluxation can be made either by a dated x-ray or by a physical exam noting 2 of the 4 following criteria to support a manually demonstrated subluxation:

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


2. Asymmetry/misalignment identified on a sectional or segmental level.


3. Range of motion abnormality (changes in active, passive and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility.)


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

**One of the two criteria documented must be either asymmetry or range of motion

         abnormality.

I strongly suggest doing spinal x-rays a minimum of once each year, instead of P.A.R.T.  Using your x-rays to determine subluxation is never challenged, where as anyone can challenge the findings of a subluxation with P.A.R.T.

 

If you have no x-ray of the area you adjusted, less than one (1) year old, you must do a P.A.R.T. form each Chiropractic visit.  Even if some of your examinations consist of the same procedures as in P.A.R.T., you must have a P.A.R.T. form each visit.  When you have current x-rays of your Medicare patient, no P.A.R.T. form is necessary.  P.A.R.T. should be placed in Item #19 on the claim form to tell the Medicare carrier you are using P.A.R.T. with this patient.

Other Payers on a Medicare Patient

There are specific guidelines we all must know and follow as we see Medicare patients that have another primary payer other than Medicare. (e.g., Workers Comp., Auto Insurance, Personal Injury, etc.)  Keep in mind, we are required to bill Medicare for ALL covered services even if there is another payer.

As a Participating Provider, you may bill your normal PI fees on this Medicare patient to all other payers and collect above the Medicare fees from other payers. 

Non-participating Providers, even though they receive the highest reimbursement from Medicare (i.e. the limiting charge), you must NEVER bill or collect from any payer on this Medicare patient above the limiting charge. (The limiting charge is the amount your Medicare carrier has set for your local.)  Item 10a through 10c on the claim form or in the electronic billing format will tell the Medicare Carrier (and other payers) who is responsible for payment.

Make a copy of the claim to the primary payer other than Medicare e.g., Workers Comp., Auto Insurance, Personal Injury, etc., and also, send a copy of the claim to the Medicare Carrier.  Be sure when billing another payer on this Medicare patient, to have the patient sign an ABN each visit, for both covered and non-covered services and use all modifiers, since Medicare will not pay.  (Example:  98941 AT GA)

The advantage of billing Medicare on this PI claim is if the PI claim fails and your patient loses the case, now Medicare will pay most of the claim because it was billed within the year time limit with all the correct modifiers and fees.
 
Questions? Give me a call today at 1-800-MY CHIRO.

Sincerely,
Dr. Street

Chiropractic Audits Gone Wild!

Chiropractic Medicare
Audits...Audits...Audits!

My phone calls are increasing especially from New York, California, Nevada, and now Alabama!

Palmetto Medicare Carrier in California and Nevada broke the ice and requested thousands of Chiropractic records as both pre-payment and post payments audits. Then, the New York Medicare Carrier went wild with requesting records on every patient.

Now the Alabama Medicare Carrier is following suit with audit after audit on Chiropractors, requesting records/documentation for a specific period of time and any portion of the preceding 6 months prior. 

These audits, first, eat up the small profits we get in Medicare. Secondly, they stress both the doctor and the staff effecting the quality of Chiropractic care delivered.  The major problem is that most Chiropractors lose some or all of their audit because of mistakes or lack of knowledge in Medicare procedures. 

Speaking with hundreds of Chiropractors dealing with audits, they all have made the following errors that cost them big time:

1. Date of current (HCFA item #14) must never be over 60 days old.


2. X-ray date must be less than 12 months old (364 days or less), or when no x-ray present, a P.A.R.T. form must be completed each and every visit. 


3. Diagnosis must make sense and match S.O.A.P. Notes to support the care rendered.


4. Lack of complete documentation by Federal Standard to proven Medical Necessity.

S.O.A.P. Notes are not the only Chiropractic documentation necessary to make a claim payable.  (Documentation is a federal document.)

Need help and/or assistance so that you can survive a Medicare audit? Please give me a call at (618) 395-3800 or consider ordering or Chiropractic Medicare DVD and booklet - Dr. Street

Chiropractic Medicare Fees and Collecting Payment

Dear Doctors and Staff,

Chiropractors are the only healthcare providers that CANNOT opt-out of Medicare. When you see seniors with Medicare in your practice you must do Medicare correctly!

Each Medicare carrier provides a fee schedule for the Chiropractors each year in each state local.  You can go to your Medicare Carrier's website search for Physician Fee Schedule (go to about page 245) and you will find 98940, 98941 and 98942 with specific fees for your local for both participating and non-participating providers.  The code with the # sign indicates the fees set for if you adjust this patient in another facility other than your office. The fees without the # sign are your in-office fees.

Participating providers may bill the Medicare Carrier whatever fee they wish.  The Medicare Carrier has the responsibility to know your Medicare fees and will automatically reimburse to the DC 80% of those fees.  The Chiropractor must collect the 20% from the patient or supplemental insurance and NEVER collect from any payor above the set fees by the Medicare Carrier. If you do, and get caught, the fines are up to $10,000.00 per incident.

A non-participating provider must know what the Medicare fees are prior to seeing or billing either the Medicare patient or the Medicare Carrier.  If they don’t and get caught, they may be fined up to $10,000.00 per incident and the same for being paid above the set Medicare fees.  The non-participating provider must never collect or bill any payor above the "limiting" charge, including a Medicare patient in auto accidents, worker’s comp., etc.

Newsletters from July 2011

July 2011

July 6, 2011

First, learn the correct way to do Medicare by "Federal Standards". Then, you can take the next step in becoming compliant and going paperless.

Everybody seems to be talking "paperless" and "compliance".  However, before you are successful being paperless and/or compliant in Medicare, you must be successful in learning and applying correct Chiropractic Medicare procedures.
The dangerous part of Chiropractic Medicare is that many Chiropractors assume that they must be doing Medicare correctly because they are being paid. That is the reason most Chiropractors lose in post-payment review audits.  The Medicare Carriers seem to be unable to review each Chiropractic claim when issued, so they hire recovery companies to review claims for money recovery from Chiropractors.

Several small mistakes can produce major problems. For example, item #14 (date of current) over 60 days old, flags the claim. The diagnosis must support the care rendered. X-rays must be no older than 12 months and/or P.A.R.T. form must be completed each and every visit if there are no current x-rays.  S.O.A.P. notes must match the billing as to the regions billed.  And, finally, your "documentation" (not the S.O.A.P. notes) must be indicated in Item #19 along with date of x-rays.

If you have attended one of our presentations or have purchased "The Basics" Chiropractic Medicare DVD, you understand the specific "documentation".

July 11, 2011
"Audit Compliance Plan"

The best way to have the most efficient and effective business management is to place together a written working audit plan for your office.  Your Compliance Officer should place your Audit Plan on a bulletin board in an accessible location so the entire staff and doctors can review.  The process should envelope everyone's ideas and responsibilities.

The Compliance Officer shall develop an education process for all doctors and staff so that everyone involved in your office takes part of the Audit Compliance Plan.  Reviewing this process each 3 to 6 months is necessary for all staff to keep from old habits and to stay in the process of becoming compliant.

Your Compliance Officer (a specific staff or doctor) is responsible in making the Compliance Plan workable, effective, and up-to-date.
NOTE:  We will have a Plan Outline ready for all interested very soon!

July 18, 2011
"S.O.A.P. Notes and Date of Current (Item #14)"

When you file a claim to your Medicare Carrier, date of current #14 indicates to the Medicare Carrier how long you have been seeing this patient for this sequence of care.  If the date of current is over 60 days old, it makes no difference about your diagnosis; your claim will be pulled for review.

The reason is even if your notes indicate an accident or exacerbation, item #14 tells the carrier it is still the same onset date and a chronic condition.  Accidents, exacerbations, etc. always changes date of onset (item #14).

All of your S.O.A.P. Notes whether hand written or dictated, need either a signature log or an attestation of all record entries.  All must be signed and legible.  Unsigned S.O.A.P. Notes are not acceptable.

July 25, 2011
"Four types of Chiropractors in Medicare which one are you?"

Medicare is a controlled program in that both the consumer and the provider have signed a contract agreeing upon specific guidelines and that they both know and follow those specific guidelines.

1. A Chiropractor That Can Not See Medicare Patients:  A doctor that has not completed a CMS 855i application, and does not have a Medicare number.  This doctor, new or old, does not have the privilege to take care of a Medicare patient.  NO, this doctor can not adjust Medicare patients while working for another Chiropractor and NO, this doctor cannot work under another doctor's NPI number.




2. Participating Provider:  A doctor who has signed a Medicare contract that has agreed to provide the Chiropractic adjustment and accept assignment on all Medicare patients.  (The money is deposited into the doctor's checking account.)  This doctor will know and follow all Medicare guidelines.




3. Non-Participating Provider Accepting Assignment:  A Chiropractor who signed a contract to be non-participating in the Medicare Program.  However, they have marked on the claim form that they will accept assignment on a claim so the Medicare carrier reimburses the doctor not the patient. This is the same as being a Participating Provider at the lowest reimbursable fee.




4. Non-Participating Provider That Does Not Accept Assignment:  A doctor who has signed a contract with the Medicare carrier to see a Medicare patient, collect from the patient for those services up to, and including, the limiting charge at time of service, bill Medicare, and the reimbursement goes to the Medicare patient.

Remember, both Participating and Non-Participating Providers must know and follow Medicare guidelines to be safe in the Medicare Program.

Newsletters from June 2011

June 2011

June 3, 2011
Chiropractic Medicare Compliance

What do the typical Chiropractor and their staff need to do to become compliant in the future Medicare arena?

Relax!  Sit back and review materials as they are presented.  I recommend not spending big bucks for software right now.  Remember the rules for becoming compliant are still being discussed with many unanswered questions.

We have two important Medicare issues to understand.  First, learning and doing Chiropractic Medicare so our patients receive their needed Chiropractic adjustments.  Secondly, doing Chiropractic Medicare correctly with proper procedure, S.O.A.P. notes and documenting the Chiropractic necessity of care so when audited, either in house or by your Medicare Carrier, you are successful. By doing Medicare correctly, once you have become compliant, your in-house audits will reveal you do, in fact, know how to do Medicare correctly. 

Most important, be sure you know how to do Medicare correctly.  If you are not sure, consider our Chiropractic Medicare DVD and booklet. Once you are actively improving your record keeping and documentation, now consider becoming Medicare Compliant.  First move, you should appoint a Compliance Officer for your Chiropractic Business. (You or one of your Staff)  The Compliance Officer's job is to start collecting information for implementing proper procedures to make your office compliant.  In the next few weeks we will have a Chiropractic Medicare Compliance Guidelines Booklet available for our fellow Chiropractors and staff.

Remember.....everyone has to do this, so keep it as simple as possible and keep on going. 

June 10, 2011
"Unusual payments and X-ray vs. P.A.R.T"

The past couple of weeks our patients and many doctors are receiving checks and direct deposits from the Medicare carriers in the amounts of around $1.60 for adjustments provided in early 2010.  Those checks and deposits represent the fee changes that occurred in 2010.  Many patients do not understand why they receive this money.

NOTE - We constantly get the question... "Must I take x-rays of the regions of the patient adjusted each 12 months?"

ANSWER - If you use an x-ray to prove a subluxation, YES, you must have x-rays of all the regions you adjust and those films must be less than 12 months old.

If you chose to not take an x-ray on your Medicare patients each 12 months, you can complete a P.A.R.T. form each visit.  Using x-rays to prove the subluxation is by far the best.  You are the authority of information you find on the x-ray.  Using a P.A.R.T. form is not as effective and safe simply because anyone else can review the P.A.R.T. form and may determine something different than you.

June 14, 2011
"PI & Medicare"

When a Medicare patient enters your office that has been in an auto accident, remember, they are still a Medicare patient.

If you are a non-participating provider, you must not bill the PI Insurance Company above the limiting charge set by your Medicare Carrier.  As a participating provider, you can bill your normal PI fee.

The Medicare patient should sign an ABN each visit so they are aware Medicare will not pay for any services.  When billed to the PI Insurance, the AT modifier is also used indicating "Active Treatment".  Example:  98941 AT GA.  The GA modifier is used if the patient signs an ABN for a covered service and a GX modifier is used if the patient signs the ABN for any non-covered service in

Medicare. Item 10a thru 10c on the claim, when completed, tells the PI Insurance Company that it is their responsibility.  The Medicare Carrier should pay nothing on this claim, unless the PI Insurance Company wins the case and pays nothing.
You can now take the denial letter from the PI Insurance Company, mail a copy to Medicare, and Medicare will now pay the claim.

IMPORTANT:  If for some reason, Medicare pays on this PI case, and the PI Insurance also pays, if you do not refund the money back to Medicare within a specific time, Medicare will take that money out of your (The Doctors) Social Security account.

June 20, 2011
"Do you have a Medicare Compliance Plan?"

Years prior, violations were limited.  However, now violations are staggering and enforcement carries major disabling fines.  Willful neglect is simply not knowing, or knowing and doing nothing.  The time of sitting back, going with the flow and doing/knowing nothing is over.

It is mandatory to have an in-office compliance program.  Your office will need a HIPPA Privacy Officer, HIPPA Security Officer and a Compliance Officer.  These are the three people asked for in an audit.

Here are the five best ways to come up with an audit:

1. Disgruntled Employee - usually comes with a filed complaint.




2. Patient Complaint - usually from billing error or patient misunderstanding.




3. Doctor Complaint - usually from questionable advertising, waiving copayments, etc.




4. X-ray Practices - most of the time while using outside x-ray facilities.




5. Errors in billing or suspicious billing practices, CMT’s, coding, etc.

If you find an in-office error, do not hesitate refunding the carrier before your carrier finds the error.

Finally, each office must have a written Policy and Procedure Plan for open line in-office communications.

We soon will have an example OIG Compliance Plan that will be available.  In the meantime, be sure you are doing Medicare correctly.  All of this and much more can be found in our Chiropractic Medicare DVD.  Thank you for your interest.

Newsletters from May 2011

May 2011

May 16, 2011

Just because you personally have not been involved in a Medicare audit does not mean you can let your defenses down!  

Palmetto GBA, the Medicare Carrier of California and Nevada issued a letter to Jurisdiction 1 Health Care Providers talking about November 2010 Medicare fee-for-service (FFS) claims error rate on paid claims error rate results nearly TWICE the national average for services rendered by Part B. All Medicare carriers have this information and are doing the same!     

The letter stated "BY FAR, the major component to the claims paid error rate is the lack of adequate documentation to support services billed."  The letter also stated, "You control the documentation describing the services your patient received, and your documentation serves as the basis for the bills sent to Medicare for the services you provided.  If your documentation does not support the services on the claim, then a payment error exists." 

Palmetto and MOST other carriers will be undertaking an AGGRESSIVE approach designed to address the cause of documentation errors.  They will INCREASE the level and frequency or pre-payment and post-payment reviews across all provider types. 

Medically unnecessary services are the result of:  
1.  Undocumented services. 
2.  Improperly documented services. 
3.  Insufficiently documented services.  

If you, as a Chiropractor and/or staff, do not know specifically what documentation is or believe documentation is only your S.O.A.P. notes please consider our Chiropractic Medicare DVD.  These Medicare Carriers are ALL stepping up audits because they are aware most Chiropractors believe Chiropractic documentation is the S.O.A.P. notes....IT IS NOT!
Chiropractors must do Medicare correctly as a Chiropractor which is different than any other healthcare providers in Medicare. DOCUMENTATION IS WITH A FEDERAL DOCUMENT, NOT JUST S.O.A.P. NOTES!

May 18, 2011

Just like the bill in New Mexico, Illinois Senate Bill 1843 attempts to change the whole meaning of chiropractic by passing a law that does not "broaden the Chiropractic Scope of Practice.... but changes the foundation of chiropractic. Senate Bill 1843 has already passed the Senate and headed to the Illinois House of Representatives. This is NOT an ICA/ACA battle!!!! This is a chiropractic battle to preserve chiropractic as originated. The bill was structured by Dr. Winterstein of National University whose goal is to make chiropractic into Medicine. Illinois, being the only Medical Practices State, has been Dr. Winterstein's dream for changing chiropractic into another health discipline.

Please take a few moments to go online and type in State of Illinois Representatives. Hit search. There you will find a list of Illinois State Representatives. Please call as many as you can and ask them to defeat Senate Bill 1843 or call 1-800-423-4690 for instructions.

ICA Calls for Defeat Illinois Senate Bill 1843 The International Chiropractors Association (ICA) and the International Chiropractors Association Political Action Committee (ICA-PAC), in response to requests from large numbers of members in Illinois, are calling on all Members of the Illinois House of Representatives to vote NO on Senate Bill 1843.   This legislation contains language that states that, “nothing in this Act shall be construed to prohibit a chiropractic physician from providing advice regarding the use of non-prescription products.” The danger in non-prescription drugs being recommended by untrained individuals is of grave concern to ICA and can certainly put the public at risk. Likewise, doctors of chiropractic have no formal training in oxygen therapies that would be authorized by the bill.   The removal of the defining language that expressly states that the practice of chiropractic is without the use of drugs or surgery clearly tips the balance in the direction of the application of drugs and since no additional education or testing or any other qualifications are mandated, this legislation inherently places the public at risk.

We urge you to vote NO on SB 1843 because:

·   It places the public at risk since the new authorities given to chiropractors to advise on “non-prescription products” which incorporates a vast range of over-the-counter substances which if inappropriately used can cause great harm, does not require any additional education or testing.

·   Chiropractic is, by its longstanding educational and definitional history, a drugless profession.

·   The public is entitled to one truly drugless healing profession and chiropractic has filled this role with proven clinical and cost effectiveness for more than 100 years.

At the top of ICA’s concerns regarding this legislation is public safety.  Studies have estimated that as upwards of 300,000 individuals may die each year as a result of pharmaceutical and medical errors. [1] Of this stunning and alarming number, a growing proportion is from non-prescription substances.  According to a 2001 report in the Journal of American Pharmaceutical Association, more than $177 billion in excess costs in the health care supply chain can be attributed to medication errors.  Sadly, estimates indicate that more than eighty percent of life-threatening medication incidents are the result of physician error. [2]   Clearly, this is not an area or an environment in which any practitioner can make a safe and effective contribution with less than a gold standard set of qualifications and credentials.   SB 1843 provides for no additional education and testing as a basis for the expansion of chiropractic scope to include pharmaceuticals.  On this basis and out of other concerns, ICA urges that this bill be defeated.    If you have any questions or would like more information please contact the International Chiropractors Association at 1-800-423-4690 or by e-mail at chiro@chiroprctic.org.
[1] Starfield B. Is US health really the best in the world? Journal of the American Medical Association (JAMA) 2000 Jul 26;284(4):483-5. Starfield B. Deficiencies in US medical care. JAMA. 2000 Nov 1;284(17):2184-5.. [2] Gurwitz, J.H., Field, T.S., Harrold, L.S., et al, “Incidence and preventability of adverse drug events among elderly persons in the ambulatory setting, (JAMA) 2003;289(9) 1107-1116.

May 23, 2011

This past Friday I sent the above ALERT email across the United States in regards to an Illinois Senate Bill 1843 that slipped through the Senate and into the House of Representative for vote. We are asking for chiropractic support to contact all Illinois Representative to either Vote NO for SB 1843 the way it presently stands or vote YES after accepting the amendment to remove language that is confusing and unnecessary.

Illinois House of Representatives are being asked to strike the words "...from providing advice regarding the use of non-prescription products or..."
SB 1843 language creates confusion in that "non-prescription products" is not defined at all.  If the intent is to authorize the Chiropractic provider to provide advice on non-prescription drugs, then extensive additional education and competence testing is absolutely essential, if such authority is desirable at all.  No such educational provisions are included in the bill and this concept has not been thoroughly and forthrightly discussed and debated throughout the legislative process.

If the intent is to authorize advice on such items as braces, pillows, orthotics and related supports, nutritional products and other commonly applied devices, items and products, then the language is unnecessary since such materials and devices have been covered and authorized to be provided by doctors of Chiropractic under the current statutory language for many decades.
Consumers in Illinois are entitled to complete clarity on the professional authorities and qualifications of all health care professionals and without this amendment, SB 1843 represents a step away from this vital goal. 

Ask the Illinois Representative to please support this proposed amendment to SB 1843.

To contact any and all Illinois State representative go to: www.ilga.gov