1. Understanding MEDICARE for the Chiropractic Assistant
Mark E Cotney, DC,
GCA Medicare Co-Chair
Atlanta, GA October 22, 2016

2. What I hope to cover today
Brief History of Chiropractic in Medicare
Dispelling some myths about chiropractic in Medicare
Documentation process for Active Care of a Medicare Patient (Bene)
Appeals Process and why it is so important
ABN
PQRS
Brief comment about MACRA and MIPS vs PQRS

3. IMPORTANT MEDICARE DOCUMENTS AND LINKS
FEE SCHEDULE
PQRS
ABN
RE DETERMINATION
RE CONSIDERATION
MEDICARE BENEFITS POLICY MANUAL CHAPTER 15 SECTION 240
CHIROPRACTIC SERVICES scroll to page 223
MEDICARE MYTHS

4. Cahaba Government Benefit Administrators®, LLC
. Cahaba GBA (Government Benefit Administrator) is the J10 A/B Medicare Administrative Contractor (MAC) for the states of Alabama, Georgia, and Tennessee.
They are Alabama BC-BS
This is regular Medicare
Not the same as Palmetto
Rail Road Employee Medicare

5. Advantage Plans more later
Not same as regular Medicare
You DO NOT HAVE TO ACCEPT IT
Even if you are a Par Doc.
Most have larger co-pays
Copays used to be $40
ACA lobbied to get it down to $20
Most have deductibles
Some will cover exams and xrays
SHBP is a Privately funded Medicare replacement
It will pay for non covered services
Supplement vs Secondary coverage

6. MAC A/B Jurisdiction MapJK
NGS J6
NGS JF
Noridian J8
WPS JE
Noridian JL
Novitas
J15
CGS J5
WPS
J11
Palmetto JJ
Cahaba JH
Novitas JF JN
FCSO

7. Medicare Timeline 1962 Medicare Act LBJ
1972 Chiro inclusion in MEDICARE as LIMITED BENEFIT
Manipulation to correct subluxation of spine NO OTHER SERVICES BY A DC
2003 MMA Demonstration Project legislated
2005 Demo project began
2007 Demo project concluded
2008 four of five demo areas show full scope chiro care will save CMS money overall
2015 ACA begins push for full scope chiropractic in Medicare(along with VA, Active duty military, etc)

8. Get all your current patients to sign this petition from your office!
There will be a big push after the election to change our coverage in Medicare
This will require an “act of congress” literally!
Full Scope coverage includes what your state scope of practice allows
Exams
X-rays
Physical Medicine modalities and procedures
Have patient sit at your computer and fill out!

9. Insignificant amounts
1983
A2000 $12.00
WAS GETTING $25 TO $35 FROM PRIVATE INSURANCE
Must X-ray yearly
Never any reviews
Insignificant amounts

10. Growth/Decline 1994 11.2 Million CMT services
$255 million to DC’s
Million CMT services
$683 million to DC’s
2007 $724 million to DC’s
Million CMT services
Over $800 million
Medicare budget $+500 Billion
.0015%

11. OIG Report 2001 67% of Chiropractic Claims were improperly paid
Monkey Wrench in the system of us!
67% of Chiropractic Claims were improperly paid
2001

12. Office of Inspector General
“provide independent assessments of HHS programs and operations in order to reduce waste, abuse, and mismanagement and to promote economy and efficiency throughout the department.”
We got a big black eye!
We were embarrassed!
It haunts us today!
2012 publications still refer back to it

13. What did they find? 400 claims from a random sampling
Reviewed by ‘independent chiropractors’
57% of these services did not meet Medicare coverage criteria
16 % were miscoded or billed at the wrong level of spinal manipulation
6 % were undocumented.
12% had multiple errors
Majority of these were Maintenance Care visits, totaling $186 Million
14% were ‘medically unnecessary for other reasons
$85 million
$24 million in Extra-spinal or Non-manipulative Treatment (massage, etc)
Up coding resulted in $15 Million in overpayments!
overall error rate of 67 percent, resulting in $285 million in improper payments.

14. What was so bad?
Supporting documentation for chiropractic services rarely met all Medicare Carriers Manual requirements. The Manual requires that specific supporting documentation be present in the chiropractic record.
Nearly 94 percent of chiropractic services, though, lacked at least one of the supporting documentation elements listed in section of the Manual (including those that were completely undocumented).
34 percent of chiropractic services were not supported by an evaluation that met the Manual’s specific requirements for documenting a subluxation.
We will talk about what is required so you will know it!

15. 2001 to 2016 Increase in Payments for DC’s
Increase in usage of Chiropractic Services
Increase in Dialogue with Medicare Officials
ACA and CMS meet regularly
GCA has a Representative in Cahaba’s CAC
Cahaba’s Deputy Medical Director attended Spring Conference at Hilton Head 2016!!
Changes in What is expected of a DC
No longer have to x-ray patient yearly
Must perform a History and Examination

16. What is required to get paid??
Does the record show a significant neuromusculoskeletal condition?
Is there a precise subluxation(s) documented by physical exam or x-ray?
Does the exam substantiate the condition and the subluxation?
Is the complaint consistent with the subluxation level(s)?
Is there a primary diagnosis of subluxation and a secondary ICD condition caused by the subluxation?
Is there a treatment plan?
Is the adjustment clearly recorded in the record as being done each visit?
Is there a response to the adjustment noted in the records (increased ROM, increased function, decreased pain, etc. that shows quality, character, and intensity that would qualitatively and quantitatively substantiate need and frequency of treatment)?
Is the adjustment therapeutic or maintenance (maintenance is non-covered by Medicare)?

17. Initial Visit Requirements brief overview
Relevant History of Patient’s Condition with Detailed Description of the Present Condition.
Evaluation of Musculoskeletal/Nervous System Through Physical Examination. & P.A.R.T.
Diagnosis.
Treatment Plan: Recommended level of care (duration and frequency of visits); Specific treatment goals; Objective measures to evaluate treatment effectiveness.
Date of Initial Treatment.

18. Subsequent Visit Requirements
History: Review of chief complaint; Improvement or regression since last visit; System review, if relevant.
Physical Examination: Exam of the spine involved in diagnosis; Assessment of change in patient condition since last visit; Evaluation of treatment effectiveness.
Documentation of Treatment Given on Day of Visit.
Any Changes to the Treatment Plan.

19. Necessity for Treatment
Must have a significant health problem in the form of a NMS condition necessitating Tx
Manipulative treatment must have a direct therapeutic relationship to the condition
Must have reasonable expectation or recovery or improvement of function

20. Types of Care Acute Subluxation Chronic Subluxation Maintenance Care
New injury, id by X-ray or Physical exam --P.A.R.T.
Tx is expected to create improvement, arrest, or retardation of condition
Chronic Subluxation
No significant improvement or resolution is expected
Continued Tx should show some functional improvement
Maintenance Care
Once chronic condition is stable, no expectations of further improvements
Tx to prevent disease, promote health, prolong quality of life
Tx to maintain or prevent further deterioration of chronic condition

21. Maintenance Therapy
A treatment plan that seeks to prevent disease, promote health and prolong and enhance the quality of life, or therapy that is performed to maintain or prevent deterioration of a chronic condition is not a Medicare benefit.
Once the maximum therapeutic benefit has been achieved for a given condition*, ongoing maintenance therapy is not considered to be medically necessary under the Medicare program
*this is where the rub comes in! MMI
Don’t be afraid to convert a patient to Maintenance Care
If you don’t and get audited you can’t collect it

22. Myths & Misunderstandings MedLearn Matters MLN
MISINFORMATION #1:
There is a 12 visit cap or limit for chiropractic services.
Correction: There are no caps/limits in Medicare for covered chiropractic care rendered by chiropractors who meet Medicare’s licensure and other requirements as specified in the Medicare Benefit Policy Manual, Chapter 15, Section (This manual is available at
on the CMS website.)
There may be review screens (numbers of visits at which the Medicare carrier or A/B MAC may require a review of documentation), but caps/limits are not allowed.
Worded badly on EOB…states denial,
It’s a challenge to your Medical Necessity
New dialogue has begun to change this
25 visits per YEAR with out review
Used to be a ‘Rolling Year”
This is the new Screen
It is hard to justify more than 25 CMT’s in 12 months.

23. Effective July 1, 2016, the Local Coverage Determination (LCD) for Medicine: Chiropractic Services (L34261) will be updated.
Effective for services billed on or after July 1, 2016, this LCD establishes a frequency limit of 25 visits per calendar year for services billed with CPT codes – and Modifier AT.
Upon the beneficiary’s twentieth visit (20th), Cahaba will notify the provider via written communication that all visits greater than (25) twenty-five in a calendar year will be subject to a pre-pay review. The intent is to notify the provider that twenty visits have occurred for the calendar year and the threshold is at risk for being beyond limit payment.
Despite allowing up to this maximum, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Additionally, Cahaba requires the medical necessity for each service to be clearly demonstrated in the patient’s medical record.
In addition, the ‘Limitations’ and ‘Utilization Guidelines’ sections were updated to include the following information:
Cahaba will allow up to 25 chiropractic manipulation services per beneficiary per calendar year.
Providers who receive denials are reminded of their appeal rights.

24. Posted June 3, 2016 in Part B (after HILTON HEAD)
Local Coverage Determination (LCD) Medicine: Chiropractic Services (L34261) – Update and Clarification
Posted June 3, 2016 in Part B (after HILTON HEAD)
Effective July 1, 2016, the Local Coverage Determination (LCD) for Medicine: Chiropractic Services (L34261) will be updated.
Effective for services billed on or after July 1, 2016, this LCD establishes a frequency limit of 25 visits per calendar year for services billed with CPT codes – and Modifier AT.

25. Upon the beneficiary’s twentieth visit (20th), Cahaba will notify the provider via written communication that all visits greater than (25) twenty-five in a calendar year will be subject to a pre-pay review. The intent is to notify the provider that twenty visits have occurred for the calendar year and the threshold is at risk for being beyond limit payment.
Despite allowing up to this maximum, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Additionally, Cahaba requires the medical necessity for each service to be clearly demonstrated in the patient’s medical record.
In addition, the ‘Limitations’ and ‘Utilization Guidelines’ sections were updated to include the following information:
Cahaba will allow up to 25 chiropractic manipulation services per beneficiary per calendar year.
Providers who receive denials are reminded of their appeal rights

26. MISINFORMATION #2:
If you are a non-participating (non-par) provider, you do not have to worry about billing Medicare.
Correction: Being non-par does not mean you don’t have to bill Medicare. All Medicare covered services must be billed to Medicare, or the provider could face penalties.
A non-par provider is actually a provider involved in the Medicare program who has enrolled to be a Medicare provider but chooses to receive payment in a different method and amount than Medicare providers classified as participating. The non-par provider may receive reimbursement for rendered services directly from their Medicare patients. They submit a bill to Medicare so the beneficiary may be reimbursed for the portion of the charges for which Medicare is responsible.

27. Misunderstanding #2
It is important to note that non-par providers may choose to accept assignment, therefore, the amount paid by the beneficiary must be reported in Item 29 of the CMS 1500 claim form. This ensures that the beneficiary is reimbursed (if applicable) prior to Medicare sending payment to the provider.
Cannot place regular fee on claim, MUST only charge the Limiting Charge from Fee Schedule--
Whether or not a non-par provider chooses to accept assignment on all claims or on a claim-by-claim basis, their Medicare reimbursement is five percent less than a participating provider, as reflected in the annual Medicare Physician Fee Schedule. (non-par fee)

28. Exception to Must File Rule
Med Pay
Third Party Liability
Worker’s Comp
All become Primary when in effect
Medicare becomes Secondary
Very Strict Subrogation Rules
But still protects the patient from your regular fee unless you are a Participating Provider
Working Aged or Employed Spouse with Coverage
Employer Insurance is PRIMARY
Medicare becomes SECONDARY

29. MISINFORMATION #3:
If you are a non-participating (non-par) provider, you will never be audited nor have claims reviewed, etc.
Correction: Any Medicare claim submitted can be audited/reviewed; the non-participating (non-par) or participating (par) status of the physician does not affect the possibility of this occurring.
CMS audits/reviews are intended to protect Medicare trust funds and also to identify billing errors so providers and their billing staff can be alerted of errors and educated on how to avoid future errors.
They want to protect the patient their BENEFICIARY!

30. MISINFORMATION #4: You can opt out of Medicare.
Correction: Opting out of Medicare is not an option for Doctors of Chiropractic. Note that opting out and being non-participating are not the same things.
Chiropractors may decide to be participating or non-participating with regard to Medicare, but they may not opt out.
For further discussions of the Medicare “opt out” provision, see the Medicare Benefits Policy Manual

31. MISINFORMATION #5:
You should get an Advance Beneficiary Notification (ABN) signed once for each patient, and it will apply to all services, all visits.
Correction: The decision to deliver an ABN must be based on a genuine reason to expect that Medicare will not pay for a particular service on a specific occasion for that beneficiary due to lack of medical necessity for that service. The ABN then allows the beneficiary to make an informed decision about receiving and paying for the service. Should the beneficiary decide to receive the service, you must then submit a claim to Medicare even though you expect the beneficiary to pay and you expect that Medicare will deny the claim. (3 options now)
Exception: Patient returns on a regular monthly basis of uninterrupted maintenance visits, The ABN is good for a year unless interrupted by a course of ACTIVE TREATMENT.

32. MISINFORMATION #6:
Maintenance care is not a covered service under Medicare.
Correction: Spinal manipulation is a covered service under Medicare, no matter which phase of care you may be in; however, maintenance care is not medically necessary and therefore not reimbursable by Medicare.
Acute, chronic, and maintenance adjustments are all “covered” services, but only acute and chronic services are considered active care and may, therefore, be reimbursable.
Maintenance therapy is defined (per Chapter 15, Section 30.5.B. of the Medicare Benefits Policy Manual)) as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.

33. MISINFORMATION #7
Non-par providers do not have the same documentation requirements as par providers.
Correction: Chiropractic care has documentation requirements to show medical necessity. The participating status of the provider is irrelevant to the documentation requirements.

34. Predictive Modeling to Detect Fraud The Centers for Medicare and Medicaid Services (CMS) announced that starting in July CMS will begin using predictive modeling technology to detect fraudulent claims. The technology is similar to that used by major credit card companies to prevent fraud. Claims will be screened for suspicious activity such as a provider billing a high number of services for individuals outside of the provider’s geographic region. The new system will alert Medicare about unusual activity and prompt investigations prior to a claim being paid. This initiative builds on the new anti-fraud tools and resources provided by the Affordable Care Act that are helping move CMS beyond its former “pay & chase” recovery operations to an approach that focuses on preventing fraud and abuse before payment is made

35. CERT Comprehensive Error Rate Testing – (How to grade the carrier)
2014
J10 12%
Chiropractic 76%
2015
J10 15%
Chiropractic 80%
Projected 2016
J10 14%
Chiropractic 44%
This is a huge improvement!!

36. WHAT IS REQUIRED? Initial visit – most important!!! Subsequent visits
New Episode---New Evaluation and Plan
Progress Evaluation
Episodic care plans for Acute condition

37. Initial Visit detailed
History
Symptoms causing patient to seek treatment
Family history, if relevant (comment if not)
Past Health History
Description of the Present Illness
Secondary and Tertiary Complaints

38. Initial Visit continued
Description of Present Illness
Mechanism of Trauma (no trauma)
Quality and character of symptoms/problem
Onset, duration, intensity, frequency, location, and radiation of symptoms
Aggravating or relieving factors
Prior treatments and medications

39. Initial Visit continued
Examination of Musculoskeletal/nervous system
Ortho- neuro
Chiropractic Evaluation
Demonstration of a S U B L U X A T I O N
PART
X-ray
Diagnosis
Primary must be subluxation
Secondary should be symptom code
SHOULD HAVE A PAIR FOR EACH AREA OF THE SPINE YOU BILL FOR IN THE RECORD—to be line 19 for extra, now there are 10 spots!
UHC/State Farm 3-4 area CMT

40. P.A.R.T. physical ID of subluxation
Pain/Tenderness
Location, quality, intensity
Observation, percussion, palpation, provocation, pain scales, algometers, pain questionnaires
Asymmetry/Misalignment
Sectional or segmental level
Posture and gait observation, static palpation, x-ray
Range of motion
Active or passive- increase or decrease- sectional or segmental
Motion palpation, instrumentation, stress views,
Tissue/Tone
Skin, fascia, muscle, ligament
Observation, palpation, instrumentation, test for length/strength
PART alone is not sufficient for care plan or initial work up
HCFA requires that at least two of the four components must be
documented, and at least one of A or R.

41. X-ray to ID Subluxation
Reasonably proximate
12 months prior
3 months after
Exception
Chronic/permanent
CT/MRI may be accepted
If you use x-ray to document subluxation you must re-take each year
Don’t forget PECOS by July 2011
Must mention x-ray findings in clinical record!
Chiropractic
Pathology

42. Initial Visit continued
Treatment Plan
Duration and Frequency of visits
Specific treatment Goals
Able to perform a task, sit without pain, walk a distance, mop the floor, sleep thru the night, etc.
Objective measures to evaluate treatment effectiveness
ROM, strength,
VAS, Pain Questionnaires,
Functional Outcome Assessments…QUALITY MEASURES!!
Date of initial treatment

43. Utilization Guidelines from GA LCD
1. All active/corrective chiropractic services must be medically reasonable and necessary and documented in the patient's medical record.
2. For the patient with an acute subluxation or an exacerbation or recurrence of an acute subluxation, the chiropractor should treat vigorously. If, after vigorous treatment, the patient has not improved, the chiropractor should re-evaluate the patient in regards to the diagnosis and treatment being provided. If the patient has made improvement, but significant signs and symptoms remain, treatment may continue on a decreasing frequency. If the patient has made no improvement, referral should be considered. If, after one month, for example, the patient is improving but the symptoms have not completely resolved, a second month of less vigorous therapy may be indicated. Finally, if there remain significant symptoms after the second month of therapy, a third month of minimal therapy may be indicated. (See documentation guidelines)
3. Guidelines for chiropractic treatment are based on "reasonable and necessary“ considerations.
Sources of Information and Basis for Decision
Haldeman S, Chapman-Smith D, Peterson, Jr D, eds. Guidelines for Chiropractic
Quality Assurance and Practice Parameters. Proceedings of the Mercy Center Consensus 1993.
Consultation with Cahaba GBA Part B CMDs from Alabama, Georgia and Mississippi.
Other Medicare Carriers’ LCDs.

44. Functional Outcome Assessments
Taken off United HealthCare Web Site
Most insurers want you to use them as a way of grading
dysfunction and
progress

45. Comment
Medicare used to require a yearly x-ray so they would pay for treatment. That was the ONLY requirement, no care limits, no frequency Guidelines, no coverage policy.
NOW IT IS A MANDATORY HISTORY & EXAMINATION with all the subtle requirements added.
….it ‘s a better requirement

46. Sample Treatment Plan
Dx: Lumbar Subluxation, Sciatica, Osteoarthritis L-spine
Tx Plan: CMT with adjunctive modalities, daily 1 week, and 3x/week for 2 weeks thereafter. Re-evaluate at that time; lumbar MRI may be indicated. Home care—ice q. 2 hr x 15 min and a lumbosacral corset/support to be worn while up. Refrain from strenuous activity for 2-3 weeks. Short term Goals- decrease pain/spasm and increase L-S ROM. Long term Goals- restore ability to sit for prolonged periods and return to normal sleep patterns.
MEC,DC
Records must be signed or initialed !
This will suffice for 1-2 Areas of CMT

47. Subsequent Visit Requirements CMT
History
Review of chief complaint—may have more than one
Improvement or regression since last visit
System review, if relevant.
Physical Examination
Area of spine involved in DX
Assessment of change in patient condition since last visit
Evaluation of treatment effectiveness
Document treatment given that day
Initial the record have staff initial record if they write in it
(vicarious liability)

48. Initial + Progress Evaluations
Obviously when interim or final exams are completed, you need to use the appropriate EM code with modifier IF YOU ADJUST SAME DAY
The -25 illustrates that you are providing an additional EM service over -and -above the pre and post -manipulative procedures typically completed on each visit.
Using this modifier allows you to be properly reimbursed for these additional EM services.

49. Primary ICD-10 Codes Segmental dysfunction OR Subluxation Diagnosis MUST be listed FIRST
Segmental and somatic dysfunction
M99.00 to M99.05
Head, Cervical, Thoracic, Lumbar, Sacral, Pelvis
Subluxation complex (vertebral)
M99.10 to M99.15

50. Secondary/Symptom diagnosis
Sprain or Strain
Radiculopathy, Neuralgia or Neuropathy
Myopathy, Spasm
Spondylosis, Arthrosis, Fusion, etc
Pain syndromes,
Disc disorders, degeneration, displacement
Any Musculoskeletal Condition

51. Secondary ICD-10 Codes aka Symptom Codes must be paired with Subluxation Codes
Must report Primary Subluxation on line 21-1
Must have Secondary/Symptom code listed next 21-2
3-4 areas or 5 areas of CMT
Must have other levels of Subluxation CLEARLY documented in record / may list them on claim if you choose
What regulation says for Medicare vs Advantage Plans, other Private Carriers SHBP
May list all pairs on line 21 of new claim form -10 Dx’s
State Farm
United Healthcare

52.
are not time -based
each includes an evaluation - management [EM] component consisting of
chart review,
care planning,
pre and post manipulative procedures,
assessment of treatment,
chart documentation,
consultation and reporting.
S.O.A.P.

53. Example Subsequent Visit
: Pt notes diminished intensity and frequency of headache. VAS decreased to 3/10 from 6/10. Subluxation Oc-C1 and C5-6 w/mild PVMS. Heat/EMS administered to Trapezius Ms bilat, 10 min. CMT administered to Atlas and C5. Continue TrPl as prescribed. Return to clinic in two days (Wednesday)
MEC,DC
CMT:
Pre, Intra, and Post service work

54. sample
: Lower back pain improving, pain was sharp/stabbing now dull ache, VAS 5/10, some L-ROM improvement. Lumbar paraspinal muscle rigidity and tenderness remains. Sat in front seat today to get here. Hypomobile/ subluxated L5,Left S-I, L3, T12. CMT rendered same. Patient is to continue with home care exercises and will return in 2 days.
MEC, DC

55. SIGNATURE IT IS A STATE REQUIREMENT TOO
The previous language in the Program Integrity Manual (PIM) required a “legible identifier” in the form of a handwritten or electronic signature for every service provided or ordered. CR 6698 updates these requirements and adds E-Prescribing language.
For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used must be a hand written or an electronic signature.
Stamp signatures are not acceptable.
Those contractors who review Medicare claims include MACs, Affiliated Contractors (ACs), the CERT contractors, Recovery Audit Contractors (RACs), Program Safeguard Contractors (PSCs), and Zone Program Integrity Contractors (ZPICs).
These contractors are tasked with measuring, detecting, and correcting improper payments as well as identifying potential fraud in the Fee for Service (FFS) Medicare Program.

56. Records require a Signature or will be denied
“The duration and frequency recommended level of care is not specified in the evaluation and it is not signed.”
“None of the notes are signed and they are largely templated”

57. What is acceptable
handwritten signatures and acceptable signature formats,
valid electronic signatures,
attestation statements on unsigned documentation, and
signature logs.

58. Attestation Statement
“I, _____[print full name of the physician/practitioner]___, hereby attest that the medical record entry for _____[date of service]___ accurately reflects signatures/notations that I made in my capacity as _____[insert provider credentials, e.g., D.C.]___ when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”
Ever read the back of a 1500 claim form?

59. Back of the Red Form

60. Computer Generated Notes
Can be GREAT
NOT To be confused with an EHR system
Save a lot of time
Easily misused
Should be customized
Must be encounter-specific
Contemporaneous
Don’t be lazy!
Example
Dr. Earl Berman, medical director CAHABA
25 ov, identical, even same misspelled word
Radiology reports

61. Self Review Process Is there a treatment plan?
Is the adjustment clearly recorded in the record as being done each visit with the specific vertebral segment(s) identified?
In order to substantiate the need and frequency of ongoing care, does your documentation note a response to treatment, i.e., increased range of motion, increased function, decreased pain, etc?
Do the subjective complaints and objective findings reflect qualitative and quantitative factors when describing onset, duration, intensity, frequency, and location?
Is the adjustment therapeutic or maintenance ?
(maintenance is non-reimbursable by Medicare)

62. Does the record show a significant neuromusculoskeletal condition?
Our Medicare sources have indicated that in a records-review process, these are some of the questions they will be asking about your records, giving consideration to the combined documentation of the initial and subsequent visit(s):
Does the record show a significant neuromusculoskeletal condition?
Is there a precise subluxation(s) documented by physical exam or x-ray?
Does the exam substantiate the condition and the subluxation?
Is the complaint consistent with the subluxation level(s)?
Is there a primary diagnosis of subluxation and a secondary ICD diagnosis that bears a direct relationship to the primary level of subluxation?

63. Contraindications – Relative and Absolute
Dynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement.
A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust, but does not rule out the use of dynamic thrust. The doctor should discuss this risk with the patient and record this in the chart.
The following are relative contraindications to dynamic thrust:
Articular hypermobility and circumstances where the stability of the joint is uncertain,
Severe demineralization of bone,
Benign bone tumors (spine),
Bleeding disorders and anticoagulant therapy, and
Radiculopathy with progressive neurological signs

64. Absolute Contraindications
Acute arthropathies characterized by acute inflammation and ligamentous laxity and anatomic subluxation or dislocation, including acute rheumatoid arthritis and ankylosing spondylitis,
Acute fractures and dislocations or healed fractures and dislocations with signs of instability,
An unstable os odontoideum,
Malignancies that involve the vertebral column,
Infection of bones or joints of the vertebral column,
Signs and symptoms of myelopathy or cauda equina syndrome,
For cervical spinal manipulations, vertebrobasilar insufficiency syndrome, and
A significant major artery aneurysm near the proposed manipulation

65. Reactivated Old Patient
New History/
Updated History
If new condition be detailed
If same, new Episode-less detailed
Mention any change in overall health history since initial evaluation on --/--/--, or say no changes since…--/--/--
New Condition, different area of spine?
Height – Weight - BP
Ortho-Neuro
X-ray if necessary
P.A.R.T.
New Care Plan
New GOALS
Horror stories
Liability issues
Fractures Missed
Date of Onset
New Diagnoses

66. 240.1.5 - Treatment Parameters
The chiropractor should be afforded the opportunity to effect improvement or arrest or retard deterioration in such condition within a reasonable and generally predictable period of time.
Acute subluxation (e.g., strains or sprains) problems may require as many as three months of treatment but some require very little treatment. In the first several days, treatment may be quite frequent but decreasing in frequency with time or as improvement is obtained.
Chronic spinal joint condition implies, of course, the condition has existed for a longer period of time and that, in all probability, the involved joints have already “set” and fibrotic tissue has developed. This condition may require a longer treatment time, but not with higher frequency.
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 and reimbursement under Medicare will be limited to not more than one treatment per day

67. Denials Examples from CAHABA and CMS OFF THEIR WEBSITES
The duration and frequency recommended level of care is not specified in the evaluation and it is not signed.
None of the notes are signed and they are largely templated.
Review of CWF shows almost monthly billing for and since 2008 suggestive of maintenance level of care. 
Submitted documentation includes visit notes for previous six month time period, but the provider did not submit the documentation to support subluxation of the spine nor the plan of care or initial assessment.
ALL LEVELS OF MANIPULATION BILLED WERE NOT PERFORMED
EACH LEVEL OF MANIPULATION DID NOT CORRESPOND TO A DOCUMENTED SYMPTOM— KINETIC CHAIN? – State Farm, UHC, Care Plus

68. The most common errors noted by Medicare auditors of chiropractic service claims are briefly described below.
• Technical errors such as missing signatures, date of service on the claim not found in the record, etc. • Documentation that does not substantiate that all procedure(s) reported were performed. For example, as a condition of payment is often missing from the beneficiary’s medical record. o No documentation that each manipulation reported related to a relevant symptomatic spinal level. spinal levels of manipulation reported had been performed; • Examples of insufficient or absent documentation for purposes of determining medical necessity are as follows: o Required elements of the history and examination were absent. o Treatment plan absent or insufficient

69. PQRS and EHR affect REIMBURSEMENT!
Discounts are imposed for:
Not reporting PQRS
Not using EHR and attesting to Meaningful Use
Reduction in Payment to Participating Providers
Non-Par Doc should look up what they are to collect on website—its in your packet!!
CAHABA.GOV
Overcharging a Medicare Bene can result in fines and sanctions***

70. Physician Fee Schedule Procedures These amounts apply when service is performed in a facility setting.
Code
Modifier
Locality
Effective Date
Par Facility
Non Par Facility
Limiting Charge Facility
EHR Limiting Charge Facility
PQRS Limiting Charge Facility
EHR + PQRS Limiting Charge Facility
Par Non Facility
Non Par Non Facility
Limiting Charge Non Facility
EHR Limiting Charge Non Facility
PQRS Limiting Charge Non Facility
EHR + PQRS Limiting Charge Non Facility
98940 01
01/01/2016
22.90
21.76
25.02
24.52
24.03
28.66
27.23
31.31
30.68
30.07 99
22.27
21.16
24.33
23.84
23.37
27.42
26.05
29.96
29.36
28.77

71. Limiting Charge Facility EHR Limiting Charge Facility
Physician Fee Schedule Procedures These amounts apply when service is performed in a facility setting.
Code
Modifier
Locality
Effective Date
Par Facility
Non Par Facility
Limiting Charge Facility
EHR Limiting Charge Facility
PQRS Limiting Charge Facility
EHR + PQRS Limiting Charge Facility
Par Non Facility
Non Par Non Facility
Limiting Charge Non Facility
EHR Limiting Charge Non Facility
PQRS Limiting Charge Non Facility
EHR + PQRS Limiting Charge Non Facility
98941 01
01/01/2016
35.09
33.34
38.34
37.57
36.82
41.21
39.15
45.02
44.12
43.24 99
34.12
32.41
37.27
36.53
35.80
39.59
37.61
43.25
42.39
41.54

72. Physician Fee Schedule Procedures
Code
Modifier
Locality
Effective Date
Par Facility
Non Par Facility
Limiting Charge Facility
EHR Limiting Charge Facility
PQRS Limiting Charge Facility
EHR + PQRS Limiting Charge Facility
Par Non Facility
Non Par Non Facility
Limiting Charge Non Facility
EHR Limiting Charge Non Facility
PQRS Limiting Charge Non Facility
EHR + PQRS Limiting Charge Non Facility
98942 01
01/01/2016
47.26
44.90
51.64
50.60
49.59
53.74
51.05
58.71
57.54
56.39 99
45.97
43.67
50.22
49.22
48.23
51.76
49.17
56.55
55.42
54.31

73. PQRS ACAToday.org– information is available to NON MEMBERS
Advocacy
Medicare
PQRS
Two measures for this year
Pain Assessment
Functional Assessment

74. Q.  What are considered appropriate assessment tools for Measure #131, the pain assessment measure?
A.  Examples of tools for pain assessment include, but are not limited to, Brief Pain Inventory (BPI), Faces Pain Scale (FPS), McGill Pain Questionnaire (MPQ), Multidimensional Pain Inventory (MPI), Neuropathic Pain Scale (NPS), Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), Roland Morris Disability Questionnaire (RMDQ), Verbal Descriptor Scale (VDS), Verbal Numeric Rating Scale (VNRS), and Visual Analog Scale (VAS)

75. Measure 131
G8730—Pain Assessed Documented as Positive AND Follow-up plan documented
G8731—Pain Assessed Documented as Negative, No follow-up required.
G8939—Pain Assessment documented. No follow up Plan, pt not appropriate or eligible
G8442—Patient pain not assessed, patient not eligible for pain assessment
G8732—Patient pain NOT Documented, Reason not specified
G Documentation of Positive Pain Assessment: No follow Up plan, no reason given

76. Q.  What are considered appropriate assessment tools for Measure #182, the functional assessment measure?
Examples of tools for the functional outcome assessment measure include, but are not limited to, Oswestry Disability Index (ODI), Roland Morris Disability/Activity Questionnaire (RM), and Neck Disability Index (NDI) and Physical Mobility Scale (PMS).
Please Note: The use of a standardized tool assessing pain alone, such as the visual analog scale (VAS), does not meet the criteria of a functional outcome assessment standardized tool

77. Measure 182
G8539—Functional assessment performed, care plan formed with goals in place based on identified deficiencies same day
G8542—Functional assessment performed, no functional deficiencies Identified, no care plan required
G8543—Functional assessment performed, no care plan documented. No reason given
G8540—Patient not eligible for FOA, documented
G8541—FOA not performed, no reason why
G8942—Documented FOA w/Standardized tool: Care Plan In place within previous 30 days

78. PQRS Measure 181 FUNCTIONAL ASSESSMENT Measure 131 PAIN ASSESSMENT
Key code
166—G8730—Pain Assessed Documented as Positive AND Follow-up plan documented
167—G8731—Pain Assessed Documented as Negative, No follow-up required.
168—G8939—Pain Assessment documented. No follow up Plan, pt not appropriate or eligible
169--G8442—Patient pain not assessed, patient not eligible for pain assessment
170—G8732—Patient pain NOT Documented, Reason not specified
173---G Documentation of Positive Pain Assessment: No follow Up plan, no reason given
Measure 181 FUNCTIONAL ASSESSMENT
184--G8539—Functional assessment performed, care plan formed with goals in place based on identified deficiencies same day
185--G8542—Functional assessment performed, no functional deficiencies Identified, no care plan required
186--G8543—Functional assessment performed, no care plan documented. No reason given
187--G8540—Patient not eligible for FOA, documented
188—G8541—FOA not performed, no reason why
189-G8942—Documented FOA w/Standardized tool: Care Plan In place within previous 30 days
#1-NP or ROP or Progress Eval G G #166 + #184
#2-Regular OV MCR G G8942 #166 + #189
#3-ROP 1 time VISIT G8509 +G8543 #173 + #186
#4-Drop in MCR G G8541 #168 + #188
#5-Maintenance MCR G G8540 #170 + #187
#6-Last visit Patient Released G G8542 #167 + #189

79. It also changes PQRS and E.H.R. attestation dramatically.
On March 26, 2015, the House passed the Medicare Access and CHIP Reauthorization Act of MACRA
This bill includes a provision to replace the Sustainable Growth Rate (SGR) formula used by Medicare to pay physicians with new systems for establishing annual payment rate updates for physicians’ services.
It also changes PQRS and E.H.R. attestation dramatically.
But we don’t know what the changes will be yet!
Stay tuned to GCA Newsletters and s!!

80. MIPS -- PQRS and EHR will be required next year too
Starting in 2017, the PQRS, EHR attestation, and Value-Based Modifiers (VM) will be combined to form the Merit-Based Incentive Payment System (MIPS). Although you will not feel the (MIPS) effects in your practice until 2019, you will still feel the effects of the old Value-Based Modifiers (VM) program in 2017 and This is all part of the continuing effort by Medicare to tie payments to the quality of care the patient receives instead of the number of services performed.

81. Stay Tuned to GCA for information!
The effects of this score will be first felt on your practice in 2019 and could result in a 4% change up or down in what you are paid. This percentage will increase through 2022, where it will max out at 9% plus or minus. In 2019 MIPS will replace the Value Based Modifier we begin using in 2017

82. Do I have to collect Co-Pays/Deductible
Medicare guidelines state: You Must Attempt to collect copays and deductibles.\
ENTICEMENT is a crime in the Medicare system
Free exams, free x-rays don’t do it
Exceptions
Smallness
Financial Hardship
No “Official Definition” of Poor
Recommend Using Poverty Guidelines

83. http://www. federalregister
2011 Poverty Guidelines for the 48 Contiguous States and the District of Columbia
Persons in family
Poverty guideline 1
$10,890 2
14,710 3
18,530 4
22,350 5
26,170 6
29,990 7
33,810 8
37,630
For families with more than 8 persons, add $3,820 for each additional person

84. Denials 90 % of denied Chiropractic Claims are not Appealed
Fraud and Abuse
New computer programs…….. Profiling like Credit Card Companies
100 x-rays in a day…..red flag
Pre set SCREENS
20 after 8 weeks (unofficial) NOW its 25/year
Lengthy Care Plans
No new date of onset
CERT Reviews
Comprehensive Error Rate Testing
RAC’S
Recovery Audit Contractors (RACs),

85. Part B: HHS OMHA Field Office $150 Minimum1.
Redetermination
Performed by the
Contractor
MAC
120 days from denial
Sent to MAC
No threshold 2.
Reconsideration
QIC,
Qualified Independent Contractor
180 days from date of receipt of the redetermination
Part B
QIC 3.
ALJ
HHS Office of Medicare Hearings and Appeals (OMHA).
60 days from the date of receipt of reconsideration notice.
Part B: HHS OMHA Field Office
$150 Minimum
Note: Claims can be aggregated

86. APPEALS PROCESS 1. Redetermination (performed by the carrier/MAC);
2. Reconsideration (performed by a Qualified Independent Contractor);
3. Hearing (performed by an Administrative Law Judge); $150 MINIMUM you may group claims
4. Review (performed by the Medicare Appeals Council (within the Departmental Appeals Board); and
5. Judicial Review (in U.S. District Court).

87. Wait a week or two to let denials accumulate
How I make an appeal
Wait a week or two to let denials accumulate
Avoid knee jerk reaction.
Cover letter stating what is in packet
(prevents lost info)
Dictate/transcribe dates of service in question if notes are handwritten
Send abbv. Notes with ledger
Make sure initial visit is complete and include with date in question
Initial or sign every visit

88. When a review is requested for a particular date of service
Always submit:
Initial visit for that segment/EPISODE of care, or
Established Patient New Condition Visit or
Progress Evaluation Visit
MAKE SURE THEY CONTAIN
Goals
Care Plan
2/week, 4 weeks or 1/week x4weeks or what ever!

89. AUDITS vs DENIALS
Read the audit letter carefully and provide all the information requested in a timely manner. Additionally, it is important to remember to attach any/all supporting documentation to your redetermination request.
If a single date of service is requested, ALWAYS include information from the initial visit and all subsequent re-examinations to ensure the reviewer has all of the information to support the service(s) provided on the requested date(s).

90. Example New Patient- February 5, 2015
Treats 8 times self dismisses from care
ROP returns for care May 20, 2015
Treats 4 times asked Dr to let him PRN
Returns PRN about every 5-6 weeks for rest of 2015
New condition March 2, 2016
Treats 3x4, and is released PRN
Decides to return monthly by appointment
Which above is ACTIVE CARE ?

91. ACTIVE CARE PATIENT IS UNDER A CARE PLAN
BEING TREATED FOR A SPECIFIC PROBLEM
IS RE-EVALUATED EVERY 4 WEEKS OR EVERY VISITS
IS COMPLIANT
I JUST WANT TO COME BACK WHEN I NEED TOO
OK –SURE– BUT THAT DOES NOT QUALIFY FOR ACTIVE CARE AND YOU WILL HAVE TO PAY FOR IT
WELL THE GUY DOWN THE STREET DOESN’T MAKE MY FRIEND DO THAT!

92. We all should file appeals of denied claims!
Redetermination
90% of denial are never appealed
120 days from date of denial
No monetary threshold
File timely when denied LET A FEW ACCUMULATE
The more appeals they get the less claims they will deny DPM
Carrier gets paid per claim
has to provide administrative service inclusive of their fee
Cover letter stating what is in packet
If notes are hand written and abbreviated
Dictate/transcribe dates of service in question
Send abbv. Notes with ledger
Make sure initial visit is complete
Initial or sign every visit

93. Form CMS-20027 http://www.cms.gov/cmsforms/downloads/cms20027.pdf
A written request not made on Form CMS must include:
Beneficiary name
Medicare Health Insurance Claim Number (HICN)
Specific service and/or item(s) for which a redetermination is being requested
Specific date(s) of service
Name and signature of the party or the representative of the party
Usually get a reply or revised EOB in 60 days

94. Requesting a Reconsideration
180 days of Redetermination, no monetary threshold.
To request a reconsideration, follow the instructions on the Medicare Redetermination Notice (MRN).
A request for a reconsideration may be made on Form CMS-20033, which can be found here:
If the form is not used, the written request must contain all pertinent information.
The request for reconsideration should clearly explain why you disagree with the redetermination.
A copy of the MRN, and any additional documentation you feel may be useful, should be sent with the reconsideration request to the QIC identified in the MRN.
Evidence not submitted at the reconsideration level may be excluded from consideration at subsequent levels of appeal unless you show good cause for submitting the evidence late.

95. Administrative Law Judge HEARING
High success rate here!
60 days from date of Reconsideration from QIC
$130 threshold
May group several patients if need
*NOTE: The amount in controversy required to request an ALJ hearing is increased annually by the percentage increase in the medical care component of he consumer price index for all urban consumers. The amount in controversy threshold for 2011 is $130.

96. Carrier controls to prevent overutilization are inconsistent.
“Although all carriers have some mechanisms to prevent and recoup improper payments for chiropractic services, a significant vulnerability surrounding this benefit persists.” OIG Report, 2001
CAHABA gets leaned on
Covers Georgia, Alabama, Mississippi
We have it better than they do
Mississippi $5600/ (50th)
Alabama $11,117/1000
Georgia $15,964/1000 Ranks in the middle
Best states Iowa, Kansas, Nebraska +$42,000/1000
{Iowa $48,000}

97. Stats show You can make more money in this system if you want too
We have more DC’s per capita than many states
We have same % of retirees as those states
We provided less service to Medicare Bene’s
Regulations and requirements are going to be inspected and followed
You can make more money in this system if you want too
$40,000 /1000 MCR Bene vs $15,000 /1000

98. Necessity for Treatment
Must have a significant health problem in the form of a NMS condition necessitating Tx
Manipulative treatment must have a direct therapeutic relationship to the condition
Must have reasonable expectation or recovery or improvement of function

99. Types of Care Acute Subluxation Chronic Subluxation Maintenance Care
New injury, id by X-ray or Physical exam
Tx is expected to create improvement, arrest, or retardation of condition
Chronic Subluxation
No significant improvement or resolution is expected
Continued Tx should show some functional improvement
Maintenance Care
Once chronic condition is stable, no expectations of further improvements
Tx to prevent disease, promote health, prolong quality of life
Tx to maintain or prevent further deterioration of chronic condition

100. Modifiers AT = Active Treatment GA = Properly delivered ABN on file
GA modifier tells CMS you expect them to deny claim and you do not think it is Medically Necessary
GZ = No ABN on file, ie you made a mistake
Please note that you may NOT collect payment from the patient.
GP = Services Delivered Under an Outpatient Physical Therapy Plan of Care (97000 series codes)
Please note this does not mean therapy services are reimbursable if delivered by a doctor of chiropractic.
GY = Non-Covered Service
(Services Which Are Statutorily Excluded or Do Not Meet the Definition of Any Medicare Benefit)
Please note that you do not use GY on maintenance care spinal CMT.
GX = Voluntary ABN on file for Excluded Service
GU = New for ABN not defined yet

101. Examples 98942-AT 98941-GA 97014 EMS change to G0283-GYGP
Hot packs are bundled by CMS

102. Quiz:
1) You have treated a patient with maintenance care spinal CMT.  Is it reimbursable under Medicare?
a) Yes. b) No.
Answer: b. NO
2) You have treated a patient for maintenance care spinal CMT and you know it isn’t reimbursable under Medicare. You also have a properly executed ABN on file. Which modifier(s) do you append to the code?
a) –AT b) –GA c) –GZ
Answer: b. GA
3) You have treated a patient for properly documented chronic care (hence, active) spinal CMT. Which modifier(s) do you append to the code and is it reimbursable?
a) –AT and yes b) –GA and yes c) –GY and no
Answer: a. AT/yes
4) You are billing Medicare for therapy services, which you know are statutorily excluded for doctors of chiropractic. Which modifier(s) do you append to the code?
a) –GP b) –GY c) –GPGY
Answer: c. GPGY

103. Locum Tenens A person, especially a physician or cleric, who substitutes temporarily for another
Q6 modifier for the fill in doc
Line 24d of Form CMS-1500 the HCPCS modifier Q6 after the procedure code.
Until further notice, the group must keep on file a record of each service provided by the substitute physician, associated with the substitute physician‘s UPIN or NPI when required, and make this record available to the carrier upon request. In addition, the medical group physician for whom the substitution services are furnished must be identified by his/her provider identification number (PIN) or NPI when required on block 24J of the appropriate line item.

104. The Rules (rock-paper-scissors)
Under Medicare, the only covered service for doctors of chiropractic is manual manipulation of the spine to correct a subluxation (CPT codes 98940, 98941, 98942).
Only active care (acute and chronic)-AT is payable. Maintenance care is not payable, although it is still spinal manipulation and therefore a covered service.
Knowing that you can have a covered service that isn't payable is a very important point to understand for beneficiary notification purposes

105. When to Use the ABN
It's a Covered Service, But It Isn't Payable Because Its Not Medically Necessary
If you have reason to believe that the treatment of a Medicare beneficiary for a particular treatment date is maintenance care, therefore being considered not medically necessary and not payable by Medicare, you would have the beneficiary sign an Advance Beneficiary Notice (ABN).
In Georgia anything over 25 visits

106. New ABN form Fill-in the estimated cost portion
Verbally review the form with your patients prior to their signing (and the patient must sign in cursive)
A few points:
When notifiying the beneficiary, you must use the ABN developed by CMS
"Blanket" ABNs are not permissible.
The ABN is date-of-service specific,   
Once an ABN has been signed for the purpose of indicating maintenance therapy, that ABN is valid for that series of maintenance treatment, until there is an exacerbation or new series of active care, for up to one year. 
Once there is an exacerbation or new acute treatment, any maintenance care following would require a newly delivered ABN.  
The release of the most recent ABN form does not automatically mean that doctors of chiropractic no longer have to file maintenance care claims. 
MUST GIVE PATIENT A COPY OF ABN AND KEEP COPY IN CHART

107. The Newest (2008)ABN May Also Be Used for Non-covered Services
Anything that is NOT spinal CMT (CPT codes 98940, 98941, 98942). 
This includes exams, modalities, x-rays, labs, etc. 
This version of the ABN will eliminate the need for the previous Notice of Exclusion from Medicare Benefits (NEMB) form, which was considered OPTIONAL by CMS
Use of it for non-covered services is OPTIONAL

108. New - NEW(2011) Medicare ABN Form
The official Medicare ABN (Advance Beneficiary Notice) form has received some minor changes which have been mandated for use beginning
November 1st, 2011.
The changes involve the removal of some parenthesis, and some changes to the formatting of the instructions.
For more information see the ChiroCode article
or the Medicare page at
Or ACAToday.org, Advocacy, Medicare, New ABN

109. Advanced Beneficiary Notice (ABN)
Use for services beyond Reasonable & Necessary
Signed before services are rendered
Sign every visit or ONCE A YEAR
if no interruption in Maintenance Care
Requires GA modifier
Proper form CMS-R-131-G
Use for MAINTENANCE CARE VISITS
Back of the packet

112. Line D of ABN Examination and X-ray Physical modalities
25 visits in a year
Braces and supports
Vitamins
And maintenance care
Non Covered service
Requires Review
Not Medically Necessary

113. What are Medicare Advantage Plans? (MA) aka Part “C”
MA plans provide Medicare beneficiaries the option of receiving their Medicare benefits through a private insurer rather than through the traditional Medicare program.
MA plans are required to cover all services that are covered under traditional Medicare and they will sometimes offer coverage for additional services and items such as hearing aids and eyeglasses.

114. Are MA plans the same as Medicare Supplement plans?
No.
MA plans replace rather than supplement traditional Medicare.
All are different
Some pay E&M, X-ray, PT
Some have HIGHER CO-PAYS than traditional MCR
Some have Limits of care, ie # of visits per year
Must call and verify for EACH
Some do not recognize GA modifier---UHC

115. My patient’s insurance card says they have a Medicare PFFS plan, what does that mean?
Private Fee For Service
If a provider sees a patient with a PFFS plan, the provider is “deemed” to be in the network for now on.
Some, not all are below fee schedule
Some pay a per diem
Most have high co-pays
If you treat a patient who has a PFFS plan you must accept the conditions of the plan and bill the PFFS plan
If you do not want to be in network with the PFFS, you cannot treat the patient.
Look for PFFS on card, call to check benefits, then decide if you want to treat patient.

116. ACA Co-Pay Info
ACA has communicated to CMS specific instances in which MA plans were charging copayments that were equal to, or more than, the total cost of care for the beneficiary and they urged CMS to address this issue for the benefit of America’s seniors
ACA received correspondence from CMS indicating that for 2012, CMS has limited the cost-sharing MA plans can charge enrollees for chiropractic services to no more than $20 for plans with copayment designs, and to 50% for those with coinsurance designs.

117. Advantage plans are different
MA plans vary with regard to some of their billing requirements,
The same CPT/HCPCS codes are used,
the ABN is not and modifier use will vary by plan.
If I don’t want to deal with the MA plan, can I just bill the patient?---YES
If you are not a contracted provider under the plan, you are under no obligation to bill or abide by that plan’s fee schedule. However, you are still limited to traditional Medicare fees (Medicare Physician Fee Schedule).
How many MA plans are there?
There were +2,000 MA plans available as of 2011

118. Medicare Advantage Plans Fraud Waste and Abuse Training
What You Need to Know
1. If you are a Medicare Advantage provider you must take the Fraud Waste and Abuse training program.
2. You will only need to take one training course to fulfill the requirement. You do not need to take one course for every Medicare Advantage plan you participate with.
3. Most training programs take only a half an hour to complete.
4. Once you complete the training program, you will receive a certificate that can then be copied and sent to the various plans when they request it.

119. Timely filing Must file with in one year of Date of Service
This can create a problem in a PI case.
Claims file after deadline will be denied and cannot be appealed
Assigned Claims filed over 12 months will be paid with 10% penalty
You cannot balance bill patient the 10%

120. Which Level to bill? 5 levels, 98942, you get more $!!!
NOT!
Did you get a letter from CAHABA a few years ago?
It had your Medicare profile in it.
I.E. how often you used each code
ACA published Guidelines say:
areas
5% to 15% of the time
areas
60% to 80%
areas
5% to 15%
10:70:20 is a good ratio, or 15:60:25, or 5:75:20
Never use one code 100% of the time

121. Cahaba Utilization 98940
1,000 enrolled beneficiaries

122. Cahaba Utilization 98941

123. Cahaba Utilization 98942

124. January-June 2010 Actual Utilization Data NATIONWIDE FIGURES
Code
National Allowed Services
Per
1000 Benes
National %
Denied
average10%
National Allowed Charges Per
98940
3,081,663
97.24
11.68
$2,331.22
98941
7,092,497
223.81
9.09
$7,433.40
98942
902,941
28.49
8.48
$1,237.06
124

125. Cahaba CONTACTS Provider Inquiry Line 877-567-7271
Beneficiary Line
Social Security Office
Provider Enrollment
MSP
Appeals

126. Simple
Medicare use to require an x-ray each year to document subluxation of the spine
Would not pay for x-ray -- cash service
Now Medicare requires a History and Examination to document need for care of subluxation and Musculoskeletal Condition caused by it
Will not pay for E&M -- must collect from patient!
History and Exam must have care plan with GOALS
They are required for EACH EPISODE
The Chiropractic Assistant is the one that needs to explain this to the patient.