Post on 29-Jun-2020
transcript
Chiropractic Services and
CERT Documentation
Presented by: Provider Outreach and Education (POE) May 2015
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– Asking questions? Use “raise/lower hand” figure
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Updated
May 2015 2
Using WebEx During Webinar
Participants •Option to ask a question at end of webinar •Use the raise/lower hand feature •Once question answered, lower hand
Chat NEW INSTRUCTION •Do NOT add additional attendees to webinar •Additional attendees must be added to the initial registration to qualify for CEU
Q/A CLOSED •Until last 30 minutes of webinar •Type question in box and send to all panelists, not host •Keep questions to topic/previous slides
Updated
May 2015 3
Continuing Education Unit (CEU)
• When registering, add all additional attendees – First and last names
– Not accepting added attending names in CHAT
• Attend entire workshop
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• Pops up after closing out of webinar
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Updated
May 2015 4
Webinar Questions and Answers
• During the last 30 minutes of presentation – Q/A section opened
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Updated
May 2015 5
May 2015 6
DISCLAIMER
This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents.
The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice.
All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at http://www.noridianmedicare.com and the CMS website at http://www.cms.gov
The identification of an organization or product in this information does not imply any form of endorsement.
CPT codes, descriptors, and other data only are copyright 2014 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.
Objective
• To increase knowledge of Chiropractic
billing and coverage guidelines
• To highlight Medical Review (MR) and
CERT audit results
• To decrease claim submission errors
May 2015 7
Agenda
• LCD
• Medical Necessity
• Documentation Guidelines
• Advance Beneficiary Notice of
Noncoverage (ABN)
• CERT Review Program
• Reminders & Resources
May 2015 8
ACRONYM DESCRIPTION
ABN Advance Beneficiary Notice of Non Coverage
CERT Comprehensive Error Rate Testing
CR Change Request
DME Durable Medical Equipment
IOM Internet Only Manual
MLN Medicare Learning Network
MPFS Medicare Physician Fee Schedule
MSP Medicare Secondary Payer
SOAP Subjective, Objective, Assessment, Plan
May 2015 9
Chiropractic LCD
Chiropractic Policy- LCD
• Local Coverage Determination (LCD) policy
– Very important that all Chiropractors read!
• JE #L33518
– https://med.noridianmedicare.com/web/jeb/policies/lcd/active
• JF #L24288
– https://www.noridianmedicare.com/partb/coverage/active.html
May 2015 11
Chiropractic Policy- LCD
• When appropriate, Noridian medical staff
completes pre-payment review
– Providers identified with data analysis/audits
May 2015 12
Chiropractic Policy – JE B
May 2015 13
Chiropractic Policy – JF B
May 2015 14
Medical Necessity
Medicare Coverage
• Medical Necessity
– Title XVIII of the Social Security Act, Section
1862 (a)(1)(A) clarifies no payment may be
made for any expenses incurred for items or
services not reasonable and necessary for the
diagnosis or treatment of illness or injury or to
improve the functioning of a malformed body
member
May 2015 16
Medical Necessity
• Demonstrate significant health problem of neuro-musculoskeletal condition
– Statement of ‘pain’ is insufficient
– Pain location must be described • Whether particular vertebra capable of producing pain
– Direct therapeutic relationship to patient’s condition
• Reasonable expectation of recovery
– Arrest/retard deterioration in condition
– Within reasonable and predictable period of time
May 2015 17
Medical Necessity
• Treatment of the spine, limited specifically by manual manipulation (use of hands), to correct a subluxation
– Demonstrated by x-ray or physical exam
– Hand held devices allowed • Controlled manually
• Medicare does not allow additional payment for device
• No other diagnostic/therapeutic service covered when furnished/ordered by chiropractic physician
– Thermography, pro-adjuster electric devices, neurocalcometer not covered
May 2015 18
Utilization Guidelines
• Chiropractic manipulation service only
reimbursed once per day
• The frequency and duration of chiropractic
treatment
– must be medically necessary
– based on the individual patient’s condition and
response to treatment
• Medical necessity determines visits/no set
number of visits
May 2015 19
Excluded Chiropractic Services
• Beneficiary responsibility
• May bill patient without billing Medicare – Acupuncture
– Counseling/education
– Dietary advice/nutritional supplements
– Lab or other diagnostic tests
– Physical therapies (exercise, ultrasound, traction)
– Office visits
– Supplies (pillows or vitamins)
– Supportive (bracing, orthopedic)
– X-rays
May 2015 20
Documentation Guidelines
Documentation-Medical Necessity
• Requirements apply whether subluxation demonstrated by x-ray or physical exam
– Applies to initial visit and subsequent visits
– Both participating/nonparticipating providers
• Document either a or b:
a) List exact bones involved • C2, L5, etc.
b) Area/region, if it implies only certain bones • Lumbo-sacral
• Sacro-iliac
May 2015 22
Documentation-Subluxation
• X-ray should be taken no more than
– 12 months prior to initiation of treatment or
– 3 months following initiation of treatment
• Previous CT scan and/or MRI acceptable
• Also maintained by referring physician
• Enter x-ray date - Item 19 (narrative)
– E.g. 2/20/15
– “x-ray date” verbiage optional
May 2015 23
• Physical Examination: – If subluxation is demonstrated by physical exam,
the medical record must include 2 of the following
4 criteria (either #2 or #3 is required): 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 (change in active, passive,
and accessory joint movements resulting in an increase or
decrease of sectional or segmental mobility)
4 Tissue, tone changes in the characteristics of contiguous or
associated soft tissues, including skin, fascia, muscle and
ligament
Documentation-Subluxation2
19 May 2015
Documentation – Initial Visit
• Patient history – Chief complaint
– Patient symptoms why seeking chiropractic treatment
– Has patient had prior chiropractic treatments
• Symptoms are direct relationship to subluxation level
• Present illness may include: – Mechanism of trauma
– Quality, character and intensity of problem/symptoms
– Frequency and duration of symptoms
– Aggravating or relieving factors of symptoms
– Prior interventions or treatments, including medications
– Secondary complaints
May 2015 25
Documentation – Initial Visit 2
• Family history (if pertinent)
• Past health history may include: – General health statement
– Prior illness(es)
– Surgical history
– Prior injuries or traumas
– Prior chiropractic care
• Physical exam – Clearly document treatment given on day of visit
– What was adjusted
May 2015 26
Documentation – Initial Visit 3
• Diagnosis – Primary diagnosis must be subluxation
• Head, Cervical, Thoracic, Lumbar, Sacral or Pelvic
– Secondary diagnosis comes from Chiropractic Policy
• Category I, II or III
– List primary/secondary for each region treated/billed
• Treatment plan – Initial treatment date
– Therapeutic modalities – education and exercise training
– Level of care recommended – duration/frequency of visits
– Specific measurable goals achieved with treatment • Objective measures to evaluate treatment effectiveness
May 2015 27
May 2015 28
Documentation – Subsequent Visits
• History – Review of chief complaint and systems
– Changes since last visit
• Physical exam – Exam of spine area involved in diagnosis(es)
– Patient condition assessment of change from last visit
– Treatment effectiveness evaluation
• Document treatment details on day of visit – What specifically was adjusted
– Clearly document treatment necessity
– Progress towards goals
May 2015 29
Documentation – Subsequent Visits 2
• Even if diagnosis is the same as last visit – document each time
– Word “same” is not acceptable
– If diagnosis changes from prior visit • Explain if it relates to past history and how
– If new diagnosis, redo P.A.R.T./S.O.A.P. notes
• Is new diagnosis due to a new injury?
– Add Initial Treatment Date (ITD) to Item 14
• Discharge when no further progress (ABN)
May 2015 30
May 2015 31
Active vs. Maintenance
Treatment
Active/Corrective Treatment
• Goal driven
• Treatment plan
• Individualized
• Usually short term
• Measurable progress towards goals
• When providing active/corrective treatment, must append AT modifier
– CPT codes (98940 – 98942)
May 2015 33
Maintenance Therapy
• Maintenance services: – Preventive
– Promote health
– Prolong or enhance quality of life
– Maintain/prevent deterioration
• When further clinical improvement cannot be expected from continuous ongoing care – Treatment is considered maintenance therapy
when chiropractic treatment is supportive, not corrective
– Not covered by Medicare, but must bill
May 2015 34
Maintenance Therapy 2
• Mandatory Claim Submission – Requires providers to bill Medicare, even if service
might deny (98940, 98941 or 98942)
• Do not append AT modifier
• Bill with additional diagnosis (optional) – V57.9 (unspecified rehabilitation procedure)
• Obtain ABN – see next section – Append GA modifier
• Never bill AT and GA modifiers together on same line – Possibly has patient under active treatment, but feels
Medicare may deem as not medically necessary
May 2015 35
Claim Requirements
Mandatory Claims Submission
• Providers must submit Medicare claims for
covered or potentially covered services
– Providers may not charge for this paperwork
• Bill direct only for non-covered/statutorily-
excluded services
• If beneficiary requests, providers must bill
Medicare for non-covered services
– MSP claims may require prior to processing
May 2015 37
Claim Requirement Highlights
• Item 14 – Date of Initial Treatment/ exacerbation of existing condition
– 12/01/13 – Patient seen for neck and back pain
– 03/01/14 – Recurrence visit after time lapse
– ITD for this course of treatment is 03/01/14
• Item 17/17B – Referring/ordering physician’s name/NPI (if necessary)
– Physician assuming order responsibility
• Item 19 – X-ray as documentation of subluxation
– 6-digit or 8-digit x-ray date with optional verbiage
– Descriptions – e.g. specific subluxation level
May 2015 38
Claim Requirement Highlights 2
• Item 21 – Diagnosis
– No decimals or descriptions
– Must be to highest level of specificity
– Up to 12 diagnoses on paper claim
• Each region billed requires both diagnoses
– Subluxation(s)/regions listed as primary diagnosis
– Resulting disorders (conditions) listed as secondary
diagnosis(es)
• Check the Chiropractic policy
May 2015 39
Manipulation Codes
98940 CMT; spinal, one to two regions
98941 CMT; spinal, three to four regions
98942 CMT; spinal, five regions
98943 – noncovered Extraspinal, one or more regions
Primary Diagnosis Codes
739.0 Head
739.1 Cervical
739.2 Thoracic
739.3 Lumbar
739.4 Sacral
739.5 Pelvic
Select secondary diagnosis from Category I, II or III 40
Secondary Diagnosis Code
• Reflect mandatory secondary diagnosis
– Neuromusculoskeletal condition for treatment
Category
Treatment
Example:
Chief Complaint
Secondary
Diagnosis
I Short Term Tension Headache 307.81
II Moderate Back Strain 847.0
III Longer Post Laminectomy 722.81
41 May 2015
Payment Inquiries
Questions Answers
Can a PAR Chiropractor
use a sliding payment
scale?
•Cannot collect more than PAR allowed for
98940-98942
•Medicare fee schedule can be lower than
private insurer; but never higher
Can a Chiropractor use
a 30% discount, if
patient pays cash at
time of service?
• Yes, if 98940-98942 involved and practice
has same discount to all other insured
•https://www.noridianmedicare.com/shared/
partb/bulletins/2012/281_oct/Medicare_Que
stions_Unrelated_to_Specific_Claims_.htm
May 2015 42
Advance Beneficiary Notice of
Noncoverage (ABN)
What is an ABN?
• Written notice that health care provider
gives to Medicare beneficiary prior to
service/procedure rendered
– Provider believes Medicare will not pay for
some or all Medicare Fee for Services
– If claim denied medical necessity, ABN
indicates beneficiary is financially responsible
• Used for Maintenance Therapy visits
May 2015 44
Revised CMS ABN (CMS-R-131)
• Dated March 2011
• CMS form available
• http://www.cms.gov/Me
dicare/Medicare-
General-Information/
BNI/ABN.html
• 100-02, Chapter 15, Section 40
May 2015 45
ABN 2
• ABN must
– State specific procedure and estimated cost
– Specific reason why provider believes Medicare likely to deny payment
– Signed/dated by beneficiary before procedure/service performed
• Cannot change ABN form except to
– Copy on provider letterhead
– Personalize sections A, B, C, D, E, F & H
May 2015 46
ABN Header
• Blank A – Notifier’s name, address and telephone #
• Blank B – Beneficiary’s name as listed on Medicare card
• Blank C – Internal identification number (patient account)
• Cannot use Medicare or social security number
May 2015 47
ABN Body
•Write out specific service
•Enter frequency and/or duration
•Enter detailed reason Medicare may not pay __________________
•Enter reasonable charge (within $100)
Service
Service
Service
May 2015 48
ABN Options
May 2015 49
•Provider not permitted to make this selection
ABN Option #2 Clarification
• Only Maintenance Therapy (98940 – 98942)
– Not for covered AT treatments
– Should be rare; not with every patient
– Be careful; if patient decides later they want
Medicare billed and timely filing not met, provider
must refund patient and is out Medicare monies
– Beneficiary or his/her representative must choose
one of the three options listed
• Patients MUST make decision (not provider)
50 May 2015
ABN Information/Signature
51 May 2015
ABN Billing Modifiers
GA Expect Medicare will deny item/service as not reasonable and necessary
•Signed ABN is on file – beneficiary liability
GX Used to report when voluntary ABN issued for a non-covered or
statutorily excluded service
•May be used with GY – beneficiary liability
GY Item/service is non-covered (excluded) from Medicare program
•No ABN needed
•Auto-denied by Noridian – beneficiary liability
GZ Expect Medicare will deny item /service as not reasonable /necessary
•Signed ABN not given prior for maintenance therapy
•No change to provider financial responsibility
•CO = Contractual Obligation
May 2015 52
Extended Course of Treatment
• Single ABN (up to one year) acceptable:
– ABN identifies all items/services and duration of
period of treatment
– No changes to treatment
– Services are not added/deleted after treatment
• ANY changes require new ABN
• Each visit, patient’s sign or initial back of ABN
original and date
– Not CMS requirement - Noridian advisement
May 2015 53
Voluntary ABN
• For services that are statutorily excluded:
– Acupuncture
– Counseling/education
– Dietary advice/nutritional supplements
– Lab or other diagnostic tests
– Physical therapies (exercise, ultrasound, traction)
– Office visits
– Supplies (pillows or vitamins)
– Supportive (bracing, orthopedic)
– X-rays
54 May 2015
Medical Review (MR)
Medical Review (MR) Audit Results
• Documentation missing patient’s name and date of service
• Missing or illegible signatures
• Illegible documentation
• Documentation supported Maintenance therapy
• No response to request for documentation
• Insufficient or absent documentation:
36 May 2015
Medical Review (MR) Audit Results2
• Claims billed from 2 to 4 regions not
supported by documentation
• If billing 2 regions, must report 2
primary/secondary diagnoses
– Documentation MUST support multiple levels
• Need time line (short, moderate, long
term), matching diagnosis(es) and
documentation
May 2015 57
MR Documentation Concerns
• Careful with software-generated documentation
– Some notes include identical entries for different
patients/ different dates of service
• Be careful with check-off sheets
– Difficult to read; lack findings; too generic
– Lack enough space to list specific information
• Non-encounter specific repetitive entries not
containing policy required components
• Whichever documentation style used, must
include required elements for medical necessity
May 2015 58
•Repetitive software
does not provide
encounter specific
documentation
results
•Example shows
Subjective/Objective
EXACTLY the same
and NOT PAYABLE
•Monies recouped
59 May 2015
Documentation Tips
• Complete and legible
• Clearly identify medical necessity
• Utilize standard abbreviations
• Include plan of treatment
• Computerized documentation may not provide individualized information
– Detail specific date of service elements
– Clarify which services necessary
– Documentation supports each level/date billed
May 2015 60
Documentation Tips 2
• Documentation needs S.O.A.P notes
– Subjective
– Objective
– Assessment
– Procedure/Plan
• Computerized documentation caution
– Cannot reflect same notes and change patient name
• May also use P.A.R.T notes
May 2015 61
Documentation – Signatures
• Handwritten or electronic signature accepted
• Must be signed prior to billing
• Stamp signatures not acceptable
– Exception for physical disability
– CR 8219 dated June 18, 2013
• Physicians/NPPs can not add late signatures
– Except short delay during transcription
– Use signature authentication process
May 2015 62
Documentation – Signatures 2
• Signature Attestation statement (if needed) – Must be signed/dated by medical record entry author
– Contain appropriate beneficiary information
– Include with requested documentation only
• JE states – https://med.noridianmedicare.com/web/jeb/cert-
reviews/signature-requirement-q-a
• JF states – https://www.noridianmedicare.com/partb/claims/cert/in
dex.html
• CR 6698 Signature Guidelines – http://www.cms.gov/transmittals/downloads/R327PI.pdf
May 2015 63
Maintaining Records
• Providers required to maintain records
– CMS suggests 6 years from initial date of
service or state requirement (if longer)
• Existing requirements
– Record retention considered part of normal
business practice
– 42 Code of Federal Regulations (CFR)
Section 424.516(d) and 45 CFR, Section
164.316(b)(2)
May 2015 64
Comprehensive Error Rate
Testing (CERT)
CERT Process
• Livanta-CERT Documentation Contractor
– Requests documentation for selected claims
• Advance Med- CERT Review Contractor
– Reviews submitted CERT documentation
forwarded by Livanta
May 2015 66
CERT – JE Home Page
May 2015 67
CERT - JF Home Page
May 2015 68
Top Errors Affecting Part B
Service Type
2013 Report 2014 Report
Improper Payment
Rate
Improper Payment
Rate
Hospital Based E/M - Initial 28.3% 31.3%
Hospital Based E/M - Subsequent 18.2% 20.7%
Critical Care E/M 22.9% 29.2%
Chiropractor Services 51.7% 54.1%
Ambulance Services 6.7% 12.4%
May 2015 69
Insufficient Documentation
• Chiropractor Claims
– Chiropractic treatment plan
– Documentation insufficient to support billed
service
70 May 2015
CERT Error Examples
• CERT requested documentation
– Missing initial/subsequent treatment plans
– No new injury reported
– Missing initial/subsequent treatment plan
documentation in patient medical record
– Deemed not reasonable and necessary
– Treatment plan records were never sent to
CERT
May 2015 71
CERT Error Examples 2
• With multiple DOS – Missing documentation to support initial visit, patient
history and treatment plan
– Daily notes not legible - unable to interpret abbreviations
– Documentation that cannot be deciphered does not support medical necessity
• Noridian requested copies of initial visit and evaluation – Received typewritten treatment plan – no signature
• Missing provider signature attestation document
– Received “altered” duplicate documentation • With addition of provider signature
• Documentation fails medical necessity requirements
May 2015 72
CERT Error Examples 3
• Missing items in progress note and treatment notes – Evaluation, plan of treatment including past health history
– Quality and character of symptoms/problems
– Onset date, intensity, frequency and prior symptoms
– Aggravating/relieving factors, interventions, treatments, medications, secondary complaints supporting treatment
• Documentation “injuries related to shoveling snow” – Mechanism of trauma – not a complaint
• Statement “recommended treatment “as needed basis” – “Return PRN” is not a treatment plan – too vague
– Manipulative services rendered must have direct therapeutic relationship to patient’s condition
May 2015 73
CERT Error Examples 4
• Multiple DOS reviewed – Areas for CMT never documented
– No treatment plan
– Whatever therapy was given appears to be maintenance
• Inappropriate/invalid ABNs given – Service is always listed as “an adjustment” with no rationale
given for why service will be denied
– No prices listed advising beneficiary of liability amounts
• Missing additional manipulated spine regions – Billed 98941 – 3 to 4 regions
– Documentation supported 1 to 2 regions
• Missing initial evaluations and treatment plan
May 2015 74
CERT Error Examples 5
• 98941 billed – submitted documentation
included signed progress notes; but missing:
– Initial evaluation and initial treatment plan
– Received unsigned typed progress notes
• Noridian requested initial evaluation; initial
treatment plan and signature attestation
– Requested documentation never received
• Service not meeting medical necessity
– LCD documentation requirements not met
May 2015 75
CERT Audit Reminder
• If CERT post pay audit contractor requests
– Fax timely all specific records/documentation
• Send to CERT contractor timely with:
– Chief complaint/Plan of Care
– Chart/Treatment notes
– Proof of medical necessity
– Referring/Ordering physician notes (if any)
– Documentation must support CPT level
May 2015 76
CERT Documentation
Checklists
• Guidance for audit request responses
• CERT requests
– https://med.noridianmedicare.com/web/jeb/cer
t-reviews/cert/checklists
– Chiropractic Documentation
May 2015 77
Reminders & Resources
http://www.roadto10.org/
Small Physician’s Route to ICD-10
CMS No Cost Tool
– Overview of ICD-10
– Specialty References
– BUILD your personal action plan
– Webcasts , Events and FAQs
– Quick References & Template Library
May 2015 79
Resources
• CMS (IOM) Medicare Benefit Policy
Manual
– http://www.cms.gov/Manuals/IOM/
– Publication 100-02, Chapter 15,
• Section 30.5, Chiropractic Coverage
• Section 240.1, Chiropractic Services-General
– Publication 100-04, Chapter 12, Section 220
– Publication 100-08, Chapter 3, Section 3.3.2.4
May 2015 80
Chiropractic Booklets http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/downloads/Chiropractors_fact_sheet.pdf
May 2015 81
October 2013
Review Programs Guide
• Medicare Claim Review Programs Booklet – January 2014
– Current April 2015
• Includes MR, CCI, MUE, CERT & RA
– http://www.cms.gov/M
LNProducts/download
s/MCRP_Booklet.pdf
May 2015 82
CMS ABN Guide
• August 2014
– http://www.cms.gov/MLN
Products/downloads/ABN
_Booklet_ICN006266.pdf
May 2015 83
Fourth Edition
Incentive Program Resources
• PQRS Website – http://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-Instruments/PQRS/
• Medicare EHR Incentive Programs – http://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/
• Value Based Modifier (VBM) – http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html
• Frequently Asked Questions (FAQs) – https://questions.cms.gov/
• American Chiropractic Association (ACA) – http://www.acatoday.org/patients/index.cfm
May 2015 84
Sign Up – Part B Medicare News!
• Receive most recent Noridian/CMS news – Tuesday/Friday
– Simple/quick signup
– Regulation/policy updates
– Payment/reimbursement
– Workshop/educational event notices
– Noridian hours of availability/related notifications
JF
JE
May 2015 85
Endeavor Online Provider Portal
• Free to providers with Internet – Beneficiary Eligibility
– Claim Status including Reviewer Comments
– Payment Floor / Prior Checks Issued
– Single Claim / Entire Remittance Advice
– Reopening & Redetermination Submission
– Appeal Status
• Additional resources include – Self-Paced tutorial for Part B
– System availability alerts on the Medicare website
– User Manual; valuable, many screen images and guides
– Workshops and presentations
• Eligibility “Main Menu” page next slide
May 2015 86
Noridian Likes Website Feedback!
•Provide constructive/complimentary feedback to continue Noridian website growth and improvement
May 2015 87
CEU Process Reminder
• When registering, add additional attendees
– First and last names
– No longer accepting names in CHAT
• Attend entire workshop
• Take short polling survey
– After closing out of webinar
• CEU emailed 3 days after presentation
– Earned 1.5 CEUs today
– No password or index number needed
88 May 2015
Updated
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