Tag Archives: Medicare

NGS Medicare Fees for 2024 Chiropractic Services CMT

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CMS has now released the 2024 fee schedules for each State*. Note that these often change between the time they are published and the time they go into effect.

According to CMS, the 2024 Part B deductible will increase $14, to $240 as of Jan 1, 2024.

NGS Medicare has released the Medicare Physician Fee Schedule (the 2024 CHIROPRACTIC FEES SCHEDULE) for codes 98940, 98941, and 98942 for Par and Non-Par Part B providers (not Facilities) for dates of service Jan 1, 2024 forward.

Fees for Wisconsin are:

medicare NSG fees 2024

*States include: CT, IL, ME, MA, MI, NH, NY, RI, VT, WI

2023 Medicare Fee Schedule

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Shown below is information regarding the 2023 Medicare Fee Schedule for Wisconsin Providers only provided by NGS Services and also a link to  CMS.gov for fee schedules in other states.

Wisconsin Providers:  Here is the 2023 Medicare Fee Schedule for your perusal.  Please make this accessible to you and your staff.

 

 

Medicare Providers Re-validation Update Announced

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UPDATED FROM JANUARY 24th, 2022

Dear Chiropractors, Office Managers, and Insurance Personnel:

“The Center for Medicare & Medicaid Services is continuing to populate providers’ re-validation due dates from a ‘TBD’ date to an actual due date.

Per CMS (data.cms.gov):

  1. The re-validation data was last refreshed on August 01, 2022.
  2. ‘Adjusted’ Re-validation Due Dates for October 2022 have been added.
  3. The next data refresh is tentatively scheduled for September 1, 2022.
  4. Affiliations now include reassignments as well as Physician Assistant(PA) employment relationships.”

https://data.cms.gov/tools/medicare-revalidation-list

=====

January 24th, 2022

As you may be aware, the Center for Medicare and Medicaid (CMS) made an accommodation during the pandemic regarding your doctor re-validation due date with Medicare. As such, CMS will be adjusting doctors’ re-validation due dates in phases starting this quarter. The Medicare Enrollment online tool, PECOS, has shared information on their homepage that enrollment re-validation has resumed in a phased approach for active providers.

What this means for you: It is critical that you check your re-validation due date and re-validate your Medicare enrollment prior to your due date. If you don’t re-validate, claims will most likely deny when their software program catches a mismatch to enrollment due dates, and you may lose your billing privileges. If you reassign your benefits to your group/Type 2 NPI, you will need to re-validate the group enrollment as well. The re-validation requirement holds regardless of if you are a participating or non-participating provider. There is no fee to re-validate.

CMS has stated they will notify providers via email on file, or mail, approximately three to four months prior to their adjusted due date. You can check your re-validation due date here:
https://data.cms.gov/tools/medicare-revalidation-list

Once you open the page, you will see two due date boxes. You may disregard the original due date shown on that page. The box to pay attention to is the “Adjusted Due Date”. If it states TBD, keep checking every couple of weeks to see if that field has been populated to show your adjusted due date.

How do you re-validate? Use online PECOS (the preferred method), linked here: https://pecos.cms.hhs.gov/pecos/login.do#headingLv1

Or submit a paper 855i application, found here: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855i.pdf

References:
Please see the initial communication here:
https://pecos.cms.hhs.gov/pecos/login.do#headingLv1

Additional related links:
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/Revalidations

https://www.cms.gov/files/document/provider-enrollment-relief-faqs-covid-19.pdf

Contact us if you have any questions – we’ve got you covered!
(This includes if you can’t get into your PECOS account because it’s been so long, or because of staff changes, or because you forget your password, call us and we can help you.)

Lisa Barnett
920-334-4561
Petty, Michel & Associates

Email: lisa@pmaworks.com, dave@pmaworks.com

Insurance Key References

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Following is a list of links to various publications with helpful information on insurance filing guidelines and requirements.  At the bottom is a convenient downloadable document with all of this information listed.
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Wisconsin Worker’s Compensation Treatment Guidelines DWD CH 81.04
https://docs.legis.wisconsin.gov/code/admin_code/dwd/080_081/81

General. Except as set forth in par. (b) and s. DWD 81.04 (5), a health care provider may not direct the use of passive treatment modalities in a clinical setting as set forth in pars. (c) to (i) beyond 12 calendar weeks after any of the passive modalities in pars. (c) to (i) are initiated. There are no limitations on the use of passive treatment modalities by the patient at home. DWD 81.06(3)(a)

Wisconsin Worker’s Compensation Tx Guidelines Departure from Guidelines / Exceptions
DWD 81.04(5) (5) Departure from guidelines. A health care provider’s departure from a guideline that limits the duration or type of treatment in this chapter may be appropriate in any of the following circumstances:

Wisconsin Unfair Claims Settlement Practices
Ins 6.11  Insurance claim settlement practices.https://docs.legis.wisconsin.gov/code/admin_code/ins/6/11/3

Wisconsin Medicaid CMS1500 Claim Instructions
https://www.dhs.wisconsin.gov/forms/f0/f01234a.pdf
https://www.forwardhealth.wi.gov/kw/pdf/2008-89.pdf

Wisconsin Medicaid – New Requirements and Clarification of Chiropractic Services
https://www.forwardhealth.wi.gov/kw/pdf/2016-35.pdf

Documentation, SOI, 20 visit limit, exam clarification.
State of Wisconsin Insurance Equality
632.87(3) Wisconsin Insurance Equality Chiropractic

Medicare Supplement Mandated Benefits Wisconsin
https://oci.wi.gov/Documents/Consumers/PI-002.pdf
Medicare Supplement and Medicare SELECT policies cover the usual and customary expense for services provided by a chiropractor under the scope of the chiropractor’s license. This benefit is available even if Medicare does not cover the claim. The care must also meet the insurance company’s standards as medically necessary.

Wisconsin Provider Manual Anthem BCBS
https://www.anthem.com/docs/public/inline/PM_WI_00006.pdf

Wisconsin Anthem BCBS Commercial Reimbursement Policy
https://www.anthem.com/docs/public/inline/C-08010.pdf

Wisconsin Anthem BCBS Commercial Modifier Rules
https://www.anthem.com/docs/public/inline/Modifier_Rules_2021.pdf

Downloadable Reference Guide: Insurance Key References

“No Surprises Act” effective January 1, 2022

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“Wondering about the new federal ruling to end surprise patient billing?

Though this mainly pertains to hospitals and emergency services, chiropractic  providers are impacted as well.  Click here to see  Medicare’s explanation on the ruling. https://www.cms.gov/nosurprises/consumers/understanding-costs-in-advance

For over 35 years, Petty, Michel and Associates has been at the forefront of educating doctors and staff on utilizing financial consultations and worksheets to estimate out a patient’s out-of-pocket financial responsibility for their care.  If you are interested in how you can obtain our Financial Consultations Toolkit,  please contact Lisa at lisa@pmaworks.com.”

Lisa

Medicare Reimbursement Cuts Delayed in 2022!

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On December 10th 2021,  President Biden signed into law a bill to delay reimbursement reductions for physicians. Further, the proposed 2% sequestration reimbursement reduction to physician services as well as to farmers, has been delayed.

Please see the 2022 Wisconsin Chiropractic physician fee schedule below.

For your reference, here are the 2020 and 2021 Wisconsin Chiropractic physician fee schedules:

For over 35 years, Petty, Michel & Associates has been at the forefront of keeping up to date with CMS Medicare & Medicaid Service’s billing and coding standards. Questions? Contact us at 414-332-4511 or email Lisa-lisa@pmaworks.com

Source: https://www.jdsupra.com/legalnews/bill-averting-medicare-sequester-cuts-4029291/

For more details on fees and relative values in your practicing state, refer to your Medicare Administrator Contractor’s (MAC’s) website.

David Michel

Medicare Part B Premium Jumps Dramatically for 2022

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stethescope on calculator Kiplinger recently shared information from the Centers for Medicare & Medicaid Services reporting that Medicare Part B premiums will jump dramatically in 2022. An increase of 14.5% or $21.60 from 2021. Deductibles will also show an increase of $30.00 going to $233 in 2022.

The article goes on to say that Medicare Part A will also see an increase in deductibles.

Medicare claims “the increases were due in part to rising health care costs and higher utilization of health care services.”

They further stated, Aduhelm, a prescribed Alzheimers drug was also to blame.

To read the article in it’s entirety visit:
https://www.kiplinger.com/retirement/medicare/603759/medicare-part-b-premium-jumps-dramatically-for-2022

The 2022 Medicare fee schedule has now been released for Wisconsin for 98940-42:

New Year = Coding Changes.

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As we leave the crazy year of 2020 and enter a fresh 2021, here is a summary of  Coding changes taking place that impacts your clinic operations and bottom line:

I. CPT Code 99201 is being deleted effective 1/1/2021

A. Documentation for CPT Codes 99202 through 99205 will be required using criteria of Medical Decision Making OR Time element to determine the level of coding.

o Medicare requirements remain the same for medical decision-making criteria using P.A.R.T. (Pain, Asymmetry/misalignment, ROM decrease, Tissue tone changes) OR diagnostic imaging with documented report of objective findings.

B. CPT 99211 (re-exam) is not being deleted but not used very frequently, and some payers do not pay chiros for this code. You may still bill 99211 when a CT licensed in history-taking and exams performs a re-exam.

C. The 2021 treatment plan model will be the same as 2020:

o Number 1 documentation priority Medicare is looking for: Goals (time or distance element, for example ADLs or specific exercise)
o Number 2 element = duration of care (for example 24 visits)
o Number 3 element = frequency of care (Example – 2X/week for 12 weeks)

II. Changes to ICD-10 codes relevant in chiropractic

1. The following codes have been Added:

A. Arthritis of temporomandibular joint

i.   M26.641 right
ii.  M26.642 left
iii. M26.643 bilateral
iv. M26.649 unspecified

B. Arthropathy of temporomandibular joint

i.   M26.651 right
ii.  M26.652 left
iii. M26.653 bilateral
iv. M26.659 unspecified

2. Deleted ICD-10 Codes:

A. M92.50, M92.51, and M92.52 deleted. (Juvenile osteochondrosis). Use M92.8 or M92.9 instead
B. R51 (this headache code deleted). Here are two specific codes added, to use instead:

i. R51.0 Headache with orthostatic component, not elsewhere classified
ii. R51.9 Headache, unspecified

III. Medicare 2021 Reimbursement on covered CMT
Please note a significant reduction in reimbursement across the board for select specialty physicians and surgeons. Here is the chiropractic fee schedule:

Referring back to the exam discussion above, you may want to consider raising your E/M code fees. However, be advised insurances will not reimburse at your full fee, and Medicare as well as most Part C plans as of this writing do not pay for exams performed by Doctors of Chiropractic. These charges are patient responsibility.

Questions? We’re here to help!

Call 920-334-4561 or email lisa@pmaworks.com

Cheers!

~Lisa Barnett
Increasing your collections through better billing and documentation.

References:

New Medicare ABN-effective 1/1/2021

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Medicare has released a new ABN which will be implemented starting January 1, 2021.  There are two versions, an English and Spanish version.  Click the link to download now.

ABN English

ABN Spanish

Remember . . .
The ABN is required for your Medicare patients to sign when:

They transition from Active Treatment to Maintenance or Wellness Care.

The ABN is voluntary when:

It functions as your financial policy, and the patient is still on Active Treatment.

GUIDELINES:

  • Do not have the patient sign an ABN at every visit, per CMS.
  • When the patient presents with a new episode/injury, the current signed ABN on file is nullified.
  • When the patient transitions back to maintenance/wellness, have them sign a new ABN.
  • The signed ABN is good for one year.
  • The patient/guardian should be the one to choose between Option A, B, or C, with the staff. explaining what each option entails. This prevents potential doctor liability down the road, i.e., the patient or guardian states to Medicare that they were forced or pressured into choosing a certain option.
  • Use an AT modifier when billing Medicare for Active Treatment (ABN not required).
  • Use a GA modifier if the patient chose the option on the form to bill Medicare, and an ABN is on file. Then the Medicare remits can be forwarded or are crossed over to the Medicare supplement plan for possible payment.
  • Use a GZ modifier when billing Medicare for maintenance/wellness care but an ABN is not on file. (The most common reason is the clinic got busy and missed having the patient sign it).
  • The ABN is not used with Part C/Medicare Replacement plans. Only use for Medicare Part B plans.
  • You may begin using the new ABN in December. The new one will be required as of 1/1/2021.

Questions? I am here to help! Contact me at lisa@pmaworks.com, or call 920-334-4561

Lisa
“Increasing your collections through better billing and documentation”

New ABN Form Released – Effective 8/31/2020

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The Centers for Medicare and Medicaid Services(CMS) recently released a new ABN Form.

The ABN, Form CMS-R-131, and form instructions have been approved by the Office of Management and Budget (OMB) for renewal.  The use of the renewed form with the expiration date of 06/30/2023 will be mandatory on 8/31/2020.  We are including the links to the forms for your convenience and they can also be viewed at the CMS Web-site. 

In addition to the expiration date on the form, there are a few other minor changes.  If you have further questions please feel free to contact Lisa at 920-334-4561.

Medicare, Yada, Yada, Yada: Fraud, Waste and Abuse Training.

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OK, I admit it. Medicare is not the most glamourous topic to write about, nor does much of it pertain to our world of the chiropractic profession as we know it. However with that said, I am doing due diligence for you and fulfilling my duty to inform you of the necessary requirements a Covered Entity must follow (that’s us included!) to keep the Office of Inspector General off our backs and to help you take preventive measures so you’re not sending back reimbursement money you earned from providing patient care.

Because . . . based on my observations in the field – and this is a review for those of you who read our PM&A articles and utilize our library- how many of you know, for example, what a Part C Medicare plan is? How many of you know that all Part C providers are required to undergo annual Fraud Waste and Abuse training?

Second example: How many of you are aware that Medicare, starting in April of this year and going into April of 2019, is sending all of their beneficiaries new ID cards in an effort to do away with social security numbers for the sake of safeguarding identification?

So how do my two examples above directly impact you, your practice, and your bottom line?

Let’s circle back to the first example. A Part C Medicare Plan is known as a Medicare Advantage Plan. It oftentimes covers more services than a straight Medicare plan does. HMO/PPOs such as Humana and Blue Cross Blue Shield have developed their own Medicare Advantage Plans and offer them to their policyholders, your patients. A patient who signs up for an Advantage Plan must also be enrolled in Medicare A (hospital), and Medicare B (outpatient provider services). Medicare Part C providers to date have been required to, annually, undergo what is called Fraud, Waste and Abuse Training. Let’s take each of the three words and define them from the Medicare and Medicaid world.

  • Fraud is known intent to deceive in order to collect money from the Medicare program illegitimately.
  • Waste is overutilization of services or other practices that, directly or indirectly, result in unnecessary costs to the healthcare system, including the Medicare and Medicaid programs. It is not generally considered to be caused by criminally negligent actions, but by the misuse of office and/or practice resources.
  • Medicare Abuse includes practices that result in unnecessary costs to the Medicare program such as over or underutilizing services. You are probably familiar with the Quality of Care initiatives such as MIPS/MACRA and the EHR incentives, implemented to help combat abuse. Common types of abuse include:
    • Billing for unnecessary services
    • Overcharging for services or supplies
    • Misusing billing codes (upcoding) to increase reimbursement*

*Downcoding is also a misuse of billing codes. Stop doing it. Although not intended to increase reimbursement it is a red flag to Medicare, and your services will be questioned as to if they were “medically necessary.”

Back to the training . . . I urge you now to complete this training by the end of December. It is intended for doctors and staff. Download the PowerPoint below, read thoroughly and after completion have each staff and doctor sign off to attest, they read through the PowerPoint. The sign-off can be as simple as logging signatures and completion date in a notebook or a spreadsheet. It is not necessary to print out the PowerPoint. Oh, and many insurance contracts require this training as a contract obligation to be part of their network as well. You can access Medicare’s training PowerPoint here: Fraud, Waste and Abuse

Referring back to the second example of new Medicare cards. You can review our previous article and checklist here: New Medicare Beneficiary Indentifiers to be Assigned Your Patients

Your staff should be asking Medicare patients for their new cards, making a copy, and making sure the address in your practice management program matches the address the Social Security office has on file. If there is a mismatch like the patient has moved and not updated their address, you will have problems getting reimbursed. Make sure your Insurance Profiles in your programs have the new Medicare IDs.

Stay tuned for more helpful articles like this. If you have any questions on the above, contact me! I’m here to help.

Lisa Barnett
920-334-4561
lisa@pmaworks.com

And remember . . .
“The Future Will Be Our Results” (Clarence Gonstead, D.C.)

New ABN Form Effective 06.21.2017

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New ABN Form and Implementation Instructions

Frequently asked questions and answers for the ABN form

New ABN English 2017(PDF) – Form CMS-R-131 goes into effect June 21, 2017. You may begin using the new one now(April 2017), but on and after June 21 per CMS, you may not use your current ABN.

New ABN 2017 (DOC) Form CMS-R-131 goes into effect June 21, 2017. You may begin using the new one now(April 2017), but on and after June 21 per CMS, you may not use your current ABN.

New ABN_Spanish 2017(PDF)-Spanish Version Form CMS-R-131 goes into effect June 21, 2017. You may begin using the new one now(April 2017), but on and after June 21 per CMS, you may not use your current ABN

ABN-Use(Doc) How and when to use the Advanced Beneficiary Notice for Medicaid Services

Script-for-ABN-form(DOC)– Script for explaining the form to the patient

Final Revised ABN-2012- Advanced Beneficiary Notice for Medicare Services – expires June 21, 2017.

Has Your Office Been Target by Medicare for an Audit?

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Ms. Lisa Barnett with Petty, Michel and Associates specializes in preventing Medicare Audits. She has helped those who have already been targeted find a fast and safe way out of trouble.

You are not alone…. Things do Happen…..
You are busy and possibly you have overlooked a certain requirement. Your computer has gone through updates and you have not kept up. Or possibly your documentation is simply inadequate in the eyes of medicare or the government.

Whether you are faced with a prepay audit or a post payment audit. I can help !

With 10 years of experience in the chiropractic industry and with documentation; and a chiropractic advocate for 30 years I care and I want to help.

Call today for your complimentary phone consultation and record review. 920-334-4561

Medicare Audit Emergency Response Number

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Medicare Audit Emergency Response Number:     

920.334.4561

 

The Medicare Audit Preparation(MAP) is available to chiropractors nationwide. This is an emergency response program and on-site appointments are scheduled based on availability. Do NOT send records without calling us first.

The MAP program covers up to three full days (24 hours) in your office, plus 90 day off-site follow up as needed. The cost is $4,995 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. 920.334.4561

*Travel expenses may apply

 

MACRA- New Info on Medicare!

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rs-medicare-info-icon

New Info on Medicare!

Happy Holidays Chiropractic Friends!

First snowfall always seems to bring renewed energies and hope – my wish is you experience this, too.

Are you ready for January 2017? Ready or not, here it comes. Today I want to introduce and give you some of the latest and greatest on what’s happening with the new Medicare reimbursement model also beginning our new year.

To start with, six new acronyms to introduce to you: MACRA, MIPS, CHIP, APM, SGR, CPIA

  • MACRA: Medicare Access CHIP Re-authorization Act of 2015
  • MIPS: Merit-Based Incentive Payment System
  • CHIP: Children’s Health Insurance Program
  • APM: Advanced Payment Model
  • SGR: Sustainable Growth Rate
  • CPIA: Clinical Practice Improvement Activities

Here’s a bit of background for you regarding the initiative. In April 2015, President Obama signed into law the Medicare Access and CHIP Reauthorization Act 2015 (MACRA). This is an act to transition Title XVIII of the Social Security Act to the Medicare sustainable growth rate and strengthen Medicare access. How? By improving physician payments and making other improvements, like the Children’s Health Insurance Program. We could say MACRA is the umbrella to the program.

What is the purpose of the change in reimbursement model? The purposes include simplifying reporting for the convenience and ease of the providers participating; decreasing the current costs of healthcare, allowing patients the best quality of care; and to make patient information sharing safe and easy. The blueprint for pay for performance is the Merit-Based Incentive Payment System, and the goal is to create an acceptable payment system for physicians and the program.

Who are the stakeholders in the broader MACRA program? They include beneficiaries (your patients), businesses, payers, providers, and state partners.

Are you eligible to participate?

Both participating and non-participating providers are eligible to participate if you meet both of the following criteria: 1) Have seen 100 or more unique patients in a year, and 2) Have billed for covered services at $30,000 or more a year. You are exempt from participating in 2017 if 2017 is your first year as a Medicare provider. You are also exempt if you do not meet one of the two criteria above.

How will it work?

CMS has indicated through various webinars that they will notify via written communication if you are or are not eligible to participate. Once you learn of your eligibility, the program will require participating providers to report on three categories for the Merit-Based Incentive Payment System:

  • Quality (i.e., Physician Quality Reporting System, also known to you as PQRS but with some tweaks).
  • Practice Improvement, focusing on clinical quality measures. For examples, patient outcomes; patient engagement and compliance; adherence to your practice systems and guidelines.
  • Advancing Care Information (this is the technical component; i.e., Meaningful Use and minimum five measures recorded in your practice’s healthcare technology).

Additionally, if you are eligible to participate and choose not to, there will be a negative adjustment of 4% to your Medicare reimbursement. If you are eligible and do choose to participate, you may receive a positive adjustment of 4 to 9% depending on your level of reporting involvement, as well as a minimum 0.5% bonus for exceptional performance if your final reporting score meets or exceeds a certain point value.

You will have two reporting options: You may report for the entire 2017 calendar year, or you may report for the partial year, one quarter, and may begin no later than October 2, 2017.

PM&A will continue to monitor any changes to the above information.

In addition, I will be conducting onsite MACRA readiness assessments at chiropractic offices and am available to visit yours. Please contact me if you are interested in learning more!

Best,

Lisa Barnett, Consultant
Petty, Michel & Associates

Call: nine two zero.334.4561

Email: Lisa@pmaworks dot com

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

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Lisa J. Barnett

Lisa J. Barnett

Download a PDF of this article

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]

The Importance of Compliance in a Chiropractic Office – HIPAA, Covered Entity, OSHA, HITECH

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Lisa J. Barnett

Lisa J. Barnett

HIPAA, Covered Entity, OSHA, HITECH – – Compliance. What’s happening in the world of compliance and why do you as a chiropractor need to be educated and remain in the know? Find out below . . .

First and foremost, according to the Health and Human Services (HHS), chiropractors are included in the covered entity category, and this is regardless of whether or not you have received Electronic Health Records incentive monies. Covered entities are required by federal law to comply with all areas of protected health information and employee safety standards. Impact of non-compliance? In February 2016, a covered entity was fined $239,800 for non compliance.

Further, according to a March 2016 survey among small practices designated as covered entities, 60 percent of the 900 plus professionals surveyed are still unaware of pending compliance audits, and 58 percent have not appointed a securities/privacy officer in their practice. Audits to our profession are forthcoming, and we cannot opt out. Keep reading on how to safeguard yourself and your practice. Also keep in mind that it takes approximately 40 to 50 hours to develop and secure a compliance program.

The three main areas of compliance you need to be aware of, educated in, and be an active participant include: HIPAA, OSHA, and IT Securities.

Health Insurance Portability and Accountability Act
The Health Insurance Portability and Accountability Act (HIPAA) law of 1996 was enacted to improve the portability and accountability of health insurance coverage, and it brought individual privacy rights to patients and requires that we notify them of their rights. It also serves to eliminate fraud, waste, and abuse in healthcare. The focus here is to safeguard your practice by securing personal (patient) health information (PHI) and personal identifiers, be it paper or electronic (ePHI). This can include data encryption, secure messaging, compliant Cloud storage, compliant software, and unique password setups. One of the areas I assess when I visit a clinic is locating where the patient paper files are kept and if they are well out of viewing from others.

Your HIPAA requirements to be compliant at the clinic level include:

  • Designating a compliance/privacy officer whose primary responsibility is to ensure compliance with the regulations
  • Establishing and implementing at least annually, training programs for all employees and doctors.
  • Implementing appropriate policies and procedures to prevent intentional and accidental disclosure/release of PHI or ePHI. Encrypting your data for example will lower your chances of ransomware or cyberattacks.

OSHA
The United States Occupational Safety and Health Administration (OSHA) Act was signed by President Nixon in December 1970. It is designed to protect worker safety and promote healthy work environments. Some of you Docs have been involved in workplace safety and onsite workplace assessments in factories. Kudos to you! You were advocating OSHA’s mission by: Educating your client and their employees on workplace safety by conducting posture and ergonomic assessments, and finding the best ways for workers’ compensation patients to get back to work and continue contributing safely and appropriately within their restrictions.

At the clinic level (can be delegated), your requirements to meet OSHA requirements include:

  • Displaying the required workplace safety and employee rights posters for all employees to review
  • Establishing annual training for yourself and your employees. Local fire departments usually are able to conduct these trainings and are willing to include other participants.
  • Developing a written emergency plan in case of fire, severe weather, etc.
  • Drawing up an exit plan and post for employees and patients to see. See example below:

evacuation map

  • Developing written procedures (universal precautions) to minimize risk exposure to bodily fluids such as blood, vomit, saliva.
  • Obtaining Safety Data Sheets for disinfectants used at the clinic, as well as if you process X-rays.
  • Have handy your Quality Assurance X-ray manual, follow it, and ensure it is accessible to those who take/process X-rays.
  • Ensuring ergonomic workplace assessments are conducted at the clinic and documented. This could include posture screenings for your employees and requiring stretch breaks – for you, too!

Information Technology (IT) Security/HITECH

The Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of HIPAA and the American Recovery and Reinvestment Act of 2009, was signed into law on February 17, 2009, to promote the adoption and meaningful use of health information technology. Section 1176(a) of the Social Security Act was revised during this timeframe to allow for significant monetary penalties up to $1.5 million for breaches/violations of protected health information. However, an interim revision (later known as The Omnibus Rule) set prohibitions on enforcing such significant monetary penalties if it was found in investigation that the covered entity did not know and with the exercise of reasonable diligence would not have known of the violation. In these cases, the breaches were punishable under the lowest tier of penalties, and further, prohibited the imposition of penalties for any violation corrected within a 30-day time period, as long as the violation was not due to willful neglect. A final ruling in January 2013 reiterates all of the above standards.

Your responsibilities to get IT Securities compliant include:

  • Assigning a securities officer
  • Conducting a risk assessment
  • Ensuring your EHR vendor and billing clearinghouse are HITECH/HIPAA compliant
  • Ensuring every vendor you work with has signed a Business Association Agreement with your office and you have those Agreements on file. These need to be updated at least annually.
  • Ensuring the clinic’s computer systems are backed up regularly, have virus-checking software, firewalls, and encrypted operating systems
  • Establishing securities policies and procedures, including on your social media networks.
  • Creating a disaster recovery plan
  • Creating a policy and procedure of notification, in the event of a data leak or leak of PHI/ePHI

Impact of non-compliance? Another covered entity was fined $25,000 for posting patient information online.

Feeling overwhelmed? We can help. Contact me on how you can get an initial Compliance Assessment and a Medicare Documentation Assessment with a Report of Findings sent to you, for a ridiculous low price of $299!*

References:

  • nueMD Cloud-based health information technology, http://www.nuemd.com/webinars
  • HIPAA Journal, http://www.hipaajournal.com/
  • United States Health and Human Services, http://www.hhs.gov/hipaa/
  • United States Occupational Safety and Health Administration, www.osha.gov/
  • Federal Register/Rules and Regulations Publication Vol. 74 No. 209
  • Federal Register/Rules and Regulations Publication Vol. 78 No. 17
  • Emergency Exit Diagram: www.steamwire.com business continuity templates

*Mileage cost may apply.

Medicare in Your Chiropractic Office: Is Your Documentation In Order?

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Lisa J. Barnett

Lisa J. Barnett

Have you ever thought you could be both a great documenter and repeatedly educate your patients on their innate intelligence . . . if you only had the time? Keep reading on how to both bulletproof your documentation for a potential audit and maintain the energy of our profession’s principles.

Let’s help build your ammunition.

First . . . did you know that the US Health and Human Services advised Medicare to target chiropractors to curb questionable and inappropriate payments, projected at $280,000,000? Seriously! And clinics are, as I write this, being audited. How do I know? Because we’re receiving phone calls and emails asking, “What do I do? I received a letter from Medicare.” As a result, I’m traveling around to help chiropractic offices prepare.

To insure yourself and what you’ve worked hard for, make sure your documentation (that is, every single note in the patient’s file/your EHR software) is citing the following information:

  • History Obtained at Initial Visit:
    • Symptom(s) causing patient to seek care
    • Family history if relevant
    • Past health history (general health, prior illness, injuries, hospitalizations, surgeries, current medications)
    • Mechanism of trauma
    • Quality and character of symptoms/problem
    • Onset, duration, intensity, frequency, location, radiation of symptoms
    • Aggravating or relieving factors
    • Prior interventions, treatments, medications, secondary complaints
  • Initial Visit or New Onset
    • History (as stated above)
    • Description of the present illness:
      • Mechanism of trauma (how did it happen?) For example, getting out of bed, twisting, gardening.
      • Quality and character of symptoms/problem
      • Onset, duration, intensity, frequency, location, radiation of symptoms
      • Aggravating or relieving factors,
      • Prior interventions, treatments, medications, secondary complaints
      • Symptoms causing patient to seek care. Symptom(s) must be related to the level of the subluxation documented.
    • Evaluation of spine/nervous system through physical examination.
      • PART: pain and tenderness, asymmetry/misalignment, range of motion abnormality, tissue, tone changes
    • Diagnosis: Primary diagnosis must be a subluxation, including the level or identified descriptive term of location, i.e., condition of the spinal joint involved, direction of position assumed by the named bone.
    • Treatment plan, to include the following:
      • Recommended level of care (duration and frequency of visits), specific goals, objective measures to evaluate treatment effectiveness, date of the initial treatment.
      • Though not a documentation requirement, this is where you will educate the patient face to face, as to their subluxation and what will happen if they don’t get it corrected, as well as educate them on their innate intelligence.
  • Subsequent Visits:
    • Review of chief complaint, changes since last visit, systems review if relevant
    • Physical Exam
      • Exam – area of spine involved in diagnosis
      • Assessment of change in patient condition since last visit
      • Evaluation of treatment effectiveness.
      • Though not a documentation requirement, this is a perfect time to re-educate the patient on chiropractic principles.
      • Documentation of the presence or absence of a subluxation
      • PART: pain and tenderness, asymmetry/misalignment, range of motion abnormality, tissue, tone changes
    • Documentation of treatment given on day of visit (technique(s) used and areas adjusted)
    • Progress or lack thereof, related to goals and treatment plan (is the patient meeting goals?)

Let me be clear: The above documentation requirements are not PM&A’s. They are Medicare’s.

Other Tips:

  • Your subjective findings in initial visits/new onsets should tell a story about what happened, how it happened, and when it happened.
  • The Visual Analog Scale (VAS) is not sufficient documentation as your sole objective tool. Use additional tools to measure objectives findings.
  • See below for a typical VAS:

VAS-Lisa

  • You should self-audit your documentation on a regular basis.

In closing, get out there, do what you do best to attract and help anyone with a spine, and follow the above documentation requirements to armor yourself in the event of an audit by Medicare and other payers. Need help staying relaxed and focused, and getting paid? Give us a call. That’s why we’re here.

Sincerely in Chiropractic,
Lisa

Lisa is now providing a no charge initial consultation regarding your Medicare documentation. You can contact at (920) 334-4561 or by email at Lisa (at) @ pmaworks.com

More information on Lisa[LINK]

Download a printable copy of this newsletter [June newsletter]

Download a customizable copy of the Checklist: [Medicare Documentation ChecklistDOC]

Print Checklist (PDF)[Medicare Documentation Checklist-PDF]

 

Medicare Changes: National Government Services LCDs: Effective 12/1/2015

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*This notice specifically pertains to those offices where the Provider of Medicare is NGS:  CT, IL, ME, MA, MN, NH, NY, RI, VT, and WI.

 

For those of you who have NGS as their Medicare provider (states listed above), we wanted to make sure you were aware of a new policy which has some big changes, mostly positive and where you could get more information about it.

The NGS(National Government Services) recently published the new Chiropractic Medicare Policy which will go into effect on 12/1/2015

For more information on the chiropractic medicare policy visit:

L66315 Chiropractic Services Policy

Sincerely,
Dave