Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 1
MAKING YOUR PRACTICE
WELL AND EXCELL
THROUGH DOCUMENTATION
UP TO DATE INFORMATION ON
HIPAA MEDICARE CARE OPTIONS FRAUD
Benjamin M. Bartolotto, BS, DC, FACC
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 2
COURSE OBJECTIVES
1. Understanding HIPAA and documenting compliance through practical and
proportional action steps
2. Confidently and correctly navigating and fulfilling Medicare documentation
requirements
3. Through treatment goal planning and outcome studies selecting the appropriate
type of care
4. Identifying record keeping red flags, identifying fraudulent activity
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 3
HIPAA
The three components the Health Insurance Portability and Accountability Act are now in
force. The premise of HIPAA was the patient’s protection over the privacy of their
healthcare information, {PHI}, with its administration under the United States
Department of Health and Human Services, the enforcement through the Division of
Health and Human Services, {HHS}, Office for Civil Rights. You can explore the depth
of HIPAA to your interest and convenience at www.hhs.gov/ocr/hipaa. 1
The original intent of HIPAA was to protect a patient’s PHI when the covered entity,
health plan, clearinghouse, and healthcare providers would transmit their health
information electronically. One of the missions of HIPAA was to standardize date
transmission, as well as electronic data interchange, {EDI}. This original concept was
then broadened to include all medical information communications. This evolving
process has brought the HIPAA to fruition. There are some simple and practical steps a
healthcare provider can take immediately to document their HIPAA compliance.
THE PRIVACY RULE - PART I
ACTION STEPS
Appoint a privacy officer/contact person in regard to office records; this can be a
healthcare provider or an office staff member. Dedicate a notebook or loose leaf binder
as the office HIPAA manual. The manual will record the name of privacy officer and
contact person, office policy and procedures, a copy of the privacy notice, signed by
1 United States Department of Health and Human Services; www.hhs.gov/ocr/hipaa
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 4
patients, as well as business agreements used for outside services such as for billing,
transcription, or collections stating that they are HIPAA compliant. Privacy notices come
in many forms but universally usually includes the following information for the patient
in regard to disclosing their health information;
Sharing of health information to receive payment, provide treatment, provide
health information to other providers, provide information to third party business
associates, {i.e. transcription services}
Share information for national security and public health reporting, disclose
information required by law, {i.e. valid court orders}
Share information for law enforcement purposes, in emergency medical situation,
appointment reminders, validate identity
May release information to coroner or medical examiner as authorized by law, for
research projects, a family or friend of your choice, governmental agencies
providing benefits and services
Share information for other reasons or sources with your written authorization
Name, address, and other contact information of the Privacy Officer
You have the right to look or receive a copy of your records at written request, if
you request copies a reasonable fee for copying and mailing may be charged
If you believe your information is incorrect or is missing you have the right to
request an amendment, that request made in writing
You have the right to have health information be shared in a confidential manner,
{i.e. sent to a different mailing address}
The patient should be provided with, and signed, an acknowledgement of receipt of
notice of privacy practices and this form inserted into the patient’s health record;
regardless if the patient retains a copy.
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 5
Include in the HIPAA office manual a signed statement by employees that they have been
informed and trained in HIPAA regulations and procedures. HIPAA training update
sessions should be recorded in the HIPAA manual, {i.e. quarterly, at regular staff
meetings, etc}. This would heighten the healthcare providers and staff’s appreciation and
sensitivity to the HIPAA environment.
General, physical safeguards of HIPAA; placement of computer screens or the use of
computer screen guards so they are not viewed by any one other than authorized office
personnel, a secure location for the fax machine, as well as file cabinets.
The sign in sheet secured at the front desk, an option, a sliding cover over the sign in
sheet only exposing a blank line for the next patient to sign in, with the signature of the
prior patient covered from view.
If open treatment areas are utilized, a private treatment area should be available if desired
by the patient.
SAMPLE OF PATIENT ACKNOWLEDGEMENT
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 6
RECEIPT OF NOTICE OF PRIVACY PRACTICES2
By signing below, I acknowledge receiving a copy of the sample
Privacy Practices, dated ________________________________
________________________ ________________ _________________
PATIENT NAME PATIENT’S DOB PATIENT SOC SEC #
______________________________________________ ______________
SIGNATURE OF PATIENT OR PERSONAL REPRESENTATIVE DATE
*If signed by a Personal Representative, the following information must also be included:
_________________________________________
NAME OF PERSONAL REPRESENTATIVE
DESCRIPTION OF THE PERSONAL REPRESENTATIVE’S AUTHORITY TO ACT
ON BEHALF OF THE PATIENT
2 New York Chiropractic College Patient Acknowledgement Receipt of Notice of Privacy Practice
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HIPAA SECURITY RULE - PART II
Effective April 2005 the Security Rule came into effect, in regard to healthcare plans,
healthcare clearinghouses, healthcare providers, anyone who transmits electronically
protected health information, {EPHI}. EPHI examples are submitting of claim forms
electronically, checking claim status and eligibility, electronic referrals, diagnostic testing
results, e-mails, etc. The HIPAA Security Rule does not apply to a healthcare provider’s
practice who does not submit/receive any information electronically. Considering the
software becoming available to healthcare providers and entities in regard to managing
their business, recording in the category of medical information and submitting the same,
and the growing interest and movement to electronic record management, the HIPAA
Security Rule will apply to the majority rather than the minority.
Covered entities are to implement safe guards to prevent improper access to patient
health information that is stored in an electronic form, including information contained in
e-mails or other electronic transmissions, electronic protected health information {EPHI}.
Measures taken must be reasonable for practice size, and each component of the rule
must be identified as required or addressable.
RISK MANAGEMENT CONSIDERATION; There are now programs that can detect,
“Metadata”, these programs which can detect the alteration or emission of electronic data.
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 8
ACTION STEPS
The HIPAA Security Rule consists of 3 safe guards; administration, physical, and
technical.
Everyday technology, which is used and taken for granted is now becoming a HIPAA
Security item. Take the following into consideration; PDA’s {Personal Digital
Assistants}, Blackberrys, are increasingly popular. As the, “information age”, marches
on the use of these devices are commonplace. If patient information is stored in these
devices, in the event that the PDA is lost or stolen the security of the patient’s
information may be breached.
Most people today would be lost without their cell phone, though the mobile cell phone
in itself has evolved into a multiple device for phone calls, text messaging, and for
transmitting pictures and videos manufactured in smaller and smaller packaging. When
returning a phone call to a patient, especially in a public atmosphere it would be advised
to acknowledge the patient’s concern and set up a time when you may call the patient in a
more private setting. It is reported that technology exists to monitor cell phone calls and
even some companies have attained a list of what cell phone numbers were called and
have sold such lists.
Many providers, of all disciplines, now communicate with patients through e-mail. On
some provider websites you can schedule appointments, download office information, as
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 9
well as download office forms, which can be printed out and completed before your
presentation to the office. Security here though is a concern, as patients may have e-mail
accessible by multiple individuals.
ACTION STEP
Have the patient sign a release allowing you to contact them through this medium, {e-
mail}. Keep a copy of any e-mail communication to patient, as this is a form of patient
contact documentation, {risk management consideration}.
NATIONAL PROVIDER IDENTIFIER {NPI}
PART III
In 1996 HIPAA mandated that the HHS adopt a standard unique health identifier for
healthcare providers consisting of 10 positions, which will eventually phase out providers
UPIN and other provider identifiers, this identifier was named the National Provider
Identifier, {NPI}. On 1-23-04 HHS published the final rule for the NPI with the effective
date of the rule 5-23-05. Providers can start applying for their NPI on 5-23-05, the
compliance date is 2 years later, on 5-23-07. As of 5-23-07 covered entities, {healthcare
providers}, will only use the NPI for all standard transactions, no other numbers will be
accepted after that date.
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ACTION STEP
To obtain your NPI contact https://nppes.cms.hhs.gov3 or you may contact the NPI
Enumerator at
NPI Enumerator
PO Box 6059
Fargo, ND 58103-6059
1-800-465-3203
On March 16, 2006, the HIPAA Enforcement Rule became effective. This rule addresses
CMP, {Civil Monetary Penalties}, for covered entities/HIPAA violations. The
enforcement rule outlines the investigative process and applies to all HIPAA components.
The HIPAA Enforcement Rule mandates HHS to impose a CMP for HIPAA violations,
the increased number of violations, the increased CMP.
For information go to: www.hhs.gov/ocr/hipaa
Your HIPAA office manual should contain
Copy of Privacy Notice
Office policy/steps to ensure the security of patient’s PHI/EPHI
Copy of your NPI
Employee signed statements of HIPAA training/awareness
Notes of HIPAA meetings
3 NPPES; National Plan & Provider Enumeration System
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HEALTH INFORMATION TECHNOLOGY FOR
ECONOMIC AND CLINICAL HEALTH ACT {HITECH}
The HITECH Act has been passed as part of the American Recovery and Reinvestment
Act of 2009. This act will expand HIPAA privacy rule in regard to notifying patients
protected health information, {PHI} disclosures. The HITECH Act enables the
Department of Health and Human Services Office for Civil Rights, {OCR}, to require
HIPAA covered entities to notify individuals in respect to PHI disclosures through
electronic health records for the purpose of treatment, payment, and healthcare
operations. The disclosures must include the following components:
• Date of disclosure
• Name and address of the entity or person receiving the disclosure
• A description of the information disclosed
• A copy of the request for disclosure or a brief description of the reason for
disclosure
For more information: http://edocket.access.gpo.gov/2010/pdf/2010-10054.pdfto
RED FLAG RULE
The Federal Trade Commission, {FTC}, along with five other agencies on November 9,
2007 issues a final rule implementing Sections 114 and 3015 of the Fair and Accurate
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Credit Transactions Act of 2003. Regulations stated that financial institutions and
creditors are required to develop and execute a written identity theft prevention program;
it must provide for the identification, detection, and response to patterns, practices or
specific activities. These are known as, “Red Flags”. Enforcement of this regulation has
been delayed from May 1, 2009 to August 1, 2009 and now scheduled to go into effect on
January 1, 2011. Many healthcare professional organizations are in disagreement as if
this regulation applies to healthcare providers and/or facilities. The AMA instituted a
lawsuit against the FTC in that regard. Photocopying a patients’ drivers license or other
picture identification for verification is a simple and practical action step. For more
information and guidance go to www.acatoday.org/redflags .
THE HEALTH CARE RECORD
Check specific state local statutes for required retention of medical records and/or x-rays.
A healthcare record is the provider’s examination, selection of diagnostic testing,
diagnosis, prognosis, and therapeutic approach to the patient’s condition. This
information can be utilized in various venues; risk management, protecting the patient,
legal documentation, utilization review, establishing medical necessity, documenting
regulatory compliance, support asset recovery, {reimbursement for services rendered}, as
well as research. The submitted documentation should underscore why the patient is
being treated, diagnosis, and therapeutic approach, decision making for providing the
treatment, as well as the anticipated degree of the therapeutic outcome.
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Every page of the patient’s file should have recorded the patient’s name on it. It is
becoming more popular to see healthcare provides utilizing computer generated notes,
these notes should be specific for patient’s on an individual basis. The computer-
generated notes should reflect the customary, reasonable examinations and procedures
which would be found to be proportional to the patient’s presenting complaints/
condition. There is a tendency that certain providers who use generated computer notes
will embellish the patient encounter with more information than is reasonable due to the
ease of using a palm pilot. Computer generated notes are becoming more popular with
providers in regard to the ease of completeness of the documentation; however, the
computer generated notes are recommended to be organized in specificity for every
patient. Computer organized notes, length and content, should be proportional to the
events of the patient encounter consistent with the patient’s diagnosis and what would be
anticipated to be reasonably and customarily performed throughout the timeline of
treatment.
Many providers will use abbreviations, which is acceptable, as long as the abbreviations
are commonly accepted and standardized in the healthcare professions.
APPROPRIATE EVALUATION AND MANAGEMENT
CODE {E&M} SELECTION4
4 CPT Codes, descriptions, and other data only are copyright 2004 American Medical Association {or such other data of publication of CPT}. All Right Reserved
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 14
There are four categories of history; problem focused, expanded problem focused,
detailed, and comprehensive. Each category must have a chief complaint accurately
recorded, as well as a selected number of the following components of the history of
present illness, {HPI}, the components of the HPI;
• Location • Quality • Severity • Timing • Duration • Context • Modifying factors • Associated signs and symptoms
A review of systems, {ROS}, is also taken into consideration. The patient’s positive or
negative responses in regard to the system related problem should be documented. An
extended ROS requires an inquiry to the system directly related to the problem and a
limited inquiry into additional systems.
Samples of systems;
• Constitutional • Eyes • ENT • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary • Neurological • Psychiatric • Endocrine • Hematologic/Lymphatic • Allergic/Immunologic
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Also taken into consideration is the past family and/or social history {PFSH}.
Past history {the patient’s past experience with illness, operations, injuries, and
treatments}
Family history {a review of medical events in the patient’s family, including
diseases which may be hereditary or place the patient at risk}
Social history {an age appropriate review of past and current activities}
A pertinent PFSH is a review of the history area{s} directly related to the problem{s}
identified in the HPI.
A complete PFSH is a review of two or all three history area{s}.
DETERMINING EXAMINATION LEVEL
Problem focused - one system
Expanded Problem Focused - affected area and additional systems up to seven
Detailed - seven or eight systems
Comprehensive - eight or more systems
{Most common examination levels in chiropractic practice; problem focused and
expanded problem focused}
COMPLEXITY OF DECISION MAKING
Two of the three elements must be met or exceeded;
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# of Dx/Mgmt. Options Complexity of Data Complication
Straightforward Minimal Minimal or none Minimal
Low Complexity Limited Limited Low
Moderate Complexity Multiple Moderate Moderate
High Complexity Extensive Extensive High
E&M CODES
Evaluation and management codes are the key to tracking patient’s evaluation and
management in regard to examination procedures, diagnostic techniques, and therapeutic
avenues and services pursued. More importantly, these codes give you a reference to the
type of service to be rendered to the patient, as well as the anticipated timeline of the
therapeutic intervention.
The following is a description of evaluation and management CPT codes.
E&M NEW PATIENT
99201 – problem focused; 10 mins.
99202 – expanded problem; 20 mins.
99203 – detailed; 30 mins.
99204 – comprehensive; 45 mins.
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99205 – comprehensive; 60 mins.
ESTABLISHED PATIENT
99211 – presence of a physician is not required
For the following codes at least 2 of the 3 components must be present, {i.e. degree of
history, examination, and decision making}
99212 – problem focused; 10 mins.
99213 – expanded problem; 15 mins.
99214 – detailed; 25 mins.
99215 – comprehensive; 40 mins.
THERAPEUTIC PROCEDURES
CMT REGIONS
98940 1-2
98941 3-4
98942 5
98943 {extra spinal} 1 or more
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MEDICAL NECESSITY
The documentation, in fact, addresses a paramount issue in the healthcare world, the
documenting of medical necessity, which can be extrapolated into what is considered,
“reasonable and necessary”. This term, while being all-important and having common
core components, does not have a universal definition.
THERAPEUTIC NECESSITY:5 exists in the presence of an impairment,
{illness/injury}, evidenced by recognized signs and symptoms, and likely to respond
favorably to the treatment/care planned.
Universally excepted components of medical necessity are;
1. The services of the healthcare provider rendered and diagnostic testing was
necessary to arrive at a diagnosis to establish care.
2. The level of services provided is consistent and proportional to the diagnosis and
can be additionally supported by objective findings.
3. The therapeutic course of care was delivered in guidelines acceptable to a
particular professional discipline and anticipated to provide a positive therapeutic
outcome.
The timeline of a course of care ideally leads to maximum medical improvement.
MAXIMUM MEDICAL IMPROVEMENT
5 Guidelines for Chiropractic Quality Assurance and Practice Parameters; Published 1993
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{MAXIMUM THERAPEUTIC BENEFIT}6
Maximum Medical or Chiropractic Improvement; return to pre-injury/illness status or
failure to improve beyond a certain level of symptomatology or disability, whatever the
treatment/care approach.
When no additional care and treatment will in all medical probability make the
patient substantially better than they are at the present time.
When the care and treatment is no longer a curative and therapeutic value. At this
point the care is then palliative.
CURATIVE AND THERAPEUTIC CARE7
Treatment/care dynamics-manual procedures
Threshold - the minimum rate and magnitude of joint load needed to bring about a
change
Dosage – the frequency of care necessary and sufficient to maintain effects while healing
occurs
Duration – the minimum treatment/care interval to obtain a stable response
6 Guidelines for Chiropractic Quality Assurance and Practice Parameters; published 1993 7 Guidelines for Chiropractic Quality Assurance and Practice Parameters; published 1993
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 20
Combination – the potentiation or competition of response by simultaneous
treatment/care applications
The treatment necessary to establish a stationary status of the patient at maximum
therapeutic benefit
o Curative care must demonstrate improvement
o Increased ROM and function
o Decreasing subjective and objective findings
PALLIATIVE AND SUPPORTIVE8
Treatment/care for patients having reached maximum therapeutic benefit, in whom
periodic trials of therapeutic withdrawal fail to sustain previous therapeutic gains that
would otherwise progressively deteriorate. Supportive care follows appropriate
application of active and passive care including lifestyle modifications. It is appropriate
when rehabilitative and/or functional restorative and alternative care options, including
home based self care and lifestyle medications, have been considered and attempted.
Supportive care may be inappropriate when it interferes with other appropriate primary
care, or when the risk of supportive care outweighs its benefits, {i.e. physician
dependence, somatization, illness behavior or secondary gain}.
8 Guidelines for Chiropractic Quality Assurance and Practice Parameters; published 1993
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 21
When a patient after a therapeutic withdrawal resumes therapeutic intervention
and there is no objective, even interim, improvement but rather a sustained plateau
of the patient’s condition, then the care would be maintenance.
PREVENTATIVE/MAINTENANCE CARE:9
Care given to reduce the incidence or prevalence of illness, impairment, and risk factors,
and to promote optimal function.
Active care10 is when the therapeutic course of care is shifted to patient participation and
responsibility, and especially into the home active care programs compliance.
Passive care11 is the intervention of a caregiver who applies a treatment, therapeutic
course of care which may include singular or a combination of modalities and procedures
to a patient.
The model of care today is being driven toward evidence-based practice.12 Evidence-
based clinical practice is defined as “the conscientious, explicit, and judicious use of the
current best evidence in making decisions about the care of individual patients…{it} is
not restricted to randomized trials and meta-analyses. It involves tracking down the best
external evidence with which to answer our clinical questions.”
9 Guidelines for Chiropractic Assurance and Practice Parameters; published 1993 10 Guidelines for Chiropractic Assurance and Practice Parameters; published 1993 11 Guidelines for Chiropractic Assurance and Practice Parameters; published 1993 12 Clinical Practice Guidelines; Number 1; Vertebral Subluxation in Chiropractic Practice 1998
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 22
Outcome studies; outcome studies track the ongoing therapeutic intervention, attaining
anticipated treatment goals. Based on the information obtained the course of therapeutic
intervention can be modified or deleted or referral to another discipline if necessary in an
attempt to obtain the best reasonable therapeutic outcome.
Some of the common outcome studies; the modified Oswestry Neck Pain and Lower
Back Pain Disability Questionnaire, the Neck Disability Index, Lower Back and
Disability Questionnaire, {Roland Morris}.
IMPAIRMENT
There can be many different scenarios at the conclusion of care. Although a resolution
outcome is obviously the conclusion of care of choice, there are undoubtedly conclusions
of less than a favorable therapeutic outcome resulting in impairment or disability.
Impairment is assessed by a medical means; therefore, is a medical issue, disability is an
administrative issue. Healthcare providers address impairment issues and the
administrative profession, {i.e. Administrative Law Judges}, address disability issues.
However, throughout the United States it is common for the medical/legal system to
ask the healthcare professional to assess disability to a reasonable degree of their
professional certainty.
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The World Health Organization, {WHO}, defines impairment as, “any loss of
abnormality of psychological, physiological, or anatomical structure or function”. From
the AMA guides impairments are defined as, “conditions that interfere with individuals
activities of daily living”.
An impairment impacts as individual’s health; it is a healthcare issue and there is an
abnormal function or deviation from the baseline in an organ system. After a therapeutic
trial of care, with a consideration of a timeline of healing and recovery, a plateau has
been achieved; therefore, the impairment becomes of a permanent nature.
DISABILITY
The World Health Organization, {WHO}, defines disability as, “any restriction or lack,
{resulting from an impairment}, with the ability to perform an activity in the manner
within the range considered normal for a human being”. AMA guides define disability
as, “an alteration of an individual’s capacity to meet personal, social, or occupational
demands, or statutory or regulatory requirements because of impairment”.
HANDICAP
The AMA guide describes a handicap as, “when an impairment is associated with an
obstacle to useful activity, a handicap may exist. An impaired individual is handicapped
if there are obstacles accomplishing life’s basic activities that can be overcome only by
compensating in some way for the effects of the impairment”.
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To deal with a handicap an individual usually requires a form of durable medical
equipment, {DME}, {i.e. walkers, canes, wheelchair, hearing aides, etc.}. Many
handicaps are temporary during a recovery, rehabilitation phase of care.
IMPAIRMENT
Impairment, {AMA guide}, “is the loss of, loss of use of, or derangement of any body
part, system, or function.” Permanent impairment has become static with or without
medication treatment, is not likely to remit despite medical treatment of the impairing
condition.
PERMANENT DISABILITY
According to the AMA guide permanent disability takes into consideration other issues
than medical. Permanent disability exists when an individual’s ability to participate in
gainful employment/activity is decreased or nonexistent because of impairment. A
permanent disability is not a stand-alone issue; there may be other contributing factors.
When a condition is considered to be permanent there is no anticipation of any significant
change in the future.
TREATMENT GOALS
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Once medical necessity and a care plan have been established, the therapeutic
intervention plan should be constructed to include both short term and long term goals.
This is dependent on the patient’s classification on presentation, {i.e. acute, subacute,
chronic, exacerbation, remission}.
Impacting the patient’s presenting complaint is comorbidity. Comorbidity continues to
be a troublesome issue with an alarmingly increasing frequency in the general population,
{i.e. obesity, elevated cholesterol levels, acid reflux, {GERD}, Type I or Type II
Diabetes, etc.}. It is not unusual to find in the file appropriate consultations or referrals
to other healthcare specialists or disciplines in regard to this issue. Regardless of the
patient’s presenting complaints and past history with comorbidity; both short and long
term goals should be realistic for a progressive positive outcome, which can be
realistically anticipated.
Treatment goals should include the type of treatment and frequency to best decrease the
patient’s symptomatology, increase function so he/she may participate in his/her
activities of daily life or ergonomics. These similar indicators are also necessary for the
patient to attain a pre-accident status.
There is a movement in healthcare, especially in chronic conditions to involve and
educate not only the patient but also the family members. This team approach gives the
immediate impacted family an appreciation of the patient’s condition, the type and
frequency of care needed, the probable symptomatology and potential cycle of
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 26
exacerbations and remissions. There is a movement in the healthcare industry to, when
possible, to reduce dependency of a patient on a healthcare provider. This will shift
many passive treatments to a more active form, having the patient engage in self help
rehabilitative programs; home stretching, exercise to increase strength and endurance of
the involved musculature, life style modifications, {dietary regulations, weight loss,
cessation of smoking}. When appropriate the patient will have a proportionate
responsibility to restore their health to what degree is possible and to maintain and
stabilize their condition.
MEDICARE ELIGIBILITY
• Largest medical program in the United States
• Individuals or spouses of individuals are eligible
o Reach 65 years of age
o US resident or permanent legal resident for at least 5 years
o Have paid into Social Security for 10 years
Eligibility prior to age 65 if the following criteria are met
o End stage renal disease
o Disability for 24 months
OIG REPORT
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The office of the Inspector General in June 2005 published the chiropractic services in
the Medicare program of Patient Vulnerability Analysis report and a follow-up report in
May 2009; Inappropriate Medicare Payments For Chiropractic services. The reports are
critical of chiropractic documentation and highlights areas of deficiencies and absence
of information that is required by the Medicare benefit policy manual. However, there
was some improvement in the May 2009 follow-up report, the chiropractic profession
still has many documentation issues in the Medicare system to be addressed and
improved upon.
Suggested web site for further information: http://oig.hhs.gov
On a positive note, on June 16, 2009, a report was published to congress on the
evaluation of the Demonstration of Coverage of Chiropractic Services Under Medicare.
The Medicare Demonstration project consisted of selected regions in the country where
chiropractic coverage was expanded to include a broad range of numerous
musculoskeletal diagnoses involving the spine, extremities, neurological system, and a
broad range of services which included extra-spinal manipulation, modalities, E&M
visits, ordering diagnostic testing such as blood, as well as radiographic plain films and
imaging studies. With the exception of the Chicago region, the report was positive in
regard to the efficacy of the chiropractic services provided and patient satisfaction.
NATIONAL GOVERNMENT SERVICES {NGS}
The Centers for Medicare/Medicaid Services, {CMS}, announced on March 18, 2008
award of the contract for Part A and Part B Medicare fee for service claims in Jurisdiction
13, {which includes the states of Connecticut and New York}, to National Government
Services, {NGS}. NGS is one of the largest Medicare contractors in the country, taking
over 280,000 providers and suppliers and 22.5 million people in 26 states and five US
territories.
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Please contact CMS for your regional Medicare contractor.
Here are some important e-mail addresses in regard to National Government Services
General information – www.NGSMedicare.com
Monthly Medical Review
www.NGSMedicare.com/ngsmedicare/PartB/NewsandPublications/MedicareMonthlyRe
view/IndexMedMonRev
LCD Policy search page – www.cms.hhs.gov/mcd/results_idsearch.asp
In ID search box put L28144
Click on any Part B chiropractic service for LCD policy
EDI enrollment
www.NGSMedicare.com/ngsmedicare/PartB/Resources/Forms/IndexFormsPartB.aspx
MEDICARE PROVIDER ENROLLMENT, CHAIN AND
OWNERSHIP SYSTEM {PECOS}
You should submit and/or update a record in the PECOS system, if you have not already
done so. It is imperative that the necessary enrollment information is in the PECOS
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 29
system so that you maintain your opportunity for Medicare future initiatives and
incentives. You may not have enrollment in PECOS if your enrollment in Medicare was
prior to the initiation of PECOS approximately 6 years ago. PECOS enrollment is
especially important in respect to incentive payments for Medicare in regard to certified
electronic health records.
For more information on the American Recovery and Reinvestment Act of 2009,
{HITECH}, visit http://www.cms.gov/Recovery/11_HealthIT.asp
PECOS is internet based, you would complete and send your own application to your
local Medicare carrier or A/B MAC, {contractor}. The application process requires your
NPI, you must create a user ID and password in the National Plan and Provider
Enumeration System, {NPPES}. A NPPES user ID and password is required to access
internet based PECOS. If you have never created a NPPES user ID and password or
cannot remember them contact http://www.cms.gov/MedicareProviderSupEnroll
The enrollment applications are available from the CMS forms page on the CMS website
http://www.cms.gov/cmsforms/cmsforms/list.asp
The enrollment applications are CMS-855I and/or CMS-855R. Mail the application and
any required additional supplemental documentation to the Medicare carrier or A/B
MAC.
Some additional informative websites; CMS Proposed Rule for meaningful use of
certified electronic health records
http://edocket.access.gpo.gov/2010/pdf/E9-31217.pdf
http://www.cms.gov/Recovery/11_HealthIT.asp
The Medicare Learning Network Catalog detailing provider responsibilities in the
Medicare program per the enrollment process.
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http://www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf
RECOVERY AUDIT CONTRACTORS (RAC)
.
From 2005 to 2008 The Centers for Medicare and Medicaid conducted a program named
the Demonstration on the Use of Recovery Audit Contractors, {RAC}, to identify over
and under payment to all types of providers. The states involved in this pilot program
were New York, California, and Florida.
After CMS paid the contractor and additional overhead expenses; the result was CMSs
net return of $373 for every $1 spent on the audit process. CMS plans by the end of 2010
to make this program permanent and to extend to all 50 states based on its successful
outcome.
Please note that if you have a cash practice and a patient is given a receipt for your
services rendered and the patient self submits to an insurance carrier, that carrier has the
right to audit your documentation to determine if the services provided were medically
necessary based on their local coverage determination policy and if not can request a
refund from the provider.
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Considering that claims generated presently will be eligible for potential RAC review
strategies to ensure appropriate documentation NOW are paramount.
MEDICARE LOCAL COVERAGE DETERMINATION {LCD}
The following is from the NGS Jurisdiction 13 LCD (New York, Connecticut). Although
most Medicare LCD’s are attempting to coordinate nationwide; in other states check with
the regional CMS office for the LCD.
1. Spine or spinal adjustments by manual means
2. Spine or spinal manipulation
3. Manual adjustment
4. Vertebral manipulation or adjustment
The above define manipulative services rendered must have a direct therapeutic
relationship to the patient’s condition and provide reasonable expectation of
recovery or improvement of function.
Axial spine aches, strains, sprains, nerve pains, and functional mechanical disabilities of
the spine are considered to be medically and necessary therapeutic grounds for
chiropractic manipulative treatment. Manual devices, {those devices that are hand held
with the thrust of the force of the device being controlled manually}, may be used by the
chiropractor performing manual manipulation of the spine; however, no additional
payment is allowed for the use of the device or for the device itself. The same or
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different providers may bill only single manipulation, {98940, 98941, or 98942}, on any
one date of service.
LOCATION OF CHIROPRACTIC SERVICES RENDERED
Chiropractic services can be rendered in a variety of locations. The following is a list of
locations and their appropriate number of which is to be inserted in box B.
Chiropractic services may be performed in the office {11}, home {12}, assisted living
facility {13}, group home {14}, inpatient hospital {21}, outpatient hospital {22},
emergency room {23}, nursing facility for patient in a Part A stay {31}, nursing facility
for patient no longer in a Part A stay {32}, custodial care facility {33}, independent clinic
{49}, comprehensive outpatient rehabilitation facility {62}, and state and local public
health clinic {71}.
ABN {ADVANCE BENEFICIARY NOTICE}
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As of March 1, 2009 the Advance Beneficiary Notice of Noncoverage {CMS-R-131}, is
to be used. The prior ABN notice, as well as the NEMB {Notice of Exclusion from
Medicare Benefits}, have sunsetted.
The ABN informs the patient that Medicare will most probably not pay for certain
services being performed. The patient has the option to either accept or reject these
services. The ABN is signed prior to the service rendered, bundled services are not
acceptable. Each ABN is specific for DOS and fee.
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MODIFIERS
It should be noted that if a modifier is attached to a code it is noted that something different
occurred at that patient encounter but the event that occurred did not rise to the level to
inherently change the code.
GY
The GY modifier is used when an item or service{s}, is statutory excluded and does not
fulfill a definition of any Medicare benefit. The GY modifier does not need to be
accompanied with an ABN. The GY modifier will be used when you are of the opinion
that an item will likely be denied because it is not a Medicare benefit, you are submitting a
claim to obtain a Medicare denial for the secondary payor and the beneficiary who may be
liable for the charges.
GA
The GA modifier, “waiver of liability on file”. When you are of the opinion that a service
rendered will be expected to be denied as not reasonable or necessary and an ABN was
provided to the patient and signed. A GA modifier documents that the patient has signed
an ABN. NOTE: The GA modifier is used on assigned claims, even in the situation where
the beneficiary refused to sign the ABN. In this scenario have the refusal of the beneficiary
to sign the ABN witnessed. The most common use of the GA modifier is when you
anticipate Medicare denial for services rendered due to treatment exceeding frequent
parameters. Noted billing patterns where the GA modifier is used without the supporting
ABN may be construed as abusive billing practices.
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GZ
The GZ modifier is utilized when an item or service is expected to be denied as not
reasonable and necessary but there is no signed ABN on file. The GZ modifier is never
appropriate to use if you anticipate Medicare to pay for the services rendered. The use of
the GZ modifier is not mandated; however, it is suggested when a provider provides a
service and forwards a claim to Medicare and the ABN was not signed. If a patient
refuses to sign an ABN this refusal should be documented by a witness, {i.e. office staff},
and noted in the patient record. This reduces the inference of fraudulent activity for
providing unnecessary medical services.
GX
A new modifier GX has been created with a definition of notice of liability issued
voluntary under payer policy. This should be used to report when a voluntary ABN was
issued for a service. The GX modifier is used to provide beneficiaries with voluntary
notice of liability regarding services excluded from Medicare coverage by statute. The
GX modifier must be submitted with noncovered charges only, {i.e.exams, modalities, x-
ray}.
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MEDICARE FACTS
On March 3, 2008 chiropractors are no longer required to bill for services that are
considered to be maintenance. Medicare will not be billed; the beneficiary will sign a
ABN option 2. If you believe that Medicare may still pay for services; are able to
demonstrate that the patient is getting functionally better, the beneficiary will sign the
ABN, option 1; modifier AT and GA will be used.
In box 23d of the CMS form you can place up to 4 modifiers. However, the carrier/MAC
is required only to process the first two modifiers and they must be the most necessary
relevant to their care to ensure reimbursement.
CMS allows doctors and suppliers to charge Medicare beneficiaries for missed
appointments; however, the Medicare beneficiary must also be charged equal amounts for
missed appointments. This is a missed business opportunity; therefore, the appointment
charge is directly billed to the patient and not to CMS as no services were provided.
National policy {Pub 100-2, Medicare Benefit Policy, Chapter 15, Section 240}, limits
the coverage of chiropractic services to the “hands on” manual manipulation of the spine
for symptomatology associated with spinal subluxation. Accordingly, CPT code 98943,
CMT, extraspinal, one or more regions, is not a Medicare benefit.
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Some chiropractors have been identified as using an “intensive care” concept of
treatment. Under this approach, multiple daily visits {as many as four or five in a single
day} are given in the office or clinic and so-called room or ward fees are charged, since
the patient is confined to bed usually for the day. The room or ward fees are not covered.
If using a paper HCFA form and you have diagnoses exceeding the 4 spaces available,
list the diagnoses in order of chief complaint, secondary, etc. The diagnoses that do not
fit on the HCFA form are recorded in the patient’s records. Note, if you use Medicare
Claims Express, {MCE}, software there are spaces for 8 diagnoses.
A chiropractor is prohibited from ordering physical or occupational therapy. Other than
the chiropractic spinal adjustment, no other therapeutic or diagnostic services furnished
by a chiropractor is covered, {i.e. laboratory tests, E&M services, modalities, supplies,
orthopedic devices, nutritional supplements}.
Be aware that there is also another system of coding called HCPCS, {Healthcare
Common Procedure Coding Systems}, used by Medicare, which addresses status of
codes and any addendums. Basically HCPCS is a guide to Medicare’s national Level II
codes used for DME, drugs, medical supplies, etc. and indicates whether a code was
added or changed. On occasion this may effect chiropractic practice, you can
periodically check any code changes that may pertain to you through your respective
regional CMS website.
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According to CMS providers providing beneficiary gifts which exceed $10 at one time,
cumulative $500 in 1 year can be liable for CMP civil monetary penalties.
MEDICARE DOCUMENTATION
The following information must be documented in the patient’s medical record for the
Initial Visit, whether the subluxation is demonstrated by x-ray or by physical
examination.
HISTORY
o Chief complaint including the symptoms present that caused the patient to seek
chiropractic treatment
o Family history if relevant
o Past health history including; general health statement, prior illness{es}, surgical
history, prior injuries or trauma, past hospitalizations {as appropriate},
medications.
DESCRIPTION OF PRESENT ILLNESS INCLUDING
o Mechanism of trauma
o Quality and character of problem/symptoms
o Onset, duration, intensity, frequency, location and radiation of symptoms
o Aggravating or relieving factors
o Prior interventions, treatments, medications, secondary complaints
o Symptoms causing patient to seek treatment
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The subluxation must be causal, i.e. the symptoms must be related to the level of the
subluxation that has been cited. A statement on a claim that there is “pain” is
insufficient. The location of pain must be described and whether the particular vertebra
listed is capable of producing pain in the area determined.
Evaluation of musculoskeletal/nervous system through physical examination
Diagnosis; the primary diagnosis must be subluxation, and must indicate the level
of the subluxation. The secondary diagnosis, must reflect the
neuromusculoskeletal condition necessitating the treatment.
Treatment plan; the treatment plan should include the following
Recommended level of care {duration and frequency of visits}
Specific treatment goals
Objective measures to evaluate treatment effectiveness
Date of initial treatment or date of exacerbation
THE FOLLOWING DOCUMENTATION IS REQUIRED FOR SUBSEQUENT
VISITS
History including
Review of chief complaint
Changes since last visit
System review if relevant
Physical examination including
Documentation of treatment given on day of visit
Exam of area of spine involved in diagnosis
Assessment of change in patient condition since last visit
Evaluation of treatment effectiveness
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Important: Documentation must be legible and made available to Medicare
upon request.
DOCUMENTING SUBLUXATION VIA X-RAY
A radiologist or an authorized ordering practitioner may accept referral for an x-ray
by doctors of chiropractic; however, the attending chiropractor may not order the x-
ray. The authorized practitioner is required to enter his/her name in item 17 of the
CMS 1500 form, as well as his/her UPIN number in item 17A of the CMA 1500
form, or the electronic equivalent as the ordering physician.
In regard to diagnostic imaging any dates of service prior to January 1, 2000, a
documented x-ray or existing MRI or CT Scan must be taken at a time, “reasonably
proximate”, according to Medicare to the initial of the course of treatment. Care is
considered to reasonably proximate if the imaging was taken no more than 12
months prior to or 3 months following the initiation of the course of treatment.
There is a provision that an imaging older than the above boundaries may be
considered adequate if it is documented in the patient’s health record that the
condition lasted greater than 12 month and reasonable objective findings that the
condition is chronic
NOTE: Medicare does not except video fluoroscopy as a method for
the diagnosis of subluxation through imaging.
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When the Doctor of Chiropractic reviews the patient’s imaging it should be
documented into the patient’s file; especially recording the level of subluxation. In
office films should be labeled with the facility, {name of doctor}, in which they were
taken, the patient’s name and date, and a right or left marker. If the imaging was
performed in a facility other than a chiropractor’s office a written report of the
reviewing physician must be included in the patient’s record.
Section 2250 of the Medicare Carrier’s Manual stipulates that judgments about the
reasonableness of chiropractic treatment must be based on the application of
chiropractic principles. Therefore, the Centers for Medicare and Medicaid has
determined that if the opinions of a radiologist and a chiropractor conflict as to the
existence of a subluxation {for a chiropractic patient}, then the opinion of the
chiropractor takes precedence.
For dates of service after January 1, 2000, an x-ray is not required to demonstrate the
subluxation. The subluxation may be established by physical examination via the
PART formula.
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DOCUMENTING SUBLUXATION
VIA PART
The P.A.R.T. evaluation process is recommended as the examination alternative to
the previously mandated demonstration of subluxation by x-ray/MRI/CT for services.
The acronym P.A.R.T. identifies diagnostic criteria for spinal dysfunction
{subluxation}. For dates of service after January 1, 2000, an x-ray is not required to
demonstrate the subluxation. The subluxation may be established by physical
examination via the P.A.R.T. formula.
{P} PAIN
Pain may be evaluated on observation, percussion, palpation, orthopedic testing, etc.
Commonly pain is evaluated by visual analog scales, pain questionnaires, etc. A
standard in the healthcare industry is the rating of a pain scale of 0-10 with the patient
rating his symptomatology from 0 being none to 10 being excruciating, {worse ever
experienced}.
{A} ASYMMETRY/ALIGNMENT
Asymmetry at a segmental or sectional level is commonly arrived at through static or
motion palpatory methods and/or diagnostic imaging {subluxation level}.
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{R} RANGE OF MOTION ABNORMALITY
ROM in regard to hyper or hypo mobility would be evaluated by motion palpation,
diagnostic imaging, ROM, observation, etc.
{T} TISSUE, TONE, TEXTURE ABNORMALITY
Tissue and tone/texture abnormality most commonly is evaluated through palpation
and strength testing.
TO ESTABLISH A SUBLUXATION DIAGNOSIS VIA P.A.R.T.
TWO OF THE FOUR COMPONENTS OF P.AR.T. MUST BE
DOCUMENTED, WITH ONE OF THOSE TWO COMPONENTS
BEING ASYMMETRY AND/OR ROM
MEDICARE DIAGNOSES
PRIMARY AND SECONDARY DIAGNOSES
{CENTERS FOR MEDICARE/MEDICAID SERVICES}
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Accompanying the primary diagnosis, a secondary diagnosis must be recorded
which supports medical necessity. It is important to note that Medicare has
established secondary diagnoses, which are listed in their local medical review
policy.
It would behoove you to review these secondary diagnoses, any other secondary
diagnoses will result in the claim being denied as not medically necessary.
Truncated diagnoses are not acceptable, it is the provider’s responsibility to avoid
truncated diagnoses and select the highest code of specificity from the available ICD-9-
CM codes.
SECONDARY ICD-9-CM CODES
Remember, both the primary and secondary diagnoses, as well as applicable
tertiary diagnosis, must be listed on each claim to avoid denial.
NOTE: Use of any ICD-9-CM code, other than what is listed in the LCD will be
denied.
CPT codes routinely utilized in Medicare, in regard to chiropractic manipulative
treatment are;
98940 1-2 Regions
98941 3-4 Regions
98942 5 Regions
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It is important to remember that regardless of what code you use to establish a
subluxation, either by x-ray or by the PART formula, the components required in
subsequent visits must document that the subluxation criteria is fulfilled for every region
reported to be adjusted. Failure to do this would result in down coding of your
reported CPT level of service.
Relative contraindications to a dynamic thrust, {the spinal adjustment is not ruled out but
risk should be discussed with the patient}, risk management issue; obtain an informed
consent.
• Joint hypermobility
• Bone demineralization
• Bone tumors
• Bleeding disorders, anticoagulant therapy
• Radiculopathy with progressive neurological deficit
Absolute contraindications
• Acute arthropathies, fractures, dislocations, healed fractures or dislocations with
signs of instability
• Vertebral column malignancies, infections of bones and joints, signs and
symptoms of myelopathy or cauda equine syndrome
• Vertebrobasilar insufficiency, significant major artery aneurysm near
manipulation site
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Generally the local medical review policy, in regard to Medicare, defines subluxation as
intervertebral motor segment in which alignment movement integrity and/or
physiological function of the spine are altered although contact between intervertebral
joint surfaces remain intact.
Classification of subluxation for Medical falls into one of three categories.
Acute Subluxation: most commonly a new injury identified through x-ray or
physical exam, in which the chiropractic care is expected to be an improvement in
arrest retardation of the patient’s condition.
Chronic Subluxation: a chronic condition is not expected to clinically resolve,
but where continued therapy can be expected to result in some function
improvement. **Once functional status has remained stable for a given
condition, the condition would then be considered maintenance therapy and
not covered. Nerve root problems; such as a nerve entrapment were the causality
is an acute or chronic subluxation. Medicare considers manipulation/adjustment
of the spine be delivered by a manual means.
**When treating chronic subluxation your daily office notes should record the
increase in functional status of the patient, even if it is a short interval of
improvement, {i.e. patient performs more activities of daily life, increased ROM,
able to engage in exercise}. In accordance with the Centers for Medicare and
Medicaid Services {CMS} “Medicare Benefit Policy Manual” when further
improvement cannot reasonably be expected from continuing care, the services are
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considered maintenance therapy, which is not medically necessary and therefore not
payable under Medicare.
Denial: the most common reasons for denial from Medicare in regard to your
services; the information does not support the need for the amount of visits, the
level of service rendered, the frequency of the service or need for care.
MEDICARE APPEALS
The Medicare appeals process is five levels; regardless of what level you wish to pursue,
the request must be filed within 6 months of the date of notice of a subsequent appeal,
hearing, ALG’s, administrative law judge’s decision, and appeals council determination.
Level I – telephone appeal
Level II – hearing request; the amount in controversy must be $100 or more
Level III – administrative law judge hearing; the amount in controversy must
be $500 or more
Level IV – appeals council hearing; the amount in controversy must be $500 or
more
Level V – judicial review; amount in controversy must be $1000 or more
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At the involved levels II thru V may combine claims that were reviewed within the past 6
months in order to meet the amount threshold of that particular level. All the appeals
level requests can be submitted to.
National Government Services Inc.
Appeals
PO Box 711
Indianapolis, IN 46207-7111
Other than NGS, CONTACT YOUR LOCAL MEDICARE CONTRACTOR FOR
APPEALS CONTACT INFORMATION.
The majority of chiropractic appeals can be handled through the redetermination {Level
I} and reconsideration {Level II}. Level I is reviewed again through the carrier and Level
II through a QIC, {Qualified Independent Contractor}. An example of the forms for
Level I and II appeal are as follows, these forms can be obtained through the CMS
website.
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Website addresses:
Center for Medicare/Medicaid Services CMS: www.cms.hhs.gov
Many Medicare patients, to occupy their time, supplement their income by returning to
part-time work. If a Medicare patient has a causal related work injury the workers’
compensation carrier would be liable for the consequential healthcare cost specific to that
event.
Many individuals today work full-time, well past the Medicare age eligibility and carry
an indemnity plan, {i.e. BCBS}, through their employer, as well as have Medicare.
Therefore; if a patient at age 70 were working full-time with health insurance benefits
through his employer, the employment health insurance would be primary and Medicare
secondary.
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TREATMENT OF FAMILY MEMBERS
CMS bars and requires the reimbursement for services rendered by a related physician or
supplier, even if an unrelated individual, partnership, or professional corporation submits
the claim.
The following are included in the definition of immediate relative
Husband and wife
Natural or adoptive parent, sibling
Stepparent, stepchild, stepbrother, or stepsister
Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law,
sister-in-law
Grandparent or grandchild
Spouse of grandparent or grandchild
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PATIENT INTERACTION SCENARIO {1}
NOTE: FEES ARE EXAMPLES ONLY
A Medicare eligible patient, a male 72 years of age, is in good health, exercises regularly
and has a preventative mindset. He finds chiropractic care beneficial for his health and
well being and presents on a scheduled basis, approximately 1 time monthly for a full
spine adjustment; a maintenance care pattern, which you have discussed with the patient
and he understands that Medicare does not pay for chiropractic maintenance care.
ACTION STEP
Have the patient sign an ABN; option 2, Medicare is not billed.
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PATIENT INTERACTION SCENARIO {2}
A new patient presents to the office, the Medicare diagnoses are; primary 739.1 and
secondary 721.0. In this particular case you are treating one region, CPT 98940, as active
treatment so you would utilize CPT 98940 with the AT modifier. Also on the initial visit
you performed a limited new patient examination; CPT 99202, performed AP and lateral
plain film x-rays in your office; CPT 72040 and applied ultrasound as an adjunct to the
chiropractic spinal adjustment CPT 97035. Based on the local coverage determination,
{LCD}, the initial new patient exam CPT 99202, the plain films of the cervical spine
CPT 72040, and the ultrasound CPT 97035 are non-covered services.
ACTION STEP
The patient may have secondary coverage for these non-covered services, so for these
services you will code them using a GY and GX modifier. This will ensure that the
proper denial will be explained on the explanation of benefits, {EOB}, from Medicare.
The patient will sign an ABN; option 1
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PATIENT INTERACTION SCENARIO {3}
The current treatment of this patient is protracted due to spinal degenerative change and
significant co morbidity. The patient’s diagnosis is 739.3, 724.2, and 722.52. The
treatments to date have numbered 30, you believe that you have the appropriate
documentation for medical necessity to continue care but you are also aware that you are
reaching the upper parameters of care frequency and additional care has the potential to
be denied.
ACTION STEP
Discuss the situation with the patient, have the patient sign an ABN, option 1 and add a
GA modifier to the CPT code; i.e. 98940 AT, GA.
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PATIENT INTERACTION SCENARIO {4}
Taking into consideration the same patient interaction scenario; however, you did not
obtain a waiver liability from the beneficiary. Therefore; you would code the date of
service CPT 98940 AT, GZ. If the patient refused to sign the ABN, have the refusal
witnessed and documented in the patient’s record.
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UTILIZATION GUIDELINE
Acute, uncomplicated pain up 3 times a week for 2 weeks, 1-3 times a week for 2 weeks.
If documented improvement continuation of care up to 4 weeks at 1-2 times per week,
treatment parameter 16-30.
Chronic pain/acute complicated pain patterns; 3 times a week for 4-6 weeks, then 2 times
a week for an additional 4-6 weeks with treatment being concluded usually less than 12-
16 weeks.
Exacerbations; episodes of care exceeding one per condition will be reimbursed only
if there is an exacerbation documented in the medical records.
RED FLAGS IN RECORDKEEPING
If a correction is needed, the correction should consist of a line drawn through the
mistake and initialed. Corrections should never be erased and the use of white out
avoided. Open spaces between entries should be avoided, as there is the potential to add
or embellish documentation after a patient encounter. Notations should be avoided being
jammed into entries, as this infers that they have been put into the entry as an
afterthought. Dark colored ink is preferred and should be consistently used throughout
the day. The provider should initial typed, transcribed notes or handwritten notes.
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Legibility of a note, when handwritten, is the responsibility of the provider. What is
documented in the record reflects experiences of the patient’s encounter. If an entry is
illegible then it is considered that what was illegibly recorded did not in fact take place.
There are certain findings and patterns, which can be considered to be suspicious
and would warrant monitoring.
Upcoding; when billing for a code higher than what was actually performed, {i.e.
billing for CPT 98941; 3-4 regions when CPT 98940; 1-2 regions service was
performed}.
Miscoding; coding for a procedure other than what was performed, {i.e.
performed 97010 application of modalities of one or more areas hot or cold packs
and billing for 97022 application of modalities to one or more area whirlpool}.
False time claims; billing for a time procedure that was not performed or
exaggerated, {i.e. billing for E&M 99202 when a E&M 99201 was performed}.
Unbundling; when a global fee or an agreed upon fee is billed is broken down
and charged per item.
Truncated diagnoses; insurance carriers today require diagnoses to be as specific
as possible; therefore, truncated or shortened diagnoses avoided. Diagnoses
should be now coded out to the highest level of specificity, {i.e. instead of 839.0
cervical subluxation unspecified, 839.05 cervical subluxation C5 level}
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WAVING COPAYS AND DEDUCTIBLES
At any time in any part of the country economic down turns can occur. It is
commonplace in the news to hear of corporations, companies, or service industries down
sizing. Subsequently, unemployment, loss or reduction of healthcare insurance coverage,
personal illness, or tragedy could result in devastating financial hardship. During these
times ones ability to pay for healthcare services, or even to meet a deductible or
copayment is impossible. As a provider you are committed to treating the patients who
require your services, at the same time you are expected to consistently charge for your
services rendered. A strategy to address this problem is to refer to the United States
Government Published Poverty Guidelines. Internet resource; Department of Health in
Human Services www.aspe.hhs.gov/poverty/05poverty.shtml.
FRAUD IN HEALTHCARE
The definition of fraud according to Encarta Dictionary;
1. Crime of cheating people; the crime of obtaining money or some other benefit by
deliberate deception
2. Somebody who deceives by pretending; somebody who deliberately deceives
people by imitation or impersonation
3. Something intended to deceive; something that is intended to deceive people – a
story that was subsequently exposed as a fraud
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FRAUD FACTS
Statistics from the Center for Medicare and Medicaid Services show that Americans
spent more than $1.7 trillion on health care in 2003. Combined with the fact that industry
experts estimate that anywhere from 3% to 10% of this total is lost to health care fraud,
that would put the minimum amount spent on health care fraud at over $100 million per
day. {Taken from Employee Benefit News – September 15, 2004}
Fraud is not only making an untrue statement. It can also be committed by concealing a
material fact. Under most circumstances a provider who renders care and who knowingly
administers the care for services not medically necessary is committing a fraud.
In 1997 CAIF’s {Coalition against Insurance Fraud}, study entitled Four Faces: Why
Some Americans do – and do not – tolerate insurance fraud, reported that the public
tolerance of insurance fraud is increasing. The potential reasons listed for committing
insurance fraud include
1. To save money
2. To get expensive work done they could not afford
3. To get back at insurance companies
The reasons why people resist fraud included the sense of right and wrong and the fear of
being caught.
The Journal of the American Medical Association in 2000 reported the following, “nearly
one of three physicians say its necessary to game the health care system to provide high
quality medical care”, “more than one in three physicians say patients have asked
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physicians to deceive third-party payers to help the patients obtain coverage for medical
services in the last year”, one of ten physicians have reported medical signs or symptoms
a patient did not have in order to help the patient secure coverage for needed treatment or
services in the last year.
In the journal of the American Medical Association 2000 reported the following; in
healthcare 80% is causal to provider fraud. Provider fraud routinely is categorized as
1. False claims
2. Billing claims
FALSE CLAIM EXAMPLE: You are treating a workers’ compensation case, biweekly
presentations, you bill the carrier for treatment over a 4 week period on the dates of the
2nd, 5th, 10th, 12th, 16th, 18th, 24th, and 26th. However, the patient cancelled on the 14th and
the 26th, in that regard the carrier was billed. However, no services are rendered.
The patient was diagnosed with cervicodorsal complaints, examination revealed objective
findings to the cervicodorsal spine documenting the medical necessity of treatment. The
appropriate CPT code in this clinical scenario is 98940 but the provider routinely bills
98941 for 3-4 regions, though only addressing and adjusting 2 regions of the spine.
THIS IS AN EXAMPLE OF UPCODING.
Though much is written in regard to upcoding, undercoding consistently occurs.
Undercoding is when a provided service to a patient is coded at a level of service less
than which was actually delivered. Professional services are expected to be provided
consistently in the patient population.
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 72
SCENARIOS
Take the following into consideration; a patient presents to the office historically as a
cash patient. Upon evaluating the patient you render a diagnosis of 847.0 LS Strain.
Your treatment selection is side posture adjustments with application of electrical muscle
stimulation to hypertonic lumbar musculature. Customarily you charge $40.00 for a
spinal adjustment, $20.00 per modality. The fee for this service rendered is $60.00;
however, with the prospects of the patient paying cash, a relief from filling out treatment
plans and insurance forms and waiting for reimbursement, you charge this patient $40.00
eliminating the fee and/or not recording the application of the modality.
Later in the day a patient presents with the same clinical scenario as our cash patient, the
same diagnosis is arrived at and a side posture adjustment, as well as electrical muscle
stimulation is selected and those services delivered. This patient has insurance; you face
the task of filling out a treatment plan, awaiting decision on the number of visits that
would be authorized, potential of filing subsequent treatment plans and insurance forms,
and waiting for reimbursement. This patient is charged $60.00 for the services rendered;
the modality is charged for and recorded. THIS IS AN EXAMPLE OF
DISCRIMINATORY UNDERCODING BILLING.
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 73
A Medicare patient presents for chiropractic care with a diagnosis of 1. 739.3 lumbar
subluxation, 2. 721.3 Lumbar Spondylosis w/o Myelopathy. The primary and secondary
diagnosis would indicate to Medicare that the condition requires a chronic treatment
parameter. You select a series of chiropractic spinal adjustments for the patient, as well
as ultrasound applications to address lumbo-sacral musculature involvement. The
modality is a non-covered Medicare service. The patient may have secondary coverage,
which may in part pay for the modality. Usually, the charges for the modality, in office
x-rays, or examinations would add to the out of pocket expense for the Medicare patient.
You are concerned about that any mounting of out of packet expense may discourage or
deter the Medicare patient from continuing to present for his/her chiropractic spinal
adjustments; therefore, you elect to not bill and/or report the modality service. This
decrease of lack of out of pocket expenses has the potential to influence the Medicare
patient to continue presenting for the covered Medicare service, the chiropractic spinal
adjustment. THIS IS AN EXAMPLE OF UNDERCODING BILLING.
These practices diminish all healthcare providers who maintain the standards of ethical
professional conduct. In the healthcare industry this fraudulent conduct will continue to
be aggressively monitored through pre and post audits, reviewing documentation and
seeking remedy for offenses through state licensing boards and the civil court system.
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 74
PEER REVIEW
The peer review process involves a non treating provider reviewing the provider’s
management of the case. Peer review is common in all healthcare disciplines.
Universally, the peer review process is implemented most commonly to address one or
more of the following issues;
History consistent with the mechanism of injury
Is the treatment rendered consistent with the diagnosis
Does the testing, current course of care, {imaging, laboratory} be reasonably
anticipated to be ordered based on the objective findings and mechanism of injury
In work related dates of loss, was the mechanism of the date of loss and the events
of consistent with the employee/employer
The patient presenting to multiple providers at times for the same discipline
Return to work; light duty, regular duty and/or limitations
Patient cannot return to any type of duty
Patient can return to full duty but the employer is not convinced that the patient
can return to his normal duty safely
Return to work dates are extended several times
Permanency is reported
The above issues are addressed at times with a, “file review”, and other times with a
hands on physical examination, the Independent Medical Examination or the IME.
The subject matter that you reviewed will assist you in documenting appropriate
regulatory compliance and supporting the necessity of your care. This is so you, the
Doctor of Chiropractic, can continue to provide and deliver to your patient’s the
“hands on” experience which has no peer; the chiropractic spinal adjustment.
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 75
QUESTIONS
1. Permanent disability is determined via objective findings
a. When the patient is receiving supportive care
b. When the patient is presenting for maintenance care
c. When the patient utilizes DME {i.e. crutches, cane}
d. Post therapeutic care
2. A Permanent Impairment Evaluation is an administrative issue with the evaluation
performed by a healthcare provider
a. True
b. False
3. Issues which initiate a Peer Review
a. Multiple extended return to work dates
b. Is treatment rendered consistent with diagnosis, testing, and course of care
c. Permanency reported
d. All the above
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 76
4. What statement is true
a. The notifier of the ABN must retain a copy of the notice
b. ABN required in urgent and emergency situations
c. The ABN must be delivered in advance to the beneficiary or their
representative so there is sufficient time to consider the options
d. Both A and C
5. A Medicare patient presents with an acute low back condition to an office staffed
by two DC’s. The patient presents to the office two times in one day; at 9 AM
and 3 PM respectively being seen by Dr. A at 9 AM and Dr. B at 3 PM. Services
rendered by each DC; 98940. Appropriate billing would be
a. Two HCFA forms; one for each provider billing 98940 for the same date
of service
b. One HCFA form signed by one provider billing 98940 two times on the
same date of service
c. One HCFA form signed by one provider for one 98940 for the date of
service
d. Two HCFA forms; one for each provider billing 98940 two times for the
same date of service
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 77
6. You have a cash practice and supply a receipt to your patient and your patient self
submits the charge for services to his/her insurance company. In order for your
services to be considered for reimbursement your documentation is required to
meet the insurer’s local coverage determination policy/health care policy bulletin
for necessity of care.
a. True
b. False
7. The services of a healthcare provider, diagnostic testing ordered, level of service
provided proportional to the diagnosis and supported by objective findings with
the care anticipated to produce a positive therapeutic outcome best describes
a. Therapeutic care
b. Medical necessity
c. Supportive care
d. Palliative care
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 78
8. When documenting a spinal subluxation for a Medicare patient through physical
examination via the PART formula; two of the four components must be present
with one of the two components being one of two specific components of PART.
What combination is correct
a. PT
b. C5 subluxation demonstrated by plain film cervical x-ray
c. AR, PA, AT, RT
d. TP, PT, C5 subluxation documented on cervical MRI study with
gadolinium
e. Both c and d
9. Examples of record keeping red flags
a. Upcoding, downcoding
b. Illegible handwriting, upcoding, truncated diagnosis
c. Downcoding, miscoding, inconsistent ink color
d. All the above
10. CMS utilizes what coding system to modify or add a code
a. HCPCS
b. CPT
c. ICP
d. Index Medicus
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 79
11. The most common examination levels in chiropractic practice
a. Detailed
b. Comprehensive
c. Problem Focused and Expanded Problem Focused
d. Problem Focused
12. The dosage of a therapeutic intervention is
a. Minimum rate and magnitude of joint load needed to bring about a change
b. Frequency of care necessary and sufficient to maintain effects while
healing occurs
c. Minimum treatment/care interval to obtain a stable response
d. Potentiation or competition of response by simultaneous treatment/care
application
13. A continuous disability for 24 months and/or end stage Renal Disease prior to age
65 are criteria for eligibility for Medicare
a. True
b. False
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 80
14. The following modifier has been created by CMS with the definition of a notice
of liability issued voluntary under payer policy. This modifier is used to provide
beneficiaries with voluntary notice of liability regarding services excluded from
Medicare coverage by statute
a. GA
b. GY
c. GX
d. GZ
15. Insurance carriers require diagnoses to be as specific as possible. The following
shortened diagnoses category should be avoided
a. Complex
b. Unbundled
c. Miscoded
d. Truncated
16. Someone who deceives by pretending, somebody who deliberately deceives
people by imitation or impersonation is a definition of
a. Fraud
b. Misrepresentation
c. Deception
d. Impersonation
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 81
17. The Coalition against Insurance Fraud study reports that the publics potential
reasons for committing insurance fraud
a. To save money
b. To get expensive work done they cannot afford
c. To save money and to get back at insurance companies
d. All of the above
18. The following codes are the key to tracking patient’s evaluation and management
in regard to examination procedures, diagnostic techniques, therapeutic avenues
and services pursued
a. Medicare modifiers
b. Classification of evaluation and management E/M services
c. PART formula
d. 98940
19. The majority of chiropractic Medicare appeals can be handled through
a. Level I redetermination
b. Level II reconsideration
c. Level III administration law judge
d. Both A & B
Wellxcel Benjamin M. Bartolotto, BS, DC, FACC 82
20. The Health Insurance Portability and Accountability Act, {HIPAA}, rule that
outlines electronically protected health information, {EPHI}
a. Privacy Rule
b. Security Rule
c. NPI Rule
d. Enforcement Rule