Tag Archives: chiropractic reimbursement

Rock Your Coding World! How to Evaluate Your Coding for Maximum Reimbursement

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Lisa J. Barnett

Lisa J. Barnett

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Hello Friends in Chiropractic!

Hope you had an awesome summer and took several opportunities to soak in some UV and Vitamin D.

This month I’d like to both expand on my July Medicare Documentation article and coach you on self-auditing evaluation and management (E/M) coding for reimbursement. Are you consistently under-coding your E/M services? It is not benefiting you to do this because more than likely you’re meeting required elements and not getting the best reimbursement available.

So, what exactly does an auditor, be it Medicare or a Commercial Payer look for in determining reimbursement for your evaluation and management services? It is pretty simple and based on both quality and as it turns out, more importantly, quantity of certain elements. Let’s look in depth how you can self-audit your E/M services*:

First, a coding history and review. In 1992, the current E/M codes were introduced as a result of a ten-year study by CMS(Centers for Medicare and Medicaid Services) and the AMA(American Medical Association). Then in 1995 and 1997, CMS and the AMA developed documentation guidelines (DG) for use of these E/M codes.

Without re-inventing the wheel, let’s lay out how you determine which code to use for your patient evaluations and management of care. To review,

  • New patient E/M codes include 99201, 99202, 99203, 99204, and 99205.
  • Established patient E/M, or re-exam, codes include 99211, 99212, 99213, 99214, and 99215.

Charting out information from CMS and ACA’s ChiroCode book, here is what we have as quantifiable elements to determine which code to bill for. Keep in mind that Necessity of Care drives our discussion below.

History, Exam, Complexity of decision-making are the three main elements in the evaluation and management note.

Let’s now diagram out for you each code and corresponding description of each element, using both New Patient and Established Patient criteria. What differences do you see? Which descriptions share commonality?

NEW PATIENT

 CODE  HISTORY  EXAM

 COMPLEXITY OF DECISION-MAKING
IN MANAGEMENT OF CARE
99201 Focused/Minor severity  Focused Straightforward
99202  Expanded/Low-to-moderate severity  Expanded  Straightforward
99203  Detailed/Moderate Severity   Detailed  Low
99204  Comprehensive/Moderate to high severity   Comprehensive  Moderate
99205  Comprehensive   Comprehensive  High

 

ESTABLISHED PATIENT

 CODE  HISTORY  EXAM

COMPLEXITY OF DECISION-MAKING IN MANAGEMENT OF CARE
99211 No key component(s) required No key component(s)  required No Key component
99212 Expanded/Low-to-moderate severity Expanded Straightforward
99213 Detailed/Moderate severity Detailed Low
99214 Comprehensive/Moderate to high severity Comprehensive Moderate
99215 Comprehensive Comprehensive High

 

Building on that, here are the quantified components indicating the minimum number of each component’s required presence in the note to code appropriately and at the maximum level:

NEW PATIENT 

HISTORY  EXAM

 COMPLEXITY OF DECISION-MAKING
IN MANAGEMENT OF CARE
 Code Chief Complaint HX  of Present Illness  Review of Systems Past Family/ Social HX  Exam (1997 DG)  Diagnoses  Data to be reviewed; # of Complaints  Risk Factors
99201 1  1  N/A  N/A  1 in affected body area  1  1  Minimum
99202 1  1-3  1 N/A  1-5  1  1  Minimum
99203 1  4+  2-9  1  6-11  2  2  Low
99204 1  4+  10+  2-3  12+  3  3  Moderate
99205 1 4+ 10+ 2-3 All components 4 4 High

All 3 elements are required in the new patient note to consider reimbursement: History, Exam, Complexity

ESTABLISHED PATIENT 

HISTORY  EXAM

 COMPLEXITY OF DECISION-MAKING
IN MANAGEMENT OF CARE
 Code Chief Complaint HX  of Present Illness  Review of Systems Past Family/ Social HX  Exam (1997 DG)  Diagnoses  Data to be reviewed; # of Complaints  Risk Factors
99201 1 N/A  N/A  N/A N/A N/A N/A  N/A
99202 1  1-3 N/A N/A  1-5  1  1  Minimum
99203 1 1-3  1  1  6-11  2  2  Low
99204 1  4+  2-9  2+  12+  3  3  Moderate
99205 1 4+ 10+ 2+ All components 4 4 High

Two (2) out of the 3 elements are required in the established patient note to consider reimbursement: History, Exam, Complexity

As you may deduce from the above established patient table, 99211’s are rarely used in chiropractic offices. Can you see why?

Additionally, give your current score an extra two points for management of care, i.e., reviewing old records and summarizing in the note stability/worsening of condition, or, two points for obtaining history from someone other than the patient. Add one point for diagnostics performed and reviewed, (i.e., x rays).

Finally, make sure to attached your -25 modifier on all E/M codes if you are giving a CMT on the same DOS.

Have a specific patient in mind and you’d like to find out if you coded and billed at the most appropriate and highest level? Contact me on how you can qualify for a complimentary audit!  Call 920.334.4561 or email lisa@pmaworks.com

Sincerely in Chiropractic,

Lisa Barnett,
PM&A Coach and Consultant
Where Managing by Numbers and Progress Says It All.
My purpose is to be the Best Chiropractic Advocate in the World

*EHR systems may already have built-in features to automate the components for you via their macros/templates.References:

  • American Chiropractic Association ChiroCode Deskbook, 2014-2017
  • Centers for Medicare and Medicaid Services, 1997 Documentation Guidelines for Evaluation/Management Services, Reference II, Medicare Physician Guide, A Resource for Resident Physicians, Practicing Physicians, and Other Healthcare Professionals
  • Centers for Medicare & Medicaid Services, Medicare Learning Network, ICN006764, August 2015, https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf
  • Gwilliam, Evan M., DC, MBA, BS, CPC, NCICS, CCPC, CCCPC, CPC-I, MCS-P, CPMA

List of Components:
History of Present Illness – Elements:
Location (example: left leg); Quality (example: aching, burning, radiating pain); Severity (example: 90 on a scale of 1 to 100); Duration (example: started 3 days ago); Timing (example: constant or comes and goes); Context (example: lifted large object at work); Modifying factors (example: better when ice/heat is applied); and Associated signs and symptoms (example: numbness in toes)

Review of Systems:
Constitutional Symptoms (for example, fever, weight loss); Eyes; Ears, Nose, Mouth, Throat; Cardiovascular; Respiratory; Gastrointestinal; Genitourinary; Musculoskeletal; Integumentary (skin and/or breast); Neurological; Psychiatric; Endocrine; Hematologic/Lymphatic; and Allergic/Immunologic

Past Family/Social History:
Past history includes experiences with illnesses, surgeries, injuries, and treatments/medications. Family history includes a review of medical events, diseases, and conditions that may place the patient at risk. Social history includes an age-appropriate review of past and current lifestyle activities.

To download the article in it’s entirety click the here [LINK]

ICD-10 Implementation Delayed until 2015 – Chiropractors Breathe a Sigh of Relief

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Good Grief!

After all the pressure to get compliant and ready for the new ICD-10, it looks like it will be delayed for another  year.  Again.

According to a report issued by the AHIMA (American Health Information Management Association):

“On behalf of our more than 72,000 members who have prepared for ICD-10 in good faith, AHIMA will seek immediate clarification on a number of technical issues such as the exact length of the delay,” said AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA

Please note the number of capital letters behind Thomas Gordon’s name. This should give us all an idea of how convoluted this process is and will continue to be.

The same article, issued on March  31, 2014 states:

CMS (Centers for Medicare and Medicaid)  has estimated that another one-year delay of ICD-10 would likely cost the industry an additional $1 billion to $6.6 billion on top of the costs already incurred from the previous one-year delay.  This does not include the lost opportunity costs of failing to move to a more effective code set, AHIMA said.

Many coding education programs had switched to teaching only ICD-10 codes to students, hospitals and physician offices had begun moving into the final stages of costly and comprehensive transitions to the new code set—even the CMS and NCHS committee responsible for officially updating the current code set changed the group’s name to the ICD-10-CM/PCS Coordination and Maintenance Committee.

The delay directly impacts at least 25,000 students who have learned to code exclusively in ICD-10 in health information management (HIM) associate and baccalaureate educational programs, AHIMA said in a statement.

The United States remains one of the only developed countries that has not made the transition to ICD-10 or a clinical modification. ICD-10 proponents have called the new code set a more modern, robust, and precise coding system that is essential to fully realizing the benefits of recent investments in electronic health records and maximizing health information exchange. (AHIMA article)

 ICD-10 is not going away. But for those of you who felt that you weren’t going to be ready by the deadline… looks like you have more time to get everyone trained and the systems worked out.

Which is nice!

Stay tuned for more info from your state associations, carriers, and CMS. We will do our best as well to keep you up to date.

Affordable Care Act and Chiropractic: A Teleclass with Dave Michel

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What is the Affordable Care Act and how will it affect you, your chiropractic business, and your patients?

In this timely teleclass, Mr. Dave Michel outlines the basics of the ACA and demystifies it’s myths and complexities.

Learn how it can affect you and your patients.

Ordinarily reserved for our Members Only confidential site,  we are making this teleclass broadly available for listening and download since this is such an important and timely topic,

 You can listen or down in two formats for your convenience: MP3 or WAV.

2013-04-18 12.30 Surviving, Striving and Thriving Through the Affordable Care Act – 50 minutes (mp3)

2013-04-18 12.30 Surviving, Striving and Thriving Through the Affordable Care Act – 50 minutes. (wav)

 

Chiropractic Maintenance Care: Medicare Settlement Means No More “Improve or You’re Out”

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In what could be a landmark decision for chiropractors that have long asserted that regular chiropractic care for seniors with chronic conditions actually saves Medicare money and keeps seniors active and independent, an agreement has been reached.

A Federal Judge has approved the proposed Settlement Agreement in the Medicare Improvement Standard case, Jimmo vs. Sebelius, [Link] clearing the way for thousands of Medicare beneficiaries to receive needed health services to maintain their current level of functioning. While not specifically aimed at chiropractic, the exciting implications remain.

The settlement, which represents a significant change in Medicare coverage rules, ends Medicare’s longstanding practice of requiring people to show a likelihood of improvement in order to receive coverage of skilled care and therapy services. It specifically pertains to “…those with disabilities or suffering from chronic illnesses such as Alzheimer’s disease, Parkinson’s disease, ALS, lung disease.” (ital added)

The Agreement, which is retroactive to the date of the suit was filed, January 18, 2011, includes skilled services covered by Medicare Part A and Part B, such as speech, occupational and physical therapy, nursing and home health services, even when the goal is maintaining the patient’s current condition rather than requiring that the patient improving.

The Medicare law has never supported the “”improvement standard.” Nevertheless, for decades beneficiaries have been denied needed services because they are not improving or have “reach a plateau”, sometimes with devastating results. The Center for Medicare Advocacy says providing maintenance services will save money in the long run, preventing decline, hospitalizations and need for more expensive services.

The official approval of the settlement means the Center for Medicare and Medicaid Services (CMS) must develop and implement an education campaign to ensure that Medicare providers are not denying coverage for vital maintenance services to those with any chronic illness who meet other qualifying Medicare requirements.

The “maintenance standard” is effective immediately. Importantly, this does NOT change anything at this time for you, your documentation, or your patients. Even though we have not seen the official documentation that Chiropractic Maintenance Care is included in this settlement, we are hopeful and following this closely.

More Info:
http://blog.aarp.org/2013/02/06/amy-goyer-medicare-pays-for-skilled-therapy-for-maintenance-with-chronic-illness/

Handling Insurance Company Refund Requests of Chiropractic Patients

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More and more, insurance companies are doing post payment audits or hiring outside firms to conduct payment reviews and requesting money back from your chiropractic office.

Refunds should never be automatically sent out based on a request from an insurance company.  Each request needs to be individually reviewed and processed and the patient’s account should be audited to determine if a refund is actually due and to whom.

Sometimes, a refund is due. Examples may be when an insurance company has double paid dates of service, or when two insurance companies both pay on the same date of service. These are legitimate refunds – ie: you have been paid more than you billed or were due for services rendered. These should be refunded.

Often however, a refund is NOT due and should be disputed. Examples might be when an insurance company or third party does a “post payment review” and determines that the care was not medically necessary, or when insurance pays but later determines that work comp or PI were primary, or when an insurance company decides that the patient did not have a particular benefit or coverage for what they already paid.

Essentially, when you have delivered quality services to a patient that were medically necessary and in the best interest of the patient, and the insurance company pays for those services, you have NOT been overpaid and no refund is due. Even if the insurance company later decides they overpaid or paid in error. These refund requests should always be disputed.

Legally, you are not obligated to repay the insurance company when you have been paid in good faith for services rendered and they paid in error. These should always be disputed.

This will not stop some insurance companies from ‘recouping’ the payment, but you should still attempt to dispute the refund request first. Our experience is that by disputing the refund you will avoid 85% of all refund requests. It is well worth the time and effort to do so.

The exception to the above involves government programs such as Medicare and Medicaid. We generally advise refunding these right away and THEN disputing the request. Remember that you must use the approved Medicare refund form and mailing address (check on line with yur local Medicare carrier for the latest form and address).

Points that can and should be used whenever disputing a refund include these (use any and all reasons that are applicable to each case):

– All services were medically necessary for the health of the patient. Our review indicated that the care was medically necessary; therefore no refund will be issued.

– This request is for a patient no longer active with our office. We have no alternative methods of collecting on these accounts. Because of a supposed error on your part, you are asking us to refund monies to you for services rendered to your insured without a foreseeable ability to collect for said services.

– We called/verified benefits on line with (Insurance Company) on each of these patients prior to the delivery of care and verified coverage for services rendered by our office. Had we been informed, we or the patient could have made a more informed decision regarding the delivery and payment for care.

– It is our understanding that (Insurance Company) has maintained a policy of not reimbursing for services if they are submitted for payment one year or longer after delivery. You are requested a refund for services over two years after their delivery and payment. It would seem that the policy should apply both ways.

– Your letter mentions that 98940 and 97140 are mutually exclusive. This is not the case when they are performed in different regions of the body as defined by the AMA. You also state that manual traction and mechanical traction are mutually exclusive. Again, this is not stated in the AMA CPT codebook and the services were performed by different providers, as our chart records show.

– The time and effort to have our office pull charts and research services from 2009 and 2010 is considerable and cannot be done without prior reimbursement, nor can these records be forwarded to (Insurance Company) without prior consent from the patient.

– We would also like to know if you have informed this patient, in writing, that due to the error on your part, that they are now liable for their medical bill from 2009?

– Our feeling is that the following court cases concluded that the insurance company is responsible for knowing their policy limits prior to paying and therefore must bear the responsibility for their own mistakes.

  1. City of Hope National Center vs. Western Life Insurance Company, 92 Daily Journal D.A.R. 10728, Decided July 31, 1992. (In this case the hospital obtained standard assignment of benefits from the patient and submitted claims, which were paid by the carrier. The insurance company later decided the treatment was experimental and requested the money back. The California Court of Appeals stated that if it’s your mistake you have to pay for it.
  2. In Federated Mutual Insurance Company vs. Good Samaritan Hospital (Neb. 1974) 214 N.W.2d 493. (The carrier contended that it mistakenly paid claims beyond the policy limits. The court held that the insurance company could not recover the money as it places an undue burden on the providers of service to subject them to retroliability.)
  3. Lincoln Nat Life Ins vs. Brown Schools (Ct.App. Tex 1988) 757 S.W. 2d 41 1. (In this case the carrier mistakenly paid claims after its policy had expired. The court denied recovery stating “Here the insurer knew it’s own policy payment provisions, but failed to notify the health care providers as to these provisions and the insurer alone made the mistake of paying beyond its responsibility . . . in the normal course of such business, the hospital has no responsibility to determine if an insurance carrier is properly tending to its business.”)
  4. National Ben. Administrators Vs. MMHRC (S.D. Miss. 1990). (Similar case as #3 with same conclusion.)

– Our office made no misrepresentations in filing claims for your insured. We extended valuable services based on preverification of benefits and assignment of payment by the insured. We were not unjustly enriched, and simply had no reason to suspect that any of the payments for services rendered were in error. Refunding the monies at this time would place an undue burden on our office.

As always, send a copy of your letter to the patients involved. The insurance company will send a letter to the patient (if we don’t send them a check) saying that “we are not cooperating and therefore the patient may be responsible”. So, strike first by presenting our side and preparing the patient.

Situation: The insurance company paid twice on one date of service and missed payments on another. They are now requesting repayment on the double payment.

Solution: Send them a letter explaining that the payments were posted to the unpaid dates and no refund will be made.

 

Situation: The insurance company claims that the work comp carrier is responsible for payment and is asking for all their money back.

Solution: Send them a letter explaining that you will bill the work comp carrier and if and when payment is received, you will refund any duplicate payment.

 

Situation: The insurance company paid for the first eight visits, then denied the next five and now wants a refund on what they paid.

Solution: Dispute the refund as per the above points and request immediate payment on the five denied visits.

 

Situation: The insurance company paid for care, but then came back and stated the patient didn’t have an active policy or coverage.

Solution: Dispute the refund as per the above points. It is the insurance company’s job to pay within the limits of their plan; you have been paid for services rendered.

If you have questions, feel free to contact me.

David Michel

Electronic Health Records and Chiropractic

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There is more and more attention being placed on the topic of Electronic Health Records. For those of you who are not familiar with this subject, you can find basic information on the web sites of CMS (Centers for Medicare and Medicaid Services) and of course, Wikipedia.  There are other sources, but reader beware: many have ties to software companies (and their advertising and promotional distributors) that are trying to make a case for buying expensive software now.

Here is a Q&A with Dave Michel and one of our clients regarding this subject which may be helpful in understanding what is going on:

===============

Dear Dave,

Dr. H wanted me to e-mail you with some of our questions and concerns. We are hearing a lot of different things the more people we talk to about it. We are hoping that you can shed some light on the situation. Here are some of our questions:

Is the deadline for reimbursement this October 2011? Or do we have until October 2012?
There is no deadline at this point. It is not a requirement and, even if it is, there will be an exemption for small offices (usually less than 10 FTEs).

Is there a checklist of things that need to be completed in order to be compliant? Do we need to have digital x-ray in order to be compliant?
Yes, there is a checklist. If you google CMS EHR Incentive you will find a couple on the CMS website (skip software vendor websites …). Digital x-ray is NOT a requirement.

Is it a tax credit or would we receive a reimbursement check? Will it just cover the EHR software or will it cover equipment upgrades/replacement as well?
Beginning May 2012, you would be possibly eligible for up to $18,000 per year in incentives paid as a check to each provider. The limit would be based on 75% of your prior year’s Medicare reimbursment. IF you are “an eligable provder” and you have demonstrated “meaningful use”.

How much should we expect to spend on this process? And how much will we get reimbursed? Is it a percentage or the exact amount? And is it a guarantee?
Great questions. EHR software for chiros ranges between $2.5 – $27k. Add to that the cost of conversion in your office (thousands) and the reduced efficiency (eg if the new program adds 2-3 minutes to each patient encounter). This is going to be a big process.

Dr. H  wants to know “what happens if we don’t become compliant?”.
Nothing. Yet …

Thank you so much for taking the time to answer our questions.
No problem! Bottom line (if you haven’t picked up on this so far …): I am not a fan of any of the EHR programs currently out there. They either add too much time to each patient visit or they produce a SOAP note that would not pass an audit / records review. There is NO guarentee that Big Government is going to be mailing out $44k checks to each provider for doing something that will really not improve the heath care delivery system

Most of what you have seen are from companies marketing their products (seminars, EHR software, etc). There is NO mandatory deadline (yet) to convert to EHR and so far, I have not received confirmation from CMS that chiropractors will receive any money or incentives to convert to EHR. I do have a letter in to CMS to get an official word and will let you know. It does not make sense to me that CMS will give each chiropractor $44,000 to convert to EHRs when the CMS program is going broke. But I will let you know.

For questions about EHR, feel free to contact Dave at Dave@PMAworks.com

Working with HSA / HRA / Flex-Spend Accounts in Your Chiropractic Office

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First, please understand the difference. Many chiropractic patients do not know what they have, so it is important that you understand these key terms.

Traditional Health Savings Account (HSA)

An HSA is a savings account set up to be used for medical expenses and nothing else. Funds directed to the HSA are pretax dollars, thus reducing taxable income, and HSA’s offer interest on the balance. The medical expenses and HSA can be used for include optical, insurance deductions, dental, chiropractic and some over-the-counter medications. Individuals who are covered by high deductible health plan (HDHP) are eligible to open an HSA.

Archer Medical Savings Account (MSA)

An Archer MSA is a tax-favored savings account designed to help you pay for qualified medical expenses if you are an employee of a small employer or a self-employed individual participating in a high-deductible health plan. Archer MSA assets may be rolled over or transferred to an HSA.

Health Flexible Spending Account (FSA)

A health FSA is an arrangement that allows employees to be reimbursed for medical expenses. Health FSAs are usually funded through voluntary salary reduction agreements with the employer. No employment or federal income taxes are deducted from contributions made to a health FSA. In general, balances in a health FSA at the end of a plan year cannot be carried over to the next year. For more information on health FSAs see IRS Publication 969,

Health Reimbursement Arrangement (HRA)

An HRA is an arrangement similar to a health FSA; however, an HRA must be solely funded by an employer. The contribution cannot be paid through a voluntary salary reduction agreement on the part of an employee. Employees are reimbursed tax free for qualified medical expenses up to the maximum dollar amount for a coverage period. Balances in an HRA at the end of a plan year can generally be carried over to the next year. For more information on health HRAs see IRS Publication 969,

Key Differences

The funds contributed to an HRA account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account (FSA), funds roll over and accumulate year to year if not spent. HSAs are owned by the individual, which differentiates them from company-owned Health Reimbursement Arrangements (HRA) that are an alternate tax-deductible source of funds.

Billing Considerations for the Chiropractic Office

All of the above plans qualify for chiropractic reimbursement. The method of obtaining reimbursement varies by the plan type. Some plans will state that they do not pay for prepaid services. This is not accurate, as they will prepay for three years of orthodontic care (braces) and similar “pay upfront” services.

A FSA, or flex-spend account, only reimburses the patient for health care costs they have already paid. The patient must “use or lose” the money that has been put into their FSA each year.

An HSA plan is directed by the patient. They will have a card, similar to a credit card (and processed exactly like a credit card, not a debit card) that pulls from their HSA. This can be used for deductibles, co-payments and prepayments on discount plans.

An HRA plan is maintained by the employer and you must bill directly to the employer (in most cases) for reimbursement.

To avoid confusion for the patient and their HRA or FSA plan, the clinic must provide the patient a receipt or invoice showing that the patient has paid for the service. When a patient begins a treatment plan in your office, and you provide a discount for payment up front for the plan of care, the invoice should show that the patient paid for XX visits in your office. It should not indicate that the patient “pre-paid” for  a care plan as this will often confuse the plan and result in your patient not being fairly reimbursed.

Questions can usually be directed to the company’s human resource department.

Chiropractic offices should promote the fact that they can provide a “Discount for Using Your HSA / Flex Spend Account”. If you have established payment at time of service discounts, or prepayment discounts, encourage patients to use these by promoting the savings they can get. People with these plans are well aware of how quickly they can burn through their heath care dollars and welcome an opportunity to save.

Using HRA Money for Supplements & Vitamins in a Chiropractic Clinic

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Recent changes due to the Affordable Care Act change how patients may use their HRA or flexspend accounts. These changes took effect on Jan 1st of this year. Here was our answer to Mary, a great Front Desk Coordinator who is on top of this.
– – – – – – – – – – – – – – – – – – – – – – – – – — – – – – –

Good Morning Dave,

I have a question. Many of our patients have flex accounts but because of the new laws about not being able to buy over the counter and being reimbursed by the flex accounts I am running into problems with our supplements.

Do you think we could get around this if the Chiropractor wrote on a script card that they (the chiropractor) have recommended the supplement to the patient?

Please let me know what your ideas are on this subject.

Thanks,

Mary

– – – – – – – – – – – – – – – – – – – – – – – – – — – – – – –

Hi Mary,

Great question, you are the first to ask that one, so you get the award! 😉

According to the IRS website (http://www.irs.gov/newsroom/article/0,,id=227308,00.html),

Q. How are the rules changing for reimbursing the cost of over-the-counter medicines and drugs from health flexible spending arrangements (health FSAs) and health reimbursement arrangements (HRAs)?

A. Section 9003 of the Affordable Care Act established a new uniform standard for medical expenses. Effective Jan. 1, 2011, distributions from health FSAs and HRAs will be allowed to reimburse the cost of over-the-counter medicines or drugs only if they are purchased with a prescription. This new rule does not apply to reimbursements for the cost of insulin, which will continue to be permitted, even if purchased without a prescription.

So the question would be, would vitamins and supplements be considered “medicine or drugs”. According to the FDA, they are not. There would be exceptions, and they are:

Supplements – The cost of supplements taken for general well-being are not reimbursable. However, the cost of supplements taken to alleviate a specific medical condition is reimbursable. Physician’s diagnosis letter required.

Vitamins – Daily multivitamins taken for general well-being are not reimbursable. Vitamins taken as treatment for a specific medical condition diagnosed by a physician are reimbursable when accompanied by a physician’s diagnosis letter and a prescription.
Massage – Fees paid for massages are not reimbursable unless to treat a physical defect or illness. Physician’s diagnosis letter required.

A chiropractor is defined under federal law as a physician. So a script would not be needed per se, but a letter of diagnosis with the prescripted supplement would. It will vary based on the patient, case and condition. Sorry this is a longer answer than your question, but I had to look up the info and put it together for you. I have also attached an article that explains the difference between plans, how to use them for chiropractic care, and how to use them for prepay plans.

I hope that clarifies the situation. Let me know if you have any questions.

thanks,

Dave

Medicare, Chiropractic, and Computer Generated Notes

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Is Your Office Looking Into Computer-Generated SOAP Notes? Read This FIRST before you invest your cash!

Thinking that your documentation could use an upgrade? You are probably right, but before you invest in a software generated note system, know that Medicare frowns on most such programs and they could actually hurt you in an audit.

As we have been saying for years, there is no good shortcut out there for doing documentation. You have to follow Medicare’s guidelines and just because your software generates a half page typed SOAP, you may still be missing the mark.

According to ChiroCode Institutes recent alert:

Medicare carrier Noridian Administrative Services recently updated and reprinted a notice on Chiropractic Software-Generated Documentation. Apparently, the piece was generated because Noridian has seen an increase in the use of software-generated documentation for chiropractic services.  Here are a few key areas where software can begin to go wrong (according to Noridian):

– In general, most computerized documentation fails to provide individualized information necessary for reimbursement.

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

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

You can read the whole article here: https://www.noridianmedicare.com/provider/updates/docs/chiropractic_software.pdf%3f. The article contains some humorous (at least to me) examples of  how the software, while randomizing text, generates almost identical SOAPs for different patients on different days.

Getting a Medicare CERT audit? Don’t send in your records without calling us first. See our website for more information on our exclusive Medicare Pre-Audit Documentation Review. LINK

Chiropractors – If You Get a Medicare Audit, Do You Know What to Do Next?

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Are You Prepared?

If You Get a Medicare Audit,
Do You Know What to Do Next?

If you haven’t already heard, CMS Medicare has launched a massive audit project aimed at chiropractic offices around the country. Executive Order #13520 “Reducing Improper Payments and Eliminating Waste in Federal Programs” has unleashed a random attack of chiropractors aimed at recovering an estimated $174,100,000 in over payments.

Medicare has hired two companies to start auditing chiropractors. There is no way to know if you will get a request for an audit, but I can tell you this from being on the road: very, very few clinics will pass a Medicare audit based on the documentation that I have seen.

That’s not to say you aren’t providing proper, necessary care. Far from that. The Medicare documentation requirements for the physician’s signature alone are three pages long.

So What Should You Do?

PM&A is prepared to help you. We have had 25 years of experience with Medicare audits and appeals. If you get a request for an audit, DON’T freak out. Do this instead:

  • Do not ignore it! You have 30 days to respond.
  • Do not let your staff photocopy and send the records out blindly!
  • Call our office immediately and request our special MPDR Program: MEDICARE PRE-AUDIT DOCUMENTATION REVIEW

We will come to your office & go through any requested records with a fine-tooth comb to assist you in ensuring that you have complete documentation for all services rendered, that each date of service is properly documented, that all PART forms are complete, and that active care modifiers have been properly used.

We will go over each entry in the chart with the treating doctor to ensure that every requirement of Medicare documentation is met for the service you rendered. If addendums need to be made, we’ll ensure that the addendums meet or exceed Medicare requirements.

We will also draft a follow up and Medicare Compliance Plan for your office for any areas that need to be corrected so that you can avoid potentially devastating pre-payment future audits or fraud charges.

We have successful fought AND WON on numerous Medicare audits. No other chiropractic management company can say that. A bad Medicare audit can cost well over $100,000 and thousands of staff hours – and more importantly, hurts your patients and their right to chiropractic coverage.

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Medicare Audit Emergency Response Number:     920.459.8500


The MPDR is available to chiropractors in WI, MN, IL, IN, & ND only. This is an emergency response program and slots will be limited to PM&A clients first, then first come. Do NOT send records without calling us first.

The MPDR program covers up to two full days (20 hours) in your office, plus limited follow up. The cost is $4,800 prepaid. PM&A management clients can receive a 20% discount if they are active and current members.

Call for terms and conditions for this service. 920.459.8500

Last Seminar/Next Seminar

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We just finished our 10 classes in 1 day seminar in Minneapolis – our “10 in 1.”  From what I heard and saw, everyone had a great time. I know we did. And for my money, I think we had some of the best professionals in the country giving presentations – as well as attending!

Dave Michel at 3Goals Seminar in Minneapolis
Dave Michel at 3Goals Seminar in Minneapolis

In addition to great presentations by Phyllis Frase on chiropractic philosophy and procedures for staff, Dave Michel on insurance, and myself on marketing and practice building, we had two guest doctors.

Dr Tom Potisk at 3-goals Seminar in Minneapolis
Dr Tom Potisk at 3-goals Seminar in Minneapolis

One was Dr. Tom Potisk who went over how he maintained a joyful practice for 25 years in a multi-doctor setting with 2 associate doctors.

Dr. Shane Walker at 3-goals Seminar in Minneapolis
Dr. Shane Walker at 3-goals Seminar in Minneapolis

Then, as a special guest, we were pleased to have Dr. Shane Walker who is the president of the Federation of Straight Chiropractors. He lit the room up with passion, statistics, and purpose and reminded everyone about the power of chiropractic, as well as it’s importance in society today.

So, just a reminder:

Our Milwaukee seminar is coming up soon.

Dave, Phyllis, and myself all have new material covering C.A. training, insurance and reimbursement procedures, and marketing and practice building.  Our presentations are all based upon the work we do each week in offices across the country – and what we see working, and not working.

For our Milwaukee seminar, we are especially pleased to have two exceptional doctors giving presentations on Thursday, May 20th.  Both are highly qualified and successful doctors that set great examples for excellence in their practice, business, and life.

We will be sending info out on them soon, but you can find out more here.

Hope to see you all in Milwaukee.

Meeting Family Deductibles

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This article was sent in to us by one of our clients. We felt it was a great suggestion and thought it might help your office when faced with the same situation.

“I just wanted to pass something on that may benefit your other offices.  If we have families that we treat where only two or three of them need to meet their deductibles, we choose the family members that are incurring the most charges and send those in right away.  The other family members we hold the charges until the family deductible is met.

“For instance, we have a family of about 8 people that we are treating that have to meet two deductibles to make their family deductible.  We are only sending CMS-1500 forms on two of those patients until the deductible is met, then we will submit all the bills from the other family members so that we don’t have bits and pieces being eaten out of everyone’s claims unnecessarily”

Filing in this manner, simplifies the collection of the patients out-of-pocket at the front desk, reduces the number of claims affected by the deductibles and overall increases the efficiency of the accounting for these patients.

Thanks Laura D from Family Chiropractic