Spring 2013: Kathy Mills Chang Notes

2/2013

www.kmcuniversity.com (855) TEAM KMC

Get Squeaky Clean with Medicare,

Documentation and Compliance

With Kathy Mills Chang, MCS-P

Certified Medical Compliance

Specialist

The Legal Stuff

Please be reminded that CPT code descriptors and compliance and coding policies do not reflect all coverage and payment policies. The existence of a CPT code does not ensure payment for any service. The coverage and payment policies of governmental and commercial payers may vary. Questions regarding coverage and payment for an item or service should be directed to particular payers. Any coding advice in this seminar reflects the opinions of Kathy Mills Chang in her role as a certified medical compliance specialist and is not a substitute for individual consultation with the appropriate authority ( CMS, legal counsel, malpractice insurance company, etc.). KMCU disclaims responsibility for any consequences or liability attributable to the use of the information contained in this seminar.

LOCAL MEDICAL REVIEW POLICY

(LMRP)• LMRP is an administrative and educational tool to

assist providers, physicians and suppliers in submitting correct claims for payment.

• Local policies outline how contractors will review claims to ensure that they meet Medicare coverage requirements.

• CMS requires that LMRPs be consistent with national guidance (although they can be more detailed or specific), developed with scientific evidence and clinical practice, and are developed through certain specified federal guidelines.

Medicare Guidelines

Medical Review Policies

Aetna BCBS

Risk Management / Records Warning Signs of Improper Documentation

• Global Indications (i.e.)

– Illegible Records

– Dates Incomplete / Absent

– Absent Signature or Initials

– Informed Consent Absent

– Documentation in pencil

– Follow – Up Exam Absent

– Patient Name / File

number absent

– Different levels of record

for different accounts

– Lack of objective language,

metrics

– Remarks about other

providers

– Blanks on forms indicate

“Not performed.” Note:

Blanks do not indicate NAD

/ WNL

– Made up abbreviations

(Have Legend)

2/2013


Practice Analysis of

Chiropractic 2010National Board of Chiropractic Examiners

• The typical practitioner now spends more

than a quarter (25.2%) of his or her work time

documenting patient care; this amount has

almost doubled since 1998 (13.8%)

Medically Necessary vs. Clinically

Appropriate Care

Medically Necessary

• Significant

improvement in clinical

findings and patient’s

functionality

Clinically Appropriate

• Life Enhancing

• Symptom relieving

• Wellness care

• Supportive Care

• Maintenance care

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Medically Necessary Care

Clinically Appropriate Care

Subsequent Visits Documentation

Requirements

• History: (29% Documentation Error Rate)– Review of Chief Complaint

– Changes since last visit

– System review if relevant

• Physical exam: (43% Documentation Error Rate)– Exam of area of spine involved in diagnosis – Objective (A, R, T)

– Assessment of change in patient condition since last

visit (PE, OA, ADL, QVAS) (Same, Better, Worse)

– Evaluation of treatment effectiveness (Same, Better,

Worse, How and Why)

• Documentation of treatment given on day of visit: (15% Documentation Error Rate)

– Failure to document the medical necessity of the chiropractor’s manual spinal manipulation(s) may result in denial of claim(s)

Subjective (P)

Assessment

Location of Symptoms

Quality of Symptoms

Intensity of Symptoms

Plan

Subsequent Visits Documentation

Requirements

• Subjective: (PART)

• Question:…Salutations, Please tell me…..

– Where the low back pain is today…what is the

quality and intensity?

– Has there been a change in your ability to lift

objects? (Function)

– How is your ability to garden? (Function)

• Record finding(s) in Progress / SOAP note

Since

Last

Visit

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Subsequent Visits:

According to Medicare

• Patient History

• Physical exam of the area of the

diagnosis

• Documentation of the treatment

provided in the visit

Must Have

• SOAP for each condition (area of the spine)

you are treating

• Congruency between treatment plan and

notes

• Listing of services performed

• Patient assessment and doctor’s assessment

• Objective tests in the areas of the spine being

treated

Acute

• CMS defines Acute as: "A patient's condition is

considered acute when the patient is being

treated for a new injury, identified by x-ray or

physical exam as specified above. The result of

chiropractic manipulation is expected to be an

improvement in, or arrest of progression of,

the patient's condition."

Acute

• New injury, identified

by x-ray or physical

exam

• Expected improvement

in, or

• Expected arrest of

progression of, the

condition

Chronic

CMS defines Chronic as: "A patient's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continue therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered."

Chronic

• Not expected to

significantly improve or

resolve with treatment

• BUT continued therapy

can result in some

functional improvement.

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MaintenanceCMS defines Maintenance Therapy as: "Chiropractic maintenance therapy is not considered to be medically reasonable or necessary under the Medicare program, and is therefore not payable. Maintenance therapy is defined 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."

Maintenance

• Wellness

– Prevent disease

– Promote health

– Prolong/enhance the

quality of life

• Supportive

– Maintain or prevent

deterioration of a

chronic condition

P.A.R.T.

• Refresh your knowledge

of P.A.R.T and how it

effortlessly fits within

your traditional S.O.A.P.

format to easily confirm

medical necessity.

• P = Pain

• A = Alignment

• R = Range of Motion

• T = Tissue Changes

S = P

• The patient shares the

information about their

Subjective complaints,

or their Pain

O = ART

• The Doctor observes the

information about the

patient’s status, through

provocative testing,

measurable outcomes, or

their Objective findings

• Range of Motion, Tissue

Changes and Asymmetry

are noted as part of the

patient’s progress

Acute Exacerbation

CMS defines Acute Exacerbation as: "An acute exacerbation is a temporary but marked deterioration of the patient’s condition that is causing significant interference with activities of daily living due to an acute flare-up of the previously treated condition. The patient’s clinical record must specify the date of occurrence, nature of the onset, or other pertinent factors that would support the medical necessity of treatment. As with an acute injury, treatment should result in improvement or arrest of the deterioration within a reasonable period of time."

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Acute Exacerbaton

• New injury, identified

by x-ray or physical

exam

• Expected improvement

in, or

• Expected arrest of

progression of, the

condition

Chronic Exacerbation

• CMS defines Chronic Exacerbation as:

"An acute exacerbation of a chronic

subluxation must represent an acute

change that is a marked deterioration of

the patient’s condition and is causing

significant interference with activities of

daily living. “Active treatment” may only

occur as long as the patient is achieving

significant clinical improvement."

Chronic Exacerbation

• Not expected to

significantly improve or

resolve with treatment

• BUT continued therapy

can result in some

functional improvement.

Daily Treatment Notes

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What is Compliance?

• As it relates to healthcare, has to do with privacy, security, coding, billing, documentation, and utilization

• Active compliance program

• Dedicated compliance officer

• CERT Reviews Revealed the following error rates in 2011

– 61% insufficient documentation

– 26% lack of medical necessity

– 7% incorrect coding

FraudFraudFraudFraud includes obtaining a benefit through intentional misrepresentation or concealment of

material facts

WasteWasteWasteWaste includes incurring unnecessary costs as a result of deficient management, practices, or controls

AbuseAbuseAbuseAbuse includes excessively or improperly using government resources

Compliance Program: Defined

• An operational

structure that will assist

the physician’s practice

in preventing fraudulent

or erroneous conduct

or behavior

The purpose of a compliance program

is:

• To integrate policies and

procedures into the

physician’s practice that

are necessary to

promote adherence to

federal and state laws

and statutes and

regulations applicable

to the delivery of

healthcare services.

Is it Mandatory?

• Came out of the

sentencing guidelines

• Affordable Care Act:

Mandatory Compliance

Plans Coming Soon

• CMS has NOT finalized

the requirements

• CMS will advance specific

proposals at some point

in the future

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How does a Compliance Program

Work?• An effective compliance

program establishes an atmosphere of compliance that permeates the entire organization.

• A compliance program should be tailored to the specific circumstances of the provider.

• The program should also feed and grow on itself.

• As problems are detected appropriate changes should be made to the program and related policies and procedures.

Let’s Start at the Very Beginning…

• Decide that the time is NOW!

• Take the first step by declaring that this is the TIME!

• Bring your team together and simply get started.

• Initial compliance meeting gets you going.

Initial Compliance Meeting

• Sets the tone

• Introduces new rules

and compliance

concepts to entire team

at once

• Doesn’t make wrong

• Clean slate to begin

• Introduces Compliance

Officer


• Be prepared

• Have Code of Conduct ready for each team member

• If the Compliance Officer will assist with this meeting, divide the presentation

• Explain the “why” behind the changes

Sample Introductory Scripting

“You may be aware that many changes are occurring in healthcare and the business of healthcare. Practices are being audited, rules are changing and here at (insert practice name) we want to stay ahead of the curve and show our commitment to an environment of the utmost compliance. For this reason, you may see some changes coming down the pike to procedures and systems we’ve had in place. There may be changes necessary to certain processes that we have learned need to be updated. We’re constantly learning and growing as we strive to stay on top of the changes as they happen. This meeting is meant to get all of us on the same page about the culture of compliance that we will be enforcing going forward.”


• Next, explain there are

different kinds of

Compliance

• OIG, HIPAA, Regulatory

boards, financial policy

compliance, etc.

• Then review the 7 steps

of the OIG Compliance

Program

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Review the 7 Steps of the OIG

Compliance Program

Step 1- Implement Policies and

Procedures

• Understand the

difference between the

two

• Assess what existing

policy and procedure is

in place that needs

attention

Why You Need Both

• Policy: This is how and

why we do things here

• Procedure: Standard

Operating Procedure

(SOP)—It’s how we

implement the policy

we’ve decided upon.

Build As You Go

• The most efficient way

to accomplish this

daunting task is to build

both manuals as you go.

• As you work through

each area of focus or

lesson, appropriate SOP

and Policy will be

developed and

implemented.

An Example of Policy

Sample Policy: Physician Education Policy

PURPOSE:

The purpose of physician and other practitioner education is to ensure all providers understand and comply with federal and state laws, statutes and regulations applicable to the delivery of health care in a clinical environment.

POLICY:

Physicians and other practitioners are required to attend all agreed upon and scheduled educational programs designed for providers. Education will be conducted subsequent to medical record audit activity and with a frequency to meet the needs of the provider. Provider compliance education will be conducted at least annually.

An Example of Procedure (SOP)PROCEDURE:

It is the responsibility of the Compliance Officer to:

• Conduct provider education with the frequency necessary to ensure compliance with

applicable federal and state laws, statutes and regulations.

• Schedule, direct and document an annual base-line medical record audit for all physicians and other practitioners. Refer to Medical Record Audit Policy.

• Provide physicians with information regarding new or changes in existing federal and state

healthcare laws, statutes and regulations.

• Develop the content of materials used for educational purposes. Medical record audit findings and other identified risk-areas will be included in the training materials.

• Conduct Compliance Program education at least annually.

• Conduct coding, billing and reimbursement education at least annually.

• Provide the Compliance Committee with a quarterly report of provider education activities.

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An Example of Procedure (SOP)Procedure for Conducting Post Audit Provider Education:

1) Compliance officer (CO) selects two dates for possible training, within one month of the audit, and sends email to all providers to select the date that works best for them.

2) CO compiles training materials for the meeting based on identified errors in the audit. Power point presentations, handouts and other training materials are prepared for the meeting.

3) Upon selecting the best date, CO sends training announcement to all providers, secures the location and arranges for agenda, refreshments, and files to be reviewed in training.

4) CO sends reminder email 2 days before scheduled training to all providers.

5) The day of the training, CO conducts the training and review.

6) Minutes of the meeting are kept and added to the compliance manual.

7) An employee training log is filled out and signed by all in attendance, and added to the compliance manual.

8) The next audit date is calendared at this time, based on the error rate determined by the previous audit.

Know and Apply These Two Important

Concepts

• A clear knowledge of both policy and procedure ensures a proper compliance program.

• Every issue may not need both

• Less is not more in this instance!

• It’s a journey, not a destination.

Physical Manuals

Digital Manuals

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Step 2- Compliance Officer or Contact

• Review the role of this

person

• Everyone is responsible

for compliance

• Officer is responsible

for overseeing all

manner of compliance,

but doesn’t work alone

Step 3- Employ Comprehensive

Education and Training

• Training is going to be

tracked and

documented

• Webinars, seminars,

conventions, and other

on the job training

should always be

recorded when relative

to a compliance related

issue

Step 4- Enforce Disciplinary Standards

• Review the code of

conduct

• Explain why everyone

must commit to

compliance

• Get the Code of

Conduct signed after all

7 steps have been

reviewed

Step 5- Respond Swiftly to Detected

Offenses

• Everyone’s eyes and ears must be open and

watching at all times

• Overpayments to Medicare must be within 60

days of the detection

• Internal processes and audits will assist with

the practice finding these occasional missteps

• Everyone must participate in supporting the

compliance officer’s efforts

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Step 6-Internal Audits and Monitoring

• More internal audits

will take place now

• Four types of audits

– Documentation

– E/M Coding Audits

– Coding Audits

– EOB Audits

• Calendar of routine

audits will be set

Step 7- Open Lines of Communication

• Insist on an Open Door

Policy

• Everyone must report

things they don’t

understand or are

curious about

• Create the system that

you’ll use for reporting

Sample Scripting

“We all recognize that the accumulation of

unspoken, unanswered problems, grievances, complaints and questions can result in dissatisfaction and can impact the working relationship. It is to everyone's advantage to bring these matters out in the open. If you have a problem or complaint, or a compliance related concern, please review it with your

supervisor, the doctor, or compliance officer as soon as possible.”

Get Code of Conduct Signed• Now that all 7 steps are

reviewed, go back to the Code of Conduct, pass it out and get everyone’s agreement.

• Collect the signed documents, make 3 copies of each at the end of the meeting

• Original: Employee’s file

• Copy: To employee

• Copy: Behind “Code of Conduct” tab in Compliance manual

Fill Out Training Sheet for this Meeting Install Compliance in Your Office

• None of this matters if you only talk and don’t act

• Installation of compliance programs can take time

• Set aside appropriate time to do a little at a time for each of the 7 steps

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Step 1- Implement Policies and

Procedures• Assess what policy and

procedure exists

• Make an action list of the most important policies first

• Documentation, Medicare, Financial, and Coding policies take precedent

• KMCU clients have sample policy for each lesson

Step 2- Compliance Officer or Contact

• Once assigned as a

compliance officer, the

journey begins

• Calendar a year’s worth

of events

• Always keep an eye out

for compliance related

issues

Daily, Weekly, Monthly, Annual and As

Needed Duties• Daily: Ongoing monitoring

• Weekly: Team meeting training; review recommended concerns

• Monthly: Compliance meeting with doctor; spot check 1-4 notes per provider; random EOB review

• Annually: Complete audit of 5-10 charts per provider; complete coding audit; review all provider contracts; review existing policy and procedure; annual compliance meeting with the team; renew the practice’s Code of Conduct; confirm key team members have completed annual training; conduct formal compliance training with the entire team

As Needed Duties

• Initial compliance training for new team members, within 10 to 90 days of employment

• Ongoing, and remedial training based on audit findings or spot check findings

• Ongoing case work for compliance incidents

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Step 3- Employ Comprehensive

Education and Training• Always document every

training with a training log signed and added to compliance manual

• Every webinar, free or otherwise should be included, if appropriate

• All outside seminars should be documented

• CO should lay out a training plan early in the year according to the calendar

Step 4- Enforce Disciplinary Standards

• Lay out a sliding scale of

discipline to be

enforced

• Range from verbal

warning and retraining

up to referral to law

enforcement

• Document, document,

document

Other Items to Include in Sanction

Policy

• Negligence

• Incompetence

• Disorderly conduct

• Fraud or falsification on employment application

• Unsuitability to job requirements

• Insubordination

• Violation of applicable statutory requirements

Step 5- Respond Swiftly to Detected

Offenses

• Be ready to take action on detected offenses

• Document time lines in writing on incident reports

• Everyone must participate in supporting the compliance officer’s efforts

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Step 6-Internal Audits and Monitoring

• Consider an outside entity to conduct a baseline audit on your behalf

• Use error rates to determine what is next

• Coding audits conducted by KMCU as part of PPP or ISP/PhD programs

Step 7- Open Lines of Communication Just Do It!

• Set a goal.

– By when will you take

the first steps?

– By when will you have

your meeting?

– By when will you get the

basics in place?

• Don’t put it off again.

• Action gets results.

ESSENTIAL ELEMENTS OF

ASSESSMENT

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Treatment Plan & Goals Measurable Functional Goals

Modalities & Rehab Treatment Effectiveness

30-Day Window to ‘Plan B’ Dr. Listening

• Listen closely to effect

on a patient’s life

• Ask thoughtful

questions about

paperwork

• O-P-P-Q-R-S T

• After gathering...poof…

we transform to…

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Dr. Finding

• Tests and

measurements

• Distinguish between

important nuances

• Record everything in

the patient’s record

Dr. Thinking

• This is assessment

• S + O = Assessment

• Enter important

comments and

diagnoses that helps to

show the picture of

what you found

Dr. Fixing

• Listening + Findings+

Thinking = Treatment

Plan

• Foundation now exists

to deliver the treatment

• Medical necessity is

shown

• It’s logical to expect the

treatment you chose

What I learn in the HISTORY

• History means

everything you learn as

Dr Listening what the

patient tells you - both

on verbally and on their

paperwork

• What risk factors or

contraindications may

be present?

• What regions or areas

of Chief Complaint are

involved?

• What ortho/neuro tests

are coming to mind as

appropriate?

What I learn in the EXAM

• Be a great detective,

during the examination

process

• You want to be focused

• QUANTIFY your findings

• MEASURE your results

• OBSERVE your patient

Exam Helps

• Dr. Jeff Miller

• Exam Doc

extraordinaire

• Flash Cards Available

this weekend: Special

Seminar Price: $40

includes shipping (first

come-first served)

2/2013


X-ray Policy

• To x-ray or not x-ray that

is the question.

• Imaging and diagnostic

testing are for

documentation …not

education.

• There should never be a

blanket x-ray policy in

any office.

X-ray Report

• Proper documentation

is key in diagnostic

imaging: you must have

a solid rationale, and a

report showing clinical

outcome, otherwise the

test is not considered

medically necessary.

X-ray Indications

• Trauma

• Red flags for infection

or cancer

• Scoliosis evaluation

(when clinical indicators

are present)

MRI Indications

• Lingering pain beyond 4 weeks

• Progressive or worsening neurological symptoms

• When fracture is strongly suspected/not seen on film.

• Painful or progressive structural deformity

• Unstable segment

• Persisting signs and symptoms

Time to sow those wild OATs!

OATs = Outcome Assessment Tools

• Visual Analog Scale

• Revised Oswestry

• Pain Drawings

• Roland-Morris Disability

• Neck Pain Disability Index

• Headache Disability Index

• Bournemouth

• Zung Psychological

Assessment Questions

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Donny Dreamboat ADL’s Doctor Thinking

• HISTORY:

• What the patient tells you

• What the patient puts on their paperwork

• E/M:

• Your exam findings

• What any additional testing tells you

• What the OATs tell youH + E = Assessment

History ExamClinical

Decision Making

H + E = Dx −−−−> > > > Tmt Plan CCGPP Prognostic Factors

• Older age

• History of Prior Episodes

• Severity of initial episode

of injury

• Number of exacerbations

• Duration of current

episode longer than 1

month

• Psycho-social factors

CCGPP Prognostic Factors

• Pre-existing pathology

• Nature of employment

• Waiting more than 7

days to seek treatment

• Congenital Anomalies

• Patient compliance ASSESSMENT LEADS TO DIAGNOSIS

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Decision Making

H + E = Dx −−−−> > > > Tmt Plan Diagnosis

• The diagnosis that you choose to represent your patients’ conditions directly relates to the level of care permitted by third-party payors when you submit your claims.

• Use an order that will accurately represent the patient’s condition on the claim form and describe his or her clinical presentation, as well as support the plan of care that you have prescribed

Position 1 – Nerve

• When a patient has a radicular symptom, include radiculitis as your first position code.

• Radiculitis is the radiation of pain down a nerve, typically into an extremity.

• The radiation of pain away from its site of origin provides justification for the diagnosis of radiculitis.

• Quality of pain: burning or shooting

• Will correlate with positive neurological findings

– Radiation, weakness, numbness, positive nerve tests

Position 2: Bone/Joint/Disc

• The pain can be biomechanically reproduced.• “I can make your body do something that makes

you recreate the pain”• Disc Degeneration or Degenerative Joint Disease

(DJD) are musculoskeletal: 722.4 Cervical DJD 722.52 Lumbar DJD

• Other musculoskeletal codes include a broad range of anomalies from scoliosis to spondylolisthesis.

• An excellent pediatric diagnosis is 781.9 Abnormal Posture

MRI Required

• 722.0: Intervertebral

disc disorders

• Muscle tears

• Rotator cuff

• Other ligamentous

damage or tears

Must Have Viable X-Ray

• Degenerative joint

disease

• Degenerative disc

disease

• Spondylolisthesis

• Compression Fracture

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Positions 3 and 4 – Muscle/Disc/Other

• For soft tissue and extremity treatment, it’s best to point the diagnosis to the code.

• If you provide tx to the soft tissues, you must include a soft tissue diagnosis.

• This includes Manual Therapy 97140.

• Functional Diagnosis must have correlating findings:

– Restricted ROM, Positive Muscle Testing

• Myalgia is an excellent supporting diagnosis to use: muscle pain: 729.1 Myalgia 728.2 DeconditioningSyndrome

Positions 3 and 4 – Catch All

• The 3rd and 4th positions can also serve as a

catch-all location for any other diagnosis that

is descriptive of your patient’s condition.

• Soft Tissue DX should be easily defendable:

true myofascitis, carpal tunnel, adhesive

capsulitis

When Using Exam Findings

• You must be able to defend your diagnosis

• Kemp’s test is positive in most facet syndromes, but in some facet syndromes are not

• Be able to tell a third party what your thought process was using what’s written in your patient record

Diagnosis Made Easy

Sample: Bettye Blue Cross

• 27 YO Female, neck, mid & low back pain of 3

years. LBP aggravated with moving her

household last week. LBP constant aching,

throbbing, and stiffness with 8/10 pain scale.

Interferes with sleep, sitting, lying down,

standing. Personal and family health histories

are unremarkable.

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Sample: Morris Medicare

• Let’s see how it all comes together…

• Morris Medicare is a 67 year old male who presents for care today related to an injury sustained while gardening & hoeing by hand in very rocky ground 2 weeks ago. He worked for 8-10 hours and frequently needed to use a pick axe.

Morris Medicare History

Morris states that that since that time he has had worsening neck and right shoulder pain. He has also been having burning pain, tingling and numbness in his left arm all the way to his fingers.

Nothing seems to make it better or worse and the symptoms are constant. He reports he cannot sleep comfortably. He verbally rates the neck pain at an 8/10, the left arm symptoms at a 7/10, and the right shoulder pain a 5/10.

Morris denies any prior injuries or complaints involving this area. His family and personal medical histories are non-contributory.

Morris Medicare Findings/Exam

Examination revealed Morris Medicare to be alert and oriented to person, place and time. He appears well developed, well nourished, and well kept. His blood pressure was 124/75 and he is at 5’11, 175 lbs.

He was tender to touch throughout her cervical spine and in her right shoulder. Moderate swelling was palpated in the right shoulder region. His cervical ranges shoulder ranges of motion were restricted (see exam form for measurements).

In the cervical spine foraminal compression test and Jacksons test was positive on the left were positive for aggravation of radiating symptoms and O’Donoghues was positive for pain on passive ranges of motion. His right shoulder Superspinatus press test was positive for shoulder pain, and Appley’s scratch tests were positive for restricted motion. Myotomalmuscle testing was performed and all upper extremity muscles test +5 bilaterally, with pain in the right shoulder. Grip and pinch strength tests were equal bilaterally.

Cervical and right shoulder films were ordered to evaluate for possible loss of joint integrity. Neck Disability Index test was performed the patient scored a 35% which is a moderate level of disability.

Morris Medicare Assessment

Upon consideration of the information available I have diagnosed Morris Medicare with Cervical-brachial syndrome, cervical strain, and AC joint sprain.

Morris is of good health and is expected to make good progress and recovery with few residuals, however due to his advanced age, the length of the current episode, and the amount of time that passed before he sought care it is reasonable to believe that his recovery may take longer than an average patient with an uncomplicated case.

It is my recommendation that he be seen 3 times per week for four weeks at which time barring any unforeseen complications or changes a re-evaluation will be performed to determine progress and further care.

Morris Medicare DX and TX plan

Morris will need to be seen 3 times per week for 4 weeks for treatment to his cervical spine and right shoulder. He has been diagnosed with cervical-brachial syndrome, cervical strain, and AC joint strain.

His treatment will consist of CMT with diversified technique to the cervical spine. Trigger point therapy will be performed to the upper trapezius musculature for 15 minutes. Pre-modulated e-stim will be performed on the right shoulder for 15 minutes and ice will be applied. Ultrasound therapy will be performed for a total of 10 minutes to the cervical spine and superspinatus musculature.

Range of motion exercises will be prescribed to the patient initially and strengthening exercises will be added as progress is appropriate. The goals of his treatment are to reduce pain and discomfort with ADLs including dressing, sleeping, and day to day activities.

Nasty-Gram

2/2013


Treatment Plan & Goals

Functional Deficit Noted:

Inability to:_______________

Functional Treatment Goal:

Able to __________________

Measurable Functional Goals

Functional Deficit Noted:

Personal Care, Lifting, Walking,

Sitting, Standing, Work,

Driving, Other:____________

Goal Setting: The Secret to Medical

Necessity

• Find out the patient’s goals

• Don’t allow pain relief only

• Combine patient goals with exam functional deficiencies to produce treatment goals

• Use goals to drive treatment plan

Modalities & Rehab

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Treatment Effectiveness

Complicating Factors:

Eval. Tx. Effectiveness Tools:

30-Day Window to ‘Plan B’

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Projected Completion of Tmt

Plan: _________

Functional Treatment Goal:

By _________(when)

Daily Assessment

• A brief assessment of

the patient’s response

to treatment should be

noted after each

treatment is completed,

an recorded in the

progress notes (ie SOAP

notes)

Ongoing Assessment

• Get to the root of how

patients are REALLY

doing at each visit

• Patients will always

report on pain.

• On an ongoing basis the

assessment should

answer two questions. . .

Function, Function, Function

• In relationship to

treatment goals

• HOW is the patient

improving?

Function, Function, Function

• WHY does the patient need

more care?

• What is left to accomplish?

OATs Determine Course Accuracy

• Mid-point of a trial of care

(week 2 of 4-week trial)

• Practitioner should re-assess whether the current course of care is continuing to produce satisfactory clinical gains using commonly accepted OATs.

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Periodic Re-Assessment

After an initial course of

treatment has been concluded

• Re-examination

• 25-modifier worthy

• Repeat the last exam

• Re-perform all positive tests

• RE-do OATs

• How far have they come

Morris Medicare Ongoing

Assessment

Visit 3 Assessment: Morris is improving as he states he is able to sleep more

comfortably now and can dress more easily. Gross ranges of motion are

slightly improved. The numbness and tingling in his fingers before now only

reached his forearm. Continued care is necessary to continue to reduce

pain, strengthen the shoulder complex, and increase range of motion.

Visit 8 Assessment: Morris continues to improve- he states that he

sleeps through the night and has no pain with dressing. He states

that he is able to carry light weights like some groceries with his right

arm now. He states that the numbness and tingling in his left arm

has subsided. Tissue swelling in the right shoulder and tenderness in

the shoulder and cervical spine are reduced.


Decision Making

H + E = Dx −−−−> > > > Tmt PlanCMT Codes

• 98940-3 the basic building

blocks and best description

of the DC’s work.

• Most comprehensive

physician code to describe

chiropractic services.

• Basic service around which

everything else is built.

Coding The CMT

• Full Spine Adjustment: The

treating doctor should

prioritize the level of

adjustment and code for

the primary area(s) of

concern.

• 98940: 30-60%

• 98941: 40-60%

• 98942: 1-10%

Extra Spinal Adjustment

• 98943-Extra spinal

adjustment

• 5 regions:

– Head, including TMJ

– UE

– LE

– Anterior ribs

– Abdomen

2/2013


Chiropractic Manipulative Treatment Codes:

Extra Spinal Code

• 98943, 1 or more

extra spinal regions

• Correlate:– Symptoms

– Exam findings

– Diagnosis

– Treatment

– Documentation

Supervised Modalities

• 97010-97028 do not require

one-on-one contact by the

provider.

• Billed only once per

encounter.

• Code 97012 Mechanical

Traction

• Code 97014 Electrical

Stimulation

Constant Attendance Modalities

• 97032-97039 require

direct one-on-one

patient contact by

provider.

• These are timed codes.

• Code 97032 manual

electrical stimulation

• Code 97035 ultrasound

Therapeutic Procedures Coding:

Active Care

• Therapeutic Procedures

are time-based codes.

• The patient is active in

the encounter.

• Require direct one-on-

one patient contact by

provider of the service.

97110 Therapeutic Exercises

• Develop one functional parameter: strength, endurance, range of motion, or flexibility

• Treadmill for endurance

• Isokinetic exercise for ROM

• Lumbar stabilization exercises for flexibility

• Stability ball to stretch or strengthen

97112 Neuromuscular

Re-education

• Used to describe those

activities that affect

proprioception

• Balance

• Coordination

• Kinesthetic sense

• Posture

• Per KMC: DON’T USE

THIS PLEASE!

2/2013


97530 Therapeutic Activities

• Used when multiple parameters are trained including balance, strength, and range of motion.

• Must be related to a functional activity with direct functional improvement expected.

• Use Outcomes Assessment Tools.

97124 Massage

• Massage is a passive procedure used for restorative effect.

• Used for effleurage, petrissage, and/or tapotement, stroking, compression, and/or percussion.

• An independent procedure from CMT and is considered separate and distinct.

97140 Manual Therapy

• Includes soft tissue and joint mobilization, manual traction, trigger point therapies, passive range of motion, and myofascial release.

• When billed with a CMT, must be in a separate body region.

• Requires a -59 modifier.

97150 Group Therapy

• When supervising more than one individual, for a service that requires direct supervision, use code 97150 for each patient.

• For example, if NMR is performed in a group setting, use code 97150 —do not use 97112 and 97150 at the same time.

• Billed once per session.

Timed Treatment Codes

• Timed codes are counted per 15 minutes

• Up to 15 minutes is not a full unit, under the CPT guidelines

• Some carriers may have you use the Medicare standard of 8 minutes for the 1st unit

• Check with each carrier and document appropriately.

• Use of the -52 modifier could negate the service

Timed Treatment Codes

• For a single timed code

being billed in a visit:

– 8 up to 23 min = 1

– 23 up to 38 min = 2

– 38 up to 53 min = 3

– 53 up to 68 min – 4

– And so on

• For multiple timed

codes billed on the

same visit, use this

standard, but count

TOTAL time spend on

each timed code

2/2013


Evaluation and Mgmt. Coding

New patient vs.

established patient coding

History

Examination

Clinical Decision Making

Components and

subcomponents

Build your way to the

correct code

Initial Visit

Exam: $120X-Rays: $130CMT: $6597014: $35

Total: $350

Routine Visit

CMT $6597110: $5097014: $3597012: $35

Total: $185

Initial Visit

Exam: $95X-Rays: $75CMT: $3597014: $15

Total: $220

Routine Visit

CMT $3597110: $3097014: $1597012: $15

Total: $95

98940: $25.1598941: $34.8698942: $42.75

100% Poverty: 75% Discount125% Poverty: 50% Discount150% Poverty: 25% Discount

Decide If You Want to Discount

• Use federal prompt pay discount guidelines

for hardship policy

• Never discount on copay or deductible for

insurance patients

• Never make side deals with the patient

• Remember, charge correctly, bill correctly,

then COLLECT according to your policy

• Easiest Fix: join a DMPO

You Are Likely Already DiscountingWhen a patient that has insurance enters your office for care – they

are bringing another “person” to the relationship

Doctor-Insurance Company

Insurance Company - Patient

2/2013


Patient-Doctor

80% Insurance Company

20% Patient

IMPLEMENT ANY DESIRED DISCOUNTS

FOR CASH PAYING PATIENTS

ChiroHealthUSA

• Designed by a Chiropractor to benefit Chiropractors

AND Chiropractic!

• ChiroHealthUSA is a DMPO – Discount Medical Plan

Organization

• A DMPO can stand in the corner the Insurance

Company occupies in the Triangle…

• Look at how the story changes!

Doctor-ChiroHealthUSA

Patient-Doctor ChiroHealthUSA- Patient

2/2013


0% ChiroHealth USA

100% Patient

Patient-DoctorDoes my

financial

policy &

discounts

offered meet

ALL

layers of

regulations?

Initial Visit

Exam: $120X-Rays: $130CMT: $6597014: $35

Total: $350

Routine Visit

CMT $6597110: $5097014: $3597012: $35

Total: $185

Initial Visit

Capped Fee: $150Or 20% Discount

Routine Visit

Capped Fee: $65Or 20% Discount

Modalities: $10Procedures: $20

100% Poverty: 75% Discount125% Poverty: 50% Discount150% Poverty: 25% Discount

Re-Exams: $25Each Film: $15

EVALUATE AND IMPLEMENT DESIRED

HARDSHIP POLICY

Clear Understanding of Hardship and

Discounted Fees

• Your hardship agreement can co-exist with other fee schedules.

• You must set the standard up front, have qualifying factors, and verify eligibility.

• Utilize a standardized form and system

Mistakes and Blunders

• What may NOT be

financial hardship?

– No insurance

– High deductible

– I don’t wanna pay that

much

– My other doctor didn’t

charge my copays

– Pulse and a spine

2/2013


Co-Pay or Deductible Waivers for

Hardship

• The waiver is not offered as part of any advertisement or solicitation;

• Waivers are not routinely offered to patients;

• The waiver occurs after determining in good faith that the individual is in financial need;

• The waiver occurs after reasonable collection efforts have failed.

BCBS Policy on Hardship

Bettye Blue Cross CHARGE Recap• Bettye must be charged actual fees

• If you participate with her carrier, you can find out if she can always qualify for contracted fees

• If Bettye is Under-Insured, she can qualify for CHUSA

• If Bettye has a high deductible or co-payment, she can “elect to self pay”.

• Bettye may qualify for hardship if her carrier will allow it.

Morris Medicare CHARGE Recap• Morris must be charged actual fees for

excluded services

• Morris COULD enjoy a 5-15%

• Morris can join CHUSA for all non-CMT

• CMT Medicare PAR: Actual Fee, then write off to Regulated Fee

• CMT Medicare Non-Par: Limiting Fee

• Morris may qualify for hardship if you follow the rules carefully, including trying some payment plan first.

Morris Medicare CHARGE Recap

• It’s still very confusing about what to charge Morris when he’s on Maintenance care.

• There are three differing opinions that have been put into writing:

– We don’t’ care what you charge!

– You can’t charge more than the limiting fee!

– You have to charge the actual fee!

2/2013


Morris Medicare CHARGE RecapCMS CMMInquiry

to: John Davila, DC

[email protected]

Dear Dr. Davila: Thank you for your most recent e-mail regarding CMS’ reference manual.

IOM 100-02, the Medical Benefit Policy Manual, Chapter 15, Section 40 states the following:

“An ABN notifies the beneficiary that Medicare is likely to deny the claim and that if Medicare does deny the claim, the beneficiary will be liable for the full cost of the

services. Where a valid ABN is given, subsequent denial of the claim relieves the non-opt-out physician/practitioner, or other supplier, of the limitations on charges that would apply if the services were covered.”

I hope this information is helpful. If you need further assistance on this inquiry, please contact us directly at [email protected] and include the following reference number (042320124070).

Chester Cash CHARGE Recap

• Chester must be charged actual fees

• Chester can enjoy a 5-15% discount per

the Feds, or if your state has TOS

published discount

• Chester should join CHUSA

• Chester may qualify for hardship

discounts.

BILL CORRECTLY

Step Two

To Bill….Means to Tell

• Billing is literal for

insurance or patient

statements

• Billing is announcing

what the fee for today

is at the front desk

• Billing is helping a NP

know what the fees are,

even on the phone

Bettye Blue Cross BILLING Recap

• Providers may bill regular fees OR

contracted fees

• Make sure you know if you are able to bill

for non-covered services

• Electronic billing vs. paper billing

• If Bettye has elected to self pay, give

receipt for ACTUAL fee collected

2/2013


Chester Cash

• Chester must be “billed” the correct fee schedule

• Whether TOS, CHUSA, Hardship or Full fee, Chester needs to understand his fee schedule (in case he comes in later for a PI)

• Chester may refer others in and needs to be clear about the full range of his fee schedule

Morris Medicare

• All CMT must be billed to Medicare for

Morris, even if it’s maintenance, unless

Option 2 is checked on the ABN form

• Morris must be required to pay for the

excluded services

• Morris should be advised of costs for

excluded services prior to their being

rendered

AT Modifier GY Modifier

GY Care Does Not Have to Be Billed to

Medicare

• A patient may decide

whether or not

statutorily non-covered

services are submitted.

• If the patient asks you

to bill Medicare, you

must.

• Why would we want to

do that?

GP Modifier

2/2013


GP is Not Used Universally With All

Carriers for DCs

• GP is usually appended

to the GY when a

therapy plan of

treatment is in play.

• Plan must be on file. – 97124

– 97032

– 97140

– 97012

– 97035

– 97110

– G0283

GZ Modifier

Let’s Hope You Don’t Ever Use GZ

• Used when an ABN

form was necessary, but

one was not signed

prior to treatment.

• Since you must submit,

you have to submit with

the modifier so it won’t

be covered.

Other Medicare Billing Oddities

• 97014 is not billed for

Electrical Stimulation

• G0283 is used instead

• One of the only places

where

subluxation/segmental

dysfunction codes work

for you

Advance Beneficiary Notice

• Must be signed when you believe a covered service (CMT) may not be covered on this visit.

• Triggering Events

• Should be filled out in front of the patient indicating the reasons are for assuming the service is going to be denied.– Medicare never covers this many visits for this diagnosis

– Medicare never covers more than one visit in the same day

– Medicare never pays for maintenance care

– My carrier has a published screen and this patient has exceeded the screen

2/2013


What About AT-GA Modifiers?Morris Medicare CHARGE Recap

• Morris must be charged actual fees for excluded services

• Morris COULD enjoy a 5-15%

• Morris can join CHUSA for all non-CMT

• CMT Medicare PAR: Actual Fee, then write off to Regulated Fee

• CMT Medicare Non-Par: Limiting Fee

• Morris may qualify for hardship if you follow the rules carefully, including trying some payment plan first.

2/2013


Morris Medicare CHARGE Recap

• It’s still very confusing about what to charge Morris when he’s on Maintenance care.

• There are three differing opinions that have been put into writing:

– We don’t’ care what you charge!

– You can’t charge more than the limiting fee!

– You have to charge the actual fee!

Morris Medicare CHARGE RecapCMS CMMInquiry

to: John Davila, DC

Dear Dr. Davila: Thank you for your most recent e-mail regarding CMS’ reference manual.

IOM 100-02, the Medical Benefit Policy Manual, Chapter 15, Section 40 states the following:

“An ABN notifies the beneficiary that Medicare is likely to deny the claim and that if Medicare does deny the claim, the beneficiary will be liable for the full cost of the services. Where a valid ABN is given, subsequent denial of the claim relieves the non-

opt-out physician/practitioner, or other supplier, of the limitations on charges that would apply if the services were covered.”

I hope this information is helpful. If you need further assistance on this inquiry, please contact us directly at [email protected] and include the following reference number (042320124070).

The SAFEST Way (IMHO)

• When maintenance

care begins, keep the

fee the same

• PAR providers keep it at

the Medicare allowable

fee

• NON-PAR providers

keep it at the Limiting

Fee

Advance Beneficiary Notice of

Noncoverage (ABN)

• GA modifier is used if

ABN is signed and filed

• Events that can cause

an ABN to be placed in

the patient file….

– > 12 CMT in 1 month

– > 30 CMT in 1 year

– > amount of CMT for

give 2nd diagnosis

– CMT is maintenance care

Morris Medicare

• Remember! ABN form IS required for

Morris for all CMT that may not be

covered.

• You must make a copy and give one to

Morris.

• Once Morris signs this ABN for CMT, it’s

good for one year, or until another

covered episode begins!

2/2013


Master the Madness

• Know your foundational Medicare pieces. Have reference material at the ready.

• Don’t dread Medicare: Just master the facts and let it become one of your most reliable payers.

• Realize Medicare is straightforward: Follow the rules, understand the definitions

• Communicate to these patients and help make care LEGALLY affordable.

Questions: [email protected]

Business

Spring 2013: Kathy Mills Chang Notes