1. Back to the Basics 2. History Book

Newsletter
May 6, 2013
Chiropractic Medicare
1. "Back to the Basics."
2. New Chiropractic History Book Introduced.
Knowing the error rate for we Chiropractors is at 72.9% as determined by CERT....knowing that they believe they have over paid we Chiropractors improper payments....somebody will be catching audits for money recovery! CERT says that the primary reason for the improper payment is "insufficient medical record documentation".

You may believe this has nothing to do with you since all of your claims have been paid. However, the 72.9% error rate is on claims that have been paid....improperly. If you believe S.O.A.P. notes is the documentation they are talking about...that’s a mistake! Documentation is not S.O.A.P. notes...it’s a document. That is why it is called documentation. That is the exact information I have been attempting to share with my fellow Chiropractors for the past 34 years.

1. The Basics in Medicare: You must prove a subluxation, x-rays each year or a P.A.R.T. form each visit. Item #14 must be less than 60 days old. Diagnosis must support the care rendered . S.O.A.P. notes in a S.O.A.P. note format. You must have "documentation" in the way of a "document" to prove chiropractic necessity of care. S.O.A.P. notes must indicate and support the CPT Code you billed.

2. NEW CHIROPRACTIC HISTORY BOOK INTRODUCTION: D. D. Palmer & B. J. Palmer started producing "The Chiropractor" booklets in December 1904. "The Chiropractor" were produced and printed each month for four years. We have made those available in two large volumes. They come with Certificate of authenticity of first copies. For those interested in Chiropractic History....these are not available anywhere else. We have a limited number available so please email or call if you are interested.

"The Medicare Claim Tells the Story" ~Newsletter 8/20/12

****
Newsletter
August 20, 2012
Chiropractic Medicare
"The Medicare Claim Tells the Story"

 

 Most of my fellow Chiropractors, when they call about an audit or pre-pay request for records, ask why they received the record request.  Most of the time they have a request for records because the items on the claim do not match.

 

 An example:  A claim with an acute diagnosis indicating an acute condition or an exacerbation may have in item #14, Date of Current, a date over 60 days.  This tells the carrier the condition is chronic so the doctor receives a request for records to verify the true story on the patient. 

Date of Current on an active patient should NEVER be over 60 days if your are expecting Medicare reimbursement.

 

 Or...the diagnosis only consists of a subluxation with maybe arthritis.  The carrier knows this patient can be adjusted twice a day for 6 months and an x-ray indicated a subluxation and arthritis.  No improvement and no reimbursement.  The diagnosis should have three parts to it.  An example: subluxation, arthritis and sprain/strain if there has been an exacerbation.

 

 If item #19 does not have both date of x-ray(less than one year) or P.A.R.T., the claim may not be payable.  The carrier may ask for patient records to verify if the doctor proved a subluxation by either an x-ray less than one year or a P.A.R.T. form for each visit.  X-rays are mandated each year, if the doctor proves subluxation by way of x-ray. A P.A.R.T. form is mandated each visit if the doctor does not use x-rays to prove the subluxation.

 

Some carriers ask for office patient records periodically to verify if the doctor has a treatment plan with the three key components.  The "documentation" provided by our program consists of both "Federal Documentation" and also a treatment plan meeting all three components.

 

Many times the carrier will ask for patient S.O.A.P. notes to verify the doctor did in fact adjust vertebrae is specific regions in which they billed Medicare. If you adjust 4 regions on your patient for example, your billing will match the S.O.A.P. notes as to the number of regions you adjusted and billed to Medicare.

 

 Generally the information on each claim should all match.....diagnosis supports the care rendered, Item #14, date of current, is less than 60 days old, Item #19 contains date of x-ray or P.A.R.T., and specific terminology indicating any exacerbation and the "documentation" has been produced.

 

 Once the correct way to do Medicare is understood, you are half the way. 

NEW Advance Beneficiary Notice of Non-Coverage (ABN) CMS-R-131(03/11)

NEW Advance Beneficiary Notice of Non-Coverage (ABN)

The centers for Medicare and Medicaid Services (CMS) has released a revised Advance Beneficiary Notice of Non-Coverage (ABN) CMS-R-131 form, http://www.cms.gov/BNI/02_ABN.asp. The ABN is issued by providers where, depending upon a situation, Medicare payment is expected to be denied.  That includes a covered service in which the doctor believes Medicare will not pay and all non-covered services billed to Medicare.

That also includes referral of a Medicare patient for any service by another health care provider including a covered service.

NOTE:  The only differences found on this revised ABN and the prior is the date of issue on the bottom of the form.  CMS-R-131(03/11)
This specific form has a mandatory use date of November 1, 2011.

Option # 2 is the primary change from the original ABN.  Please keep in mind, Option #2 is used ONLY for non-covered service.  Taking a covered service as 98940, 98941 or 98942, calling it maintenance care, with the patient checking Option #2 and not billing the Medicare Carrier for the Chiropractic adjustment is "thin ice" maneuvering.

The Chiropractic adjustment is the only reimbursable service for Chiropractors.  When a Chiropractor adjusts a patient to correct a vertebral subluxation, then that is a covered service in Medicare not maintenance care.

The doctor must learn to honestly and specifically "document" the Chiropractic necessity of care by "federal standards."  The patient who has a subluxation has had either an accident, exacerbation, or a specific "Neuronal Component".  It is the doctors job to prove the subluxation, document the cause of subluxation, and correct the subluxation with an adjustment.  That is a covered service by Medicare.

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.

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.