fall 2012: arkfeld notes

Indiana State Chiropractic Association

Fall Convention 2012

Ted A. Arkfeld, DC, MS, CPC

DisclaimerAdvanced Compliance Technologies, PLLC, and Genius Solutions, Inc., denies responsibility or liability for any erroneous opinions, analysis, and coding misunderstandings on behalf of individuals undergoing this independent study program. The coding topics taught here are for the sole purpose of the chiropractic profession, any transference to other healthcare disciplines are at the risk of the individual coder’s discretion.We have based the majority of this program on the guidelines set forth by the CPT Code Book, ICD-9, and HCPCS information found in the ChiroCode DeskBook, and in The Medicare Manual, as it relates to Chiropractic practice.No legal advice is given in this manual, and we encourage you to refer any such questions to your healthcare attorney.

2009 ReportAfter the 2006 OIG review, it was found that Medicare inappropriately paid $178 million for chiropractic claims in 2006.

This documents us as showing no real improvement in our documentation. This will lead to increasing audits and other methods to enforce that inappropriate payments are not paid out to us, including further possible caps and cuts in the near future.

Documentation Problems

“Chiropractors often do not comply with the Manual documentation requirements.”Pg 16 of the 2009 OIG report

**See “AT” modifiers and “wellness care” as examples.**

Documentation ProblemsSeparate from the undocumented claims already mentioned,83 % of chiropractic claims failed to meet one or more of the documentation requirements.

Consequently, the appropriate use of the AT modifier could not be definitively determined through medical review for 9 percent of sampled claims, representing $39 million.

2009 Report

“Efforts to stop payments for maintenance therapy have been largely ineffective.”Pg ii of the 2009 OIG report

Documentation Problems1. The medical reviewers indicated

that treatment plans are an important element in determining whether the chiropractic treatment was active/corrective in achieving specified goals (therefore allowable or not).

2. Another important element was a documented Initial Visit Date for each episode.

Documentation Problems

Of the 76 % of records that reviewers indicated contained some form of treatment plan:

43 % lacked treatment goals

17 % lacked objective measures

15 % lacked the recommended level of care

Use the OIG Report for Your Good

1.Use this report to begin improving the policies and procedures in your practice.

2.Use this report to check and enhance your documentation skills.

3.Use this report as an opportunity to become compliant and create your own healthcare stimulus and reform.

Medicare & You

Medicare Program

Medicare, which is the Nation’s largest purchaser of health care (and, within that, of managed care), processes over 1 billion fee-for-service claims per year.

The Medicare program is funded through the Hospital Insurance (HI) and Supplementary Medical Insurance (SMI) trust funds and is composed of four parts:

Medicare Program

Medicare Part A: Pays for hospital, skilled nursing facility (SNF), home health, and hospice care for the aged and disabled. It is financed through the HI trust fund, which is funded primarily by payroll taxes paid by workers and employers.

Medicare Program

Medicare Part B: Pays for physician and outpatient hospital services, laboratory tests, medical equipment, and other items and services not covered by Part A. It is financed through the SMI trust fund, which is funded primarily by transfers from the general fund of the U.S. Treasury and by monthly premiums paid by beneficiaries.

Medicare Program

Medicare Part C: Known as Medicare Advantage (MA), provides health care coverage choices for Medicare beneficiaries through private health care companies that contract with Medicare to provide benefits. Part C is funded by both the HI and SMI trust funds.

Medicare Program

Medicare Part D: the prescription drug benefit program created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)

High Risk

The size and scope of the Medicare program place it at high risk for payment errors

The Top 1010 Misconception

s about

Medicare

Misconception #1

Truth: There are no caps in Medicare for chiropractic at this time.

However, there may be periodic review screenings, or intervals at which the carrier may require a review of documentation to allow continued service.

There is a 12 Visit Cap on Chiropractic Services

I can treat Medicare patients without being registered.

Truth: It is illegal to treat Medicare patients and not be registered with Medicare.

You may choose to be a “participating” or “non-participating” provider, but you must register. If you treat a Medicare patient with a spinal CMT code, you MUST submit a claim.

Misconception #2

Truth: Any Medicare claim submitted can be audited/reviewed despite provider status.

The status of the physician does not affect the probability of this occurring.

Misconception #3

If you are a non-par provider, you will never be audited or have

claims reviewed

If you are a non-participating provider (non-par), you do not have to

worry about billing Medicare

Truth: Being non-par does not exempt you from having to bill Medicare.

ALL Medicare-covered services must be billed to Medicare or the provider could face penalties.

Misconception #4

Non-par providers do not have the same documentation requirements as

par providers

Truth: Chiropractic care has documentation requirements to show medical necessity.

The participation status of the provider is irrelevant.

Misconception #5

You can ‘opt out’ of Medicare.

Truth: Opting out is NOT an option for Doctors of Chiropractic.

If you treat Medicare patients, you must register as ‘participating’ or ‘non-participating’. If you don’t want to deal with Medicare, then don’t treat Medicare patients. It is illegal to treat Medicare patients and not submit a claim.

Misconception #6

Maintenance care is NOT a covered service under

Medicare.Truth: Spinal manipulation is a covered service under Medicare, no matter which phase of care you may be in; however, maintenance care is not REIMBURSABLE.

Acute, and Chronic conditions are all ‘covered’, under Medicare if medically necessary.

Misconception #7

Medicare requires unreasonable record keeping and documentation to receive

reimbursement

Truth: Medicare has specific documentation requirements, but nothing extraordinary.

Whether a Medicare patient or not, chiropractors should be exercising specific standards in their chart notes with thorough documentation for every encounter.

Misconception #8

Chiropractors can make special offers to Medicare patients.

Truth: Inducements of any kind are strictly forbidden for Medicare patients. Free exams, x-rays, even chicken dinners could lead doctors to accusations of fraud.

An exception to this rule is if you waive a portion of the patient’s fee due to documented financial hardship. “Smallness” is another exception; this is where you can write off the amount being collected if it is less than your cost to try to collect it. This would apply to very small dollar amounts such as $2.86.

Misconception #9

An Advance Beneficiary Notice (ABN) should be signed once for each patient and it will

apply to all services, and all visits

Truth: The decision to deliver an ABN must be based on a genuine reason to expect that Medicare will deny payment for the service due to lack of medical necessity.

Misconception #10

Medicare Benefit Policy Manual Chapter 15 – Covered Medical and Other Health Services

Table of Contents (Rev. 109, 08-07-09)

Medicare Documentation

CMS Manual System, Pub 100-02, Chapter 15, Section 240.1.2

What is Medical Necessity?

Medicare’s Definition

The patient must have a significant health problem, in the form of a neuromuscular skeletal condition, necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.

Medicare Requirements for Chiropractic Claims

Under Medicare Chiropractors are limited to three reimbursable codes.

98940 (CMT; spinal, one to two regions)

98941 (CMT; spinal, three to four regions)

98942 (CMT; spinal, five regions)

AT Modifier

The AT modifier should follow the CMT code on claims submitted to Medicare. This will identify that the patient is in acute treatment for either an acute for chronic subluxation.

Acute Treatment

Your documentation must reflect that the patient is in active/corrective treatment.

Medicare Article: Part IIEssentials of Documentation

Medicare does have specific requirements for documentation, but nothing extraordinary.

Whether a patient is covered by Medicare, or not, all chiropractic encounters should be represented by appropriate, specific, record-keeping that adheres to a basic standard.

D. Documentation Requirements: Initial Visit - the following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:

1.History as stated above.

2.Description of the present illness including:- Mechanism of trauma;- Quality and character of symptoms/problem;- Onset, duration, intensity, frequency, location, and radiation of symptoms;- Aggravating or relieving factors;- Prior interventions, treatments, medications, secondary complaints; and-Symptoms causing patient to seek treatment.

These symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo or osteo), rib (costo or costal) and joint (arthro) and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must relate to the spine as such. The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited. A statement on a claim that there is "pain" is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined.

Medicare Documentation Requirements

• Be legible

• Clearly identify patient, date of service, and service provider

• Accurately report all pertinent facts, findings, and observations

• Use standardized medical abbreviations or include a key of the abbreviation scheme

• Include appropriate diagnosis for the service provided

Documentation must meet the following criteria:

Initial Visit Must-Have’s

The initial visit should, at minimum include:

1.Patient History 2.Description of the Presenting Complaint3.Evaluation Findings 4.Diagnosis 5.Treatment Plan 6.Initial Visit Date

History

Statement of Health Past Health HistorySocial/Family HistoryDescription of the

Presenting Complaints Any Secondary

Complaints

Presenting Complaint Symptoms Mechanism of Trauma Quality and Character of the

Pain Onset, Duration, Intensity,

Frequency, Location, and Radiation of Symptoms

Aggravating/Relieving Factors Prior Interventions Treatments Medications

Documentation of Subluxation

Subluxation may be demonstrated by:

X-ray Physical Examination

Demonstrated by X-ray The x-ray analysis to

demonstrate subluxation must be taken at a time reasonably proximate to the initiation of a course of treatment.

An x-ray is considered reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of a course of chiropractic treatment.

Demonstrated by X-ray In certain cases of chronic

subluxation (e.g., scoliosis), an older x-ray may be accepted, provided the beneficiary’s health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent.

Demonstrated by CT or MRI

A previous CT scan and/or MRI is acceptable evidence if a subluxation of the spine is demonstrated.

Demonstrated by Physical Exam (P.A.R.T.)

Pain Asymmetry Range of Motion and Tissue tone changes

Subluxation demonstrated by Physical Examination Evaluation of the neuromusculoskeletal system to identify:

P.A.R.T.

EvaluationPhysical examination and

evaluation of the musculoskeletal/nervous system.

Document everything you do and detail your findings.

PAIN/TENDERNESS

Pain/tenderness is evaluated in terms of location, quality, and intensity.

PAIN/TENDERNESS

1. Observation2. Percussion3. Palpation4. Provocation

Pain and tenderness findings may be identified through on or more of the following:

PAIN/TENDERNESSPain intensity may be assessed using one or more of the following:

1. Visual Analog Scales

2. Algometers3. Pain

Questionnaires

Asymmetry Misalignment

Asymmetry/misalignment is identified on a sectional or segmental level.

Asymmetry MisalignmentAsymmetry/misalignment may be identified through one or more of the following:

Observation (posture and gait analysis)

Static Palpation Diagnostic Imaging

Range of Motion Abnormality

Range of motion abnormalities may be identified through one or more of the following:

1. Motion Palpation2. Observation3. Stress diagnostic

imaging4. Range of Motion

Measurements

Tissue/Tone Tissue and or tone texture may be identified through one or more of the following procedures:

1. Observation2. Palpation3. Use of Instruments4. Tests for length and

strength

Medicare DocumentationTo demonstrate a subluxation based on physical examination, two of the four criteria mentioned are required, one of which must be asymmetry/misalignment or range of motion abnormality.

Treatment PlanInclude the recommended level

of care with duration and frequency of visits

Specific treatment goals

Objective measures to evaluate treatment effectiveness

Always include the date of the initial treatment and sign it

Sample Treatment Plan05-05-06

• CMT and adjunctive modalities daily for 1 week and 3x/wk for the following 2 weeks. Re-eval at that time; L MRI may be indicated. Off work 2 wks. Home care: Cryo q 2 hrs x 15 mints; avoid strenuous activity; LS supports to be worn when standing.

• Short-term goals: Minimize pain (<3) and spasm; increase pain-free LS flexion (>45 degrees).

• Long-tern goals: Restore ability to tie shoes w/o pain, sit/stand for prolonged periods (>2 hrs.), and get in/out vehicles w/o difficulty; return normal sleep patterns.

Dr. C. My Signature

Subsequent VisitsSubsequent visits should be documented and should include no less than the following:

Subjective comment on patient’s progress and changes since last visit

Physical exam findings including changes since last visit

Documentation of the treatment given on the day of the visit (Don’t just refer back to the plan from the initial visit without also documenting today’s findings!)

Subjective

S: Review of chief complaint, note any changes since the last visits, system review if relevant (any surgeries, illness, trauma, or medications since last visit?)

ObjectiveO/A: Physical/regional exam Examine the area of the spine involved

in the diagnosis and note findings. Assess change in the patient’s condition since the last visit.

Evaluate the treatment for effectiveness. (Note, listings and type of technique are not currently required by CMS or CPT in reporting; however, for the thoroughness of the record we’d recommend these details.)

Plan

P: Document the treatment given on the day of the visit and any adjunctive therapy

Documentation of Subluxation

Subluxation may be demonstrated by:

X-rayPhysical Examination

Demonstrated by X-ray

The x-ray analysis to demonstrate subluxation must be taken at a time reasonably proximate to the initiation of a course of treatment.

An x-ray is considered reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of a course of chiropractic treatment.

Demonstrated by X-ray

In certain cases of chronic subluxation (e.g., scoliosis), an older x-ray may be accepted, provided the beneficiary’s health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent.

Demonstrated by CT or MRI

A previous CT scan and/or MRI is acceptable evidence if a subluxation of the spine is demonstrated.

Demonstrated by Physical Exam (P.A.R.T.)

Pain Asymmetry Range of Motion and Tissue tone changes

Subluxation demonstrated by Physical Examination Evaluation of the neuromusculoskeletal system to identify:

P.A.R.T.

Evaluation

Physical examination and evaluation of the musculoskeletal/nervous system.

Document everything you do and detail your findings.

PAIN/TENDERNESS

Pain & Tenderness are evaluated in terms of location, quality, and intensity.

PAIN/TENDERNESS

1. Observation2. Percussion3. Palpation4. Provocation

Pain and tenderness findings may be identified through one or more of the following:

PAIN/TENDERNESSPain intensity may be assessed using one or more of the following:

1. Visual Analog Scales

2. Algometers3. Pain

Questionnaires

Asymmetry Misalignment

Asymmetry/Misalignment is identified on a sectional or segmental level.

Asymmetry MisalignmentAsymmetry/misalignment may be identified through one or more of the following:

Observation (posture and gait analysis)

Static Palpation Diagnostic Imaging

Range of Motion Abnormality

Range of motion abnormalities may be identified through one or more of the following:

1. Motion Palpation2. Observation3. Stress diagnostic

imaging4. Range of Motion

Measurements

Tissue/Tone Tissue and or tone texture may be identified through one or more of the following procedures:

1. Observation2. Palpation3. Use of Instruments4. Tests for Length and

Strength

Medicare Documentation

To demonstrate a subluxation based on physical examination, two of the four criteria mentioned are required, one of which must be asymmetry/ misalignment or range of motion abnormality.

Treatment PlanInclude the recommended level

of care with duration and frequency of visits

Specific treatment goals

Objective measures to evaluate treatment effectiveness

Always include the date of the initial treatment and sign it

Subsequent VisitsSubsequent visits should be documented and should include no less than the following:

Subjective comment on patient’s progress and changes since last visitPhysical exam findings including changes since last visitDocumentation of the treatment given on the day of the visit

(Don’t just refer back to the plan from the initial visit without also documenting today’s findings!)

S.O.A.P. Notes

Subjective

S: Review of chief complaint, note any changes since the last visit, system review if relevant (any surgeries, illness, trauma, or medications since last visit?)

ObjectiveO: Examine the area of the spine

involved in the diagnosis and note findings. Assess change in the patient’s condition since the last visit.

Note, listings and type of technique are not currently required by CMS or CPT in reporting; however, for the thoroughness of the record we’d recommend these details.

Assessment

A:Evaluate the treatment for effectiveness.

Plan

P: Document the treatment given on the day of the visit, and any adjunctive therapy

10/28/2009 Basic Exam

PATIENT DEMOGRAPHIC INFORMATION: Name: Mr. Low Back Pain Gender: MDate of Birth: 5/29/1970Race: Caucasian Mr. Low Back Pain complains of low back pain.

CAUSATION DETAILS: Mr. Low Back Pain related to me that his chief complaint was brought about by raking leaves. His date of onset was 10/28/2009. Mr. Low Back Pain indicated that he has had this complaint multiple times previous to this episode. The primary complaint is getting worse since the onset. This onset of the primary complaint started as follows:The patient stated he was raking leaves yesterday for a prolonged period of time and began to have low back complaints shortly after. He stated he was turned to the side raking from left to right and bent over somewhat for about two hours when he began to have pain in the right L4-S1 areas. This morning when waking up he had pain on both sides of his lower back area.

SUBJECTIVE: Mr. Low Back Pain indicated on his visit today that he has been feeling constant moderate pain in the lower back area. This is restricted movement as well as stiffness and sore pain generalized in the left lumbar, left sacroiliac area, right lumbar and right sacroiliac area. Mr. Low Back Pain's low back pain feels worse due to arising from a chair, bending and repetitious movements. He states that nothing reduces the severity. The patient was asked to rate his pain and severity on a scale of 1 to 10. He estimated his low back pain at 4

REVIEW OF SYSTEMS: GU: Denies polyuria, nocturia, incontinence, or hematuriaGI: Denies nausea, vomiting, diarrhea, constipation, incontinence.

PAST MEDICAL HISTORY: Low Back Pain has not taken any prescription medications to treat these symptoms. The patient has no history of surgical procedures used to treat this problem.

FAMILY HISTORY: He has no family history of problems.

SOCIAL HISTORY A social history was obtained from Mr. Low Back Pain. Mr. Low Back Pain's social history was reviewed and was found to be consistent with previous findings.Mr. Low Back Pain is married. He has two children. He has a bachelor's degree. He usually exercises. Low Back Pain stated that he occasionally drinks alcohol. He never uses tobacco products.

OSWESTRY ASSESSMENT: The Oswestry Daily Living Assessment was used to indicate Mr. Low Back Pain's perceived pain and disability. It is a valid indicator since he rated his condition as it affects his daily living activities, thus avoiding interviewer interference. The patient related his capability in the activities of daily living as follows: Pain Intensity: "The pain comes and goes and is moderate." Personal Care: "Washing and dressing increases the pain and I find it necessary to change my way of doing it."

Lifting: "Pain prevents me from lifting heavy weights off the floor." Walking: "Pain prevents me from walking more than 1/2 mile." Sitting: "Pain prevents me sitting more than 1/2 hour." Standing: "I cannot stand for longer than 1/2 hour without increasing pain." Sleeping: "Because of pain, my normal night's sleep is reduced by less than one-quarter." Traveling: "I get some pain while traveling, but none of my usual forms of travel make it any worse."

Degree of Pain: "My pain is gradually worsening." On 10/28/2009, the patient's revised oswestry pain score was 52. The patient's score fell into the 40 - 60% range indicating a severe disability.

GENERAL APPEARANCE: This patient is a well-appearing 68 year old male in mild distress. The patient was awake, alert and oriented and in moderate pain. He demonstrated appropriate illness behavior. Mr. Low Back Pain showed spasticity. The patient appeared comfortable. The patient showed normal grooming and appropriate dress.

VITAL SIGNS: Pulse Rate 82Sitting Pressure/Systolic L: 120Sitting Pressure/Diastolic L: 80Temperature 98.6Height 5'6"Weight 150

ORTHO/NEURO:

Minor's Sign was present bilaterally. The patient was seated and was asked to stand. The examiner noted that the patient supported their weight on the uninvolved side by balancing on the uninvolved leg, placing the hand on the back and flexing knee and hip on the involved side. This was done on the other side following a repeat of the test.

Tripod Sign was present bilaterally. The patient was seated with their legs dangling off the table at the knees. They were instructed to extend their knees. This caused the patient to lean backward in order to perform this test.

Kemp's Standing Test elicited localized pain in the right L4-S1 facet joints. With the patient standing, the examiner stood behind and anchored the pelvis and sacrum with one hand while grasping the opposite shoulder with the other hand. The shoulder was then forced obliquely back, down, and medial. The patient experienced localized low back pain on the right side.

Bechterew Sitting Test was negative bilaterally. With the patient seated and legs dangling over the edge of the table, the examiner instructed the patient to extend one knee straight out then repeat with the other knee. Then, the patient repeated the maneuver with both knees. The patient was able to do this without any pain and without leaning backwards.

Valsalva's Test was negative. The examiner instructed the patient to bear down as if having a bowel movement. This increased the intrathecal pressure. Bearing down did not cause any significant pain.

Straight Leg Raise Test was negative bilaterally. With the patient lying supine on the examining table, the examiner lifted the leg upward by supporting the patient's foot around the calcaneus. In order to make sure the knee remained straight, the examiner placed the free hand on the anterior aspect of the knee. The patient did not experience significant pain. When the test was performed on the other leg, the same results were obtained.

Lasegue Test was negative bilaterally. With the patient supine and knee fully extended, the examiner placed one hand under the patient's heel and the other hand over the knee to prevent flexion. The examiner then slowly flexed the patient's thigh at the pelvis to 90 degrees. The patient did not experience any significant pain.

Patrick's Test was negative bilaterally. With the patient supine, the examiner placed the foot of the patient's involved side on the opposite knee. This made the hip joint flexed, abducted, and externally rotated. In this position, the patient did not experience any significant pain. The same result was obtained on the other side.

Ely Heel to Buttock Test was positive bilaterally. This two stage test was performed with the patient lying prone. The examiner flexed the patient's knee approximating the heel to the opposite buttock. From this position, the examiner hyperextended the patient's thigh. The test was positive if the patient was unable to do the test, unable to extend the thigh, if femoral radicular pain was produced, and/or if upper lumbar discomfort was present. The positive was obtained on the other side.

Nachlas Test was positive bilaterally. The examiner stood on the side of the patient ipsilateral to the pain while the patient lay prone. With one hand, the examiner raised the foot of the involved side and maximally flexed the knee. With the other hand, the examiner pushed downward on the patient's pelvis. The patient experienced pain in the joint. The same result was obtained on the other side.

Yeoman's Test was positive bilaterally. The patient was prone on the examination table. With one hand the examiner stabilized the sacroiliac joint being tested. The examiner flexed the knee of the leg tested to 90 degrees. The examiner then hyperextended the thigh of the leg tested by lifting it off of the examining table. Pressure was maintained over the sacroiliac joint being tested. This test was also done on the other side. This test was positive as demonstrated by sacroiliac pain over both of the sacroiliac joints.

RANGE OF MOTION: Spinal ROM:Lumbar:Pelvic Sacral Angle DecreasedFlexion DecreasedExtension DecreasedRight lateral flexion DecreasedLeft Lateral Flexion Decreased

OBJECTIVE: On examination of the spinal joints, a severe amount of restricted joint function at T10 - T12, L1 - L5 and the left ilium - sacrum was detected. On palpation of the spinal segments there was a moderate pain level at T10 - T12, L1 - L5 and the ilium - sacrum bilaterally. There is severe spasticity of the lower trapezius, latissimus and sacrospinalis and gluteus maximus bilaterally found on palpation.

DIAGNOSIS: 739.3 Segmental Dysfunction, Lumbosacral Region 724.8 Lumbar Facet Syndrome 739.5 Nonallopathic Lesions of Pelvic Region, not elsewhere classified 728.85 Spasm of Muscle 739.4 Nonallopathic Lesions of Sacral Region, not elsewhere classified 724.2 Lumbar Spine Pain

ASSESSMENT: The patient will remain on acute care status. The patient has experienced an exacerbation which is defined as an increase in the severity of a disease or any of its signs or symptoms. This is typically due to a significant irritation or flare-up of the patient's complaint without a specific incident. May be secondary to performing the activities of daily living (ADL).

DISCUSSION:The patient stated he was raking from left to right which would place a repetitive rotary movement on the lumbar spine, with compressive forces loading on the right lumbar facet joints and tensile forces on the left paraspinal muscles. The patients past x-rays clearly indicate degenerative joint disease in the facet joints, however he was asymptomatic prior to raking of the leaves. This new activity resulted in a mechanism of trauma to the right L4-S1 facet joints and straining of the left paraspinal muscles. This is validated by the history of the event and the examination findings of decreased range of motion, pain being elicited on Kemp’s Testing, and palpatory spinal tenderness and muscle spasms in the lumbar spine.The mechanism of trauma satisfies the definition of exacerbation of a neuromusculoskeletal condition. The definition per Medicare guidelines state:

Necessity for Treatment:1. The patient must have a significant health problem in the form of a neuromusculoskeletalcondition necessitating treatment, and the manipulative services rendered must have adirect therapeutic relationship to the patient's condition and provide reasonableexpectation of recovery or improvement of function. The patient must have a subluxationof the spine as demonstrated by x-ray or physical exam, as described above.

Necessity for Treatment: (continued)

- Acute subluxation: A patient's condition is considered acute when the patient isbeing treated for a new injury, identified by x-ray or physical exam as specifiedabove. The result of chiropractic manipulation is expected to be an improvementin, or arrest of progression, of the patient's condition.PLAN: The patient is rescheduled for tomorrow. 1) Office/Op Visit, New Pt, 3 Key Components: Expand Prob Focus Hx; Expand Prob Focus Exam; Strtfwd Dec: 1) Lumbar Spine2) Adjustment 3-4 Areas: 1) Lumbar Spine 2) Left Sacroiliac 3) Right Sacroiliac 4) Sacrum3) Mechanical Traction: 1) Lumbar Spine

Signed Iama Doctor, DC

Medicare

When a Medicare patient returns with new symptoms or a flare up of previous symptoms, you must document if it was due to one of the following:

1. Exacerbation2. Aggravation3. Insidious

Exacerbation

Exacerbation: An increase in the severity of a disease or any of its signs or symptoms. This is typically due to a significant irritation or flare-up of the patient’s complaint without a specific incident. May be secondary to performing the activities of daily living (ADL).

Aggravation

Aggravation: Significant irritation or flare-up of the patient’s condition due to a specific incident.

Insidious

Insidious: Denoting a disease/lesion that progresses gradually with unapparent symptoms. Implies no actual traumatic event. The pain is typically described as developing without cause or reason. Repetitive micro trauma disorders (i.e. carpal tunnel syndrome) are often described this

Care Plans

What is a Treatment PlanWhat is a Treatment Plan

Review 42 CFR s 410.61

Review Medicare Carriers Manual 2251.2

Why is a Treatment Plan so Why is a Treatment Plan so important?important?

• Medicare requires “extended care” providers to have a treatment plan

• CPT, E/M Service require a treatment plan

• Boards of Examiners require treatment plans

• Insurance Carriers require a treatment plan

• Treatment plans make daily notes much more effective and easier

MechanicsMechanics – How do I Actually Create How do I Actually Create a Treatment Plana Treatment Plan?

• Does it have to be on paper?

• How do I combine this treatment plan in my medical documentation software?

• What payers are really looking for …

– Do you even have a treatment plan in the first place?

.

Major Elements of a Treatment Plan

Diagnoses (write them out)

Specific Procedures

Target – Site / Organ System

Frequency / Times per Week & Duration / # of weeks

Amount/Reps

Goal / Rationale (consider both long and short-term goals)

Signed by the provider

Passive / Active Stages (interpretation)

Let’s review the sample

Date of Plan: 10/6/2009Patient Name: Tony RomoPatient ID#: 002628Doctor Name: Ted Arkfeld, DC

Based on a detailed New Patient Examination Level 2 (99202), performed on 10/6/2009, the following Care Plan was created for Patient Tony Romo:

Diagnoses: 739.1 Cervical subluxation723.1 Cervicalgia

Contributing Conditions: Emotional stress

Aggravating Conditions: Work

Diagnostic Tests: No diagnostic tests were performed.

Based on the findings, there will be 2 stages of care; Passive / acute and Active or Rehabilitative. The long-term goals are restoring tolerance to normal activities of daily living and enhance flexibility. Based on the patient's condition, re-evaluations are planned, for each stage of care, to assess the benefits of care and ensure functional improvement.

During the Passive / acute stage, the following services will be provided:98940 - CMT 1-2 Regions consisting of diversified technique will be performed to the Neck, specifically to the Cervical Vertebrae, to decrease pain and facilitate healing of inflamed and injured neurological and musculoskeletal tissues. This will be provided 3 times per week for 4 weeks.97012 - Mechanical Traction consisting of static traction pull will be performed to the Neck, specifically to the Cervical Vertebrae, to facet distraction. This will be provided 1 time per week for 1 week.99213 - Level 3 Re-evaluations will be performed once every 4 weeks.

During the Active or Rehabilitative stage, the following services will be provided:98940 - CMT 1-2 Regions consisting of diversified technique will be performed to the Neck, specifically to the Cervical Vertebrae, to correct body mechanics. This will be provided 1 time per week for 1 week.97110 - Therapeutic Exercise (Ea. 15 Min) consisting of Thera-Band exercises will be performed to the Neck, specifically to the Cervical, to correct body mechanics, increase mobility/range of motion, increase strength, and re-establish neuromuscular control. 1 unit will be provided 3 times per week for 4 weeks.99213 - Level 3 Re-evaluations will be performed once every 4 weeks.

The patient will be re-evaluated at the end of care, with Level 2 (99212), at which time a Wellness Care Plan will be discussed.

Treatment Goals

A treatment plan should have two goals:

1. Reducing or eliminating the patient’s pain.

2. Increasing or restoring their functional activities.

They Do Not Care

Insurance companies do not care about individual chiropractor’s treatment philosophy.

They care about profit.

Symptom Based We can still have

maintenance visits, they just cannot be billed to insurance companies.

Chiropractors must treat on a symptom basis in order to submit insurance claims that are medically necessary.

Compliance Tip of the Day

Base everything on the presenting complaints of the patient and you will always be compliant.

Is it really that easy?

Correct Coding

Proper Coding

1. Proper coding identifies the reason for the patient’s visit.

2. Proper coding is required for your office to get paid.

Very Simply:Very Simply:

The Diagnosis Code indicates the patient’s condition.

The Procedure Code indicates what was performed.

Both must be linked together in order to establish medical necessity.

Coding

Translate Clinical Findings With the

With the new ICD-10-CM language, doctors of chiropractic will now be able to translate their true clinical findings into a code set that allows for specificity.

Diagnosing Problems

Unfortunately, the lack of specificity (and accuracy) possible with the ICD-9-CM codes resulted in our profession becoming somewhat lazy in our ability to diagnose.

The Problem

• Cheat Sheets (lists of old time favorites that they have been reimbursed for in the past)• A false belief that diagnosis codes “do not change that much” or “but I only use a small number of codes”• Some strange belief, as a profession, that we are DOCTORS of chiropractic, but are somehow exempt from being proficient in examination, diagnosis determination, and proper coding

ICD-10-CM Adoption

The adoption of ICD-10-CM will require the chiropractic profession to enhance theirdocumentation of clinical care in order to be reimbursed more accurately.

ICD-10-CM will change the landscape of chiropractic coding for years to come.

Offices that become proactive now in educating their staff will see only minor bumps in the road with their insurance reimbursements come October 2013.

Implementation Challenges of ICD-10-CM

How difficult would it be for your office if a mandate came down from the government requiring that only French could be spoken in your office by October 2013?

Clinical Impressions

Coding/Compliance Pearl: The diagnosis must support the patient's subjective symptomatology, mechanism of injury (if applicable), objective findings and radiographic evaluations (if necessary).

The diagnosis should be as accurate as possibleand express the etiology of the patient's condition.

1500 Claim Form

1500 Health Insurance Claim Form

• Industry Standard

• Required by Medicare & Third-party Payers

Date of Onset

Another important element was a documented Initial Visit Date for each episode.

Box 14

Insert the date of first treatment or date of exacerbation.

Note: The date of first treatment is NOT the first time they entered your office, but is the first visit for this occurrence of the current condition.


The 1500 claim form allows you to post four (4) diagnoses in box 21.

The primary diagnosis in the #1 slot should directly correlate with the chief complaint.


Even though there are only four slots, do not limit your diagnoses to just these slots.

For every area of treatment, there must be a corresponding diagnosis code.

1500 Claim Form

The 1500 claim form allows for up to four (4) diagnoses in box 21.

The primary diagnosis goes into the number 1 slot and should directly correlate with the chief complaint.

The remaining slots should have conditions associated with the chief complaint, or a secondary complaint listed.

Even though there are only four slots, do not limit your diagnoses to just these slots.

1500 Claim Form

For every area you are treating, there must be a corresponding diagnosis.

This always begs the question, “if there are only four slots and I have ten diagnoses, where do I put the other six?”

For Medicare, Auto, and Worker’s Compensation cases, you use box 19 of the claim form.

For most Blue Cross Blue Shield and other commercial carriers, they only want four diagnoses, so make sure those correlate to the chief complaint and any secondary complaints.

However, all diagnoses must be in your documentation.

Documentation Examples for Procedure & DX Codes

Patient presents to the office with a chief complaint of neck pain.

The objective findings reveal decreased cervical spine range of motion, palpatory muscle spasms, and articular dysfunction at C5 and C6.

1. 739.1 Segmental Dysfunction Cervical2. 728.85 Muscle Spasms 3. 723.1 Cervical Spine Pain


Patient presents to the office with a chief complaint of neck pain with a secondary complaint of right arm pain.

The objective findings reveal decreased cervical spine range of motion most noticeable with right rotation and extension causing increased pain with duplication of the radiating pain into the right arm. There is a positive cervical compression, right and left shoulder abduction for increasing the radiating pain. Cervical distraction was positive for decreasing the right arm pain. Muscle strength testing was 4/5 in the right middle deltoid, and biceps, all testing on the left was normal. Sensory findings were significant for hypesthesia in the right C5-C6 dermatomes, left negative. Deep tendon reflexes were 1+ in the biceps and brachioradialis tendons on the right. Palpatory tenderness and muscle hypertonicity were found in the cervical and upper thoracic musculature, along with subluxations at C5-C6.

1. 739.1 Segmental Dysfunction Cervical2. 723.4 Brachial neuritis

3. 729.1 Myofascitis4. 723.1 Cervical Spine Pain


Patient presents to the office with an acute flare up of a chronic condition to her neck and upper back. The patient has recently been gardening with her head bent down for prolonged periods of time. She is now experiencing a deep dull ache in the cervical spine made worse with extension and moving her head right and left to check for traffic.

The objective findings reveal bilateral rounding of the shoulders forward with an anterior head translation. Decreased cervical spine range of motion especially on extension where she points to the C5-C7 facet joints bilaterally as painful. All orthopedic tests were negative for a radiating component, but did elicit localized pain in the C5-C7 facet joints bilaterally. Cervical Distraction was positive for relieving the pain. All motor and sensory findings were normal. Moderate palpatory tenderness was found in the cervical paraspinals and C5-C7 facet joints, where subluxations were also present.

Radiology Report was reviewed and revealed cervical degenerative disc disease with facet hypertrophy at the C5-C7 spinal areas.

1. 739.1 Segmental Dysfunction Cervical2. 722.4 Degeneration of Cervical Disc

3. 724.8 Facet Syndrome4. 723.1 Cervical Spine Pain


Patient presents with a chief complaint of low back pain secondary to riding in a car for a 6 hour drive. The pain is described as a deep dull ache that becomes sharp when leaning back and to the left. Patient also states he is having mid-back and neck complaints as well.

The objective findings reveal a positive minor’s sign and difficulty in transitioning from a sitting to a standing posture. Lumbar range of motion actively and passively perform is restricted on all planes of testing with pain being centralized in the L4-S1 areas bilaterally. Kemp’s Test is positive for localized pain in the L4-S1 facet joints bilaterally. Straight leg raise, Valsalva’s, Bechterew’s and Patrick’s tests all are negative. Motor testing reveals 4/5 in the quadriceps, and hamstrings on the left. Sensory findings indicate hypesthesia in the left L4-S1 dermatomes. Palpatory findings indicate tenderness and moderate muscle spasms in the lumbar spine and paraspinals bilaterally. Subluxations were found in the L4, L5, Right and Left S/I joints and the Sacrum. Cervical and Thoracic subluxations were present.

An MRI taken 6 weeks prior reveals L4-L5 left posterior disc herniation and L5-S1 central disc protrusion.1. 739.3 Segmental Dysfunction Lumbar2. 724.4 Lumbosacral radiculitis3. 722.10 Lumbar IVD w/out4. 724.2 Lumbar Spine Pain 5. 739.5 Segmental Dysfunction Pelvis

6. 728.85 Muscle Spasms7. 739.4 Segmental Dysfunction Sacrum8. 739.1 Segmental Dysfunction9. 739.2 Segmental Dysfunction Thoracic10. 724.1 Thoracic Spine Pain

Audits

What are they looking for?

1.Health Care Fraud

2.Health Care Abuse

Medicare Fraud / Civil Money Penalty 42 U.S.C. § 1320a-7a(a)(1)(E)

“Any person… that knowingly presents or causes to be presented…a claim… for items or services that a person knows or “should have known” are not medically necessary has submitted a “False Claim”.

Medicare Fraud

Examples of Fraud

Billing for services that were not rendered

Billing for services using another provider’s NPI number

Violating anti-kickback statutes and Stark Laws

Upcoding to higher levels when the provider knew the criteria had not been “met or exceeded”

Health Care Abuse

Health Care AbuseHealth Care Abuse

Abuse may, directly or indirectly, result in unnecessary costs to the Medicare program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary.

Examples of Abuse

Charging in excess for services or supplies

Providing medically unnecessary services

Medicare Reviews

Medicare can review your files at any time

for any reason.

Who can Initiate a Review?

1. OIG (Office of the Inspector General)

2. CMS (Centers for Medicare & Medicaid Services)

3. Local Carrier WPS (Wisconsin Physicians Service), or MAC (Medicare Administrative Contractors)

Types of Reviews

Automated Reviews: performed by computers at the carrier level

Routine Reviews: by Non-Medical Staff

Complex ReviewsOnce you have received a

request for records, you are officially under review.

The OIG

Is concerned with fraud

Has their own inspectors and auditors

Does not need a warrant to come into your office and review your files

Can impose civil monetary penalties

CMS

Is concerned with Abuse

They use Contractors and Subcontractors

– Comprehensive Error Rate Testing (CERT)

– Recover Audit Contractors (RAC)

What Triggers an Audit?

Disgruntled Employee

Profile is the same for all patients Everyone receives a 98941 or

98942 CMT

Cookie Cutter Chiropractic

Upcoding

Canned Notes

Failure to do Re-Exams

What Triggers an Audit?

Ghost Billing

Improper ICD-9 Coding

Improper Exam Sequence

Irrelevant Exam Findings

Down Coding

Waiving Deductibles and Co-pays

What should I do if I’m Audited?

Don’t bury your head in the sand thinking it will all just go away

Carefully review what they are asking for and the time frame for submission

Retain a DC who is a CPC to audit your files Respond in a timely fashion Do not send originals Always send information by Certified Mail No excuses (i.e. the clinic did not burn down,

the dog did not eat the files) Once sent, return your focus to treating your

patients

What if I get a Negative Outcome?

Do Not Just Pay!

Get Help!→ A DC who is a CPC→ A Healthcare Attorney

Start the Appeals Process Immediately!

Medicare Appeals Process

1.First Level— Redetermination at the Carrier Level You have 120 days from the date of the notification

letter to start the appeals process.

2.Second Level— Reconsideration by a Qualified Independent Contractor (QIC)

First Coast Services Options Jacksonville, Florida You have 180 days from the redetermination findings to

move to this level.

3.Third Level— Administrative Law Judge (ALJ) You have 120 days from the reconsideration findings.

4.Fourth Level— Departmental Appeals Board (DAB) You have 60 days from the ALJ findings.

5.Fifth Level— Judicial Review the amount must be at least $1,800.00

You have 60 days from the DAB findings.

Prevention

Education→ Compliance Program

Electronic Medical Records→ Encounter Specific Verbiage→ Clinical Assessment

Outcomes→ Efficiency → Peace of Mind

Billing & Coding Traps Audit Triggers

Six High Risk Areas that Lead to Problems1. NPI number problems2. Inaccurate Evaluation & Management

coding3. Not coding to the highest level of

specificity4. Improper coding and documentation of

time based codes5. Inaccurate billing and coding to Medicare6. Payment (care package/family package)

Plans

Evaluation & Management Coding

E/M Coding

How to correctly bill and code for each E/M level for New and Established Patient Visits

Learn how to increase your revenue with appropriate coding

E/M Coding

You will learn how to avoid common mistakes and billing errors that lead to denials, and possibly post-payment audits.

Under-coding for E/M Services is costing your clinic MONEY. Get paid for the services your doctor renders.

E/M Codes

Account for about 90% of family practitioners’ revenue

Account for about 10% to 15% of chiropractic revenue

Proper evaluation & management (E/M) codingwill get you paid, and will get you paid more!

Evaluation & Management Coding

• The most important aspect of all new and established patient encounters is E/M code selection.

• Proper E/M coding drives medical necessity.

Proper E/M Coding Gets you Paid, Correctly!

E/M Services Must be Performed

They are crucial for the determination of:

1. Mechanism of Injury

2. Objective Findings

3. Diagnostic Impressions

4. Treatment Plans

Terminology

New Patient New Patient

A new patient is one who has not received any professional services from a physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.

Terminology

Established PatientEstablished Patient

An established patient is one who has received professional services from the physician, or another physician of the same specialty who belongs to the same group practice, within the past three years.

Who is Not a New Patient?

VERY IMPORTANTVERY IMPORTANT

Any patient who has been under your care, or another physician in your group, within the past three years, no matter if they have a new injury or new insurance, IS NOT A NEW PATIENT.

NOT a New Patient,

• Someone who has seen another physician in a group practice of a different specialty, but all physicians use the same tax identification number

• A patient who was previously under care, but who is currently, now, involved in either an auto or worker’s compensation case also

Would Therefore Also IncludeWould Therefore Also Include

E/M CPT CodesE/M CPT Codes

Level History Exam Decision

Time

99201 Prob Focus Prob Focus Straight For 10 Minutes

99202 Expanded Expanded Straight For 20 Minutes

99203 Detailed Detailed Low 30 Minutes

99204 Comprehen Comprehen Moderate 45 Minutes

99205 Comprehen Comprehen High 60 Minutes

E/M Established Patient E/M Established Patient CodesCodes


Time

99211 Physician Presence Not

Required

Physician Presence Not

Required


Required

5 Minutes

99212 Prob Focus Prob Focus Straight Forward

10 Minutes

99213 Expanded Expanded Low 15 Minutes

99214 Detailed Detailed Moderate 25 Minutes

99215 Comprehensive Comprehensive High 40 Minutes

Components of a Proper E/M Service

There are seven (7) components There are seven (7) components to each of the E/M codes.to each of the E/M codes.

These components translate into the work necessary to properly document a code, or to help you determine the actual code you should be selecting.

E/M Components

History KeyExamination KeyMedical Decision Making Key

Counseling ContributoryCoordination of Care ContributoryNature of Presenting Problem ContributoryTime Contributory

Key Components

1. History

2. Examination

3. Medical Decision Making

The three key components in choosing

an appropriate level of E/M service are:

Key Components

For new patient E/M codes, all three key components must be met or exceeded.

(3 out of 3 rule)

For established patient E/M codes, two out of three must be met or exceeded.

(2 out of 3 rule)

E/M CPT Codes


Time


10 Minutes

99202 Expanded Expanded Straight Forward

20 Minutes

99203 Detailed Detailed Low 30 Minutes

99204 Comprehensive Comprehensive Moderate 45 Minutes


E/M Established Patient Codes


Time

99211 Physician Presence Not

Required


Required


Required

5 Minutes


10 Minutes

99213 Expanded Expanded Low 15 Minutes

99214 Detailed Detailed Moderate 25 Minutes


HistoryLet’s Start at the Beginning

Patient History

Chief Complaint

History of Present Illness (HPI)

Review of Systems (ROS)

Past, Family, and Social histories

The AMA lists the following as components of a history:

The Intake Process

This process has now become VERYVERY important because:

It determines the chief complaint of the patientIt determines the correct evaluation & management code selectionIt provides a key component of medical necessity

History

Not all histories are the same, which is especially true in auto and worker’s compensation cases.

Terminology

Patient HistoryPatient History

The AMA CPT Code Book states the chief complaint, history of present illness (HPI), review of systems (ROS), and the past medical, family and social histories are all components of the patient’s history.

Terminology

Chief ComplaintChief Complaint

A chief complaint is a concise statement describing the symptoms, problem, condition, diagnosis, or other factor that is the reason for the encounter. It is usually stated in the patient’s own words.

Chief Complaint

The chief complaint should be the first notation in all medical records and is required for all levels of history.

It needs to be documented by the service provider.

History of Present Illness (HPI)

1. Location2. Quality3. Severity4. Duration5. Timing6. Context7. Mod. Factors8. Signs/Symptoms


The Review of Systems is often either not obtained or the relevance of information that was documented is not problem pertinent.

For many offices the intake forms that have ROS information is lacking questions relating to the fourteen (14) systems recognized by the AMA CPT Code Book, or too many questions that do not provide any useful information to the provider.

Many times, this portion of the history is considered too tedious and time consuming for the physician and is omitted even though higher level E/M codes require a ROS.


The 14 systems as per the AMA CPT The 14 systems as per the AMA CPT Code Book:Code Book:

1 Constitutional 8. Musculoskeletal2. Eyes 9. Integumentary3. Ears, Nose, Mouth, Throat 10.

Neurological4. Cardiovascular 11. Psychiatric5. Respiratory 12. Endocrine6. Gastrointestinal 13.

Hematologic/Lymphatic7. Genitourinary 14.

Allergic/Immunologic


A complete Review of Systems (ROS) is not necessary for each new or established patient encounter and should always be problem pertinent for the chief complaint.


Example 1 Example 1

For patients presenting with neck pain, a problem pertinent ROS would obtain information about the following systems:

EyesEars, Nose, Mouth, ThroatCardiovascularMusculoskeletal


Example 2 Example 2

For patients presenting with low back pain, a problem pertinent ROS would obtain the following:

GastrointestinalGenitourinary Musculoskeletal

Past Medical, Family & Social History

Past HistoryPast History

A review of the patient’s past medical history should include information on previous occurrences of the chief complaint, surgeries, fractures, traumas, treatments, medications, and home therapies.

(PFSH)(PFSH)


Family HistoryFamily History

A review of the patient’s family history to include any conditions or cause of death of parents, siblings, or children. This should include asking about diabetes, hypertension, cancer, or any other disease related to or that may delay recovery of the chief complaint.


Social HistorySocial History

This should include information on marital status, occupation, educational level achieved, and current/previous use of alcohol, tobacco, and drugs.

It is important not to overlook the musculoskeletal system review for previous episodes of neck, or back pain. This is a very simple method of obtaining the necessary information for the various E/M requirements.

99201 (Problem Focused History)

HPI 1-3 Elements, Brief

ROS No ROS Needed

PFSH No Past Medical, Family or Social History Needed.

99202 (Expanded Problem Focused History)

HPI 1 - 3 Elements, Brief

ROS 1- ROS Needed

PFSH No PFS History Needed

99203 (Detailed History)

HPI 4+ Elements, Extended

ROS 2 - 9 ROS Pertinent

PFSH 1 Relevant Review of PFS

99204 to 99205 (Comprehensive History)

HPI 4+ Elements, Extended

ROS 10+ ROS

PFSH 3 Relevant PFS

Examples of the History Section

99202 Adult 7/23/2009

CAUSATION DETAILS: Mr. Joe Doe believes his symptoms were caused by a sports injury while

playing softball. His date of onset was 7/23/2009 for the lumbar spine discomfort. Prior to this episode Mr. Doe stated that he has never experienced this problem before.

This onset of the primary complaint started as follows:The patient presents today with a chief complaint of left sided low back

pain secondary to a knee injury that will require surgery. For the past two weeks he has been on crutches which are resulting in the lower back complaints.

SUBJECTIVE: Mr. Doe presented today and indicated that he is experiencing

intermittent mild pain in the area of the lumbar spine. This is achy and dull pain left lumbar, left sacroiliac area and left lower lumbar area. Mr. Doe states that nothing makes him feel better while his low back pain is made worse by walking. A 1 to 10 pain scale was used for Mr. Doe to assess his current status. He assessed his low back pain at 2.


99202 Jane Doe 7/24/2009

PATIENT DEMOGRAPHIC INFORMATION: Name: Ms. Jane Doe Gender: FSocial Security Number: 123-45-6789Date of Birth: 4/7/1955Race: CaucasianMarital Status: Married

CAUSATION DETAILS: Ms. Jane Doe related to me that her chief complaint was brought

gradually and cannot pinpoint a mechanism of injury. Jane was unsure of the exact date of onset, but indicated that it was over a year ago. Prior to this episode, Ms. Doe stated that she has never experienced this problem before.

The patient presents today with a chief complaint of anterior ASIS pain with radiation into the left S/I joint.


SUBJECTIVE: Ms. Doe enters the office today and states she is

feeling frequent mild to moderate pain in the lower back. This is sharp pain generalized in the left hip, left upper-medial thigh, and the left sciatic region. Ms. Doe stated that massaging by hand makes her more comfortable but her low back pain is a lot more uncomfortable due to arising from a chair and getting out of bed. The patient was asked to rate her pain and severity on a scale of 1 to 10. She estimated her low back pain at 4.


REVIEW OF SYSTEMS (ROS)

General: Denies fever, chills, fatigue, and no major weight loss or gainPsych: Denies depression, anxiety, insomnia, irritabilityGU: Denies polyuria, nocturia, incontinence, or hematuriaEyes: WORK GLASSES/CONTACTSCVA: Denies chest pain, palpitations, fainting, shortness of breath, or ankle swellingResp: Denies cough, wheezing or shortness of breath.GI: CONSTIPATIONM/S: Refer to HPIInteg: Denies rashes, lesions, infections, and change in hair or nailsNeuro: Refer to HPI, denies seizures and loss of memory problems.Endocrine: THYROID DISORDERHematologic: No history of anemia, abnormal bleeding, bruising, heat or cold intoleranceImmune: Denies hives, hay fever, persistent infections or enlarged lymph nodes


PAST MEDICAL HISTORYPAST MEDICAL HISTORYMedication taken for these symptoms includes acetaminophen. The patient has no history of surgical procedures used to treat this problem.


FAMILY HISTORY FAMILY HISTORY Her family history is positive for high blood pressure.

ExaminationThe Middle & Main Body

Examination

Examination Examination

The collection of diagnostic information discovered through physical applications such as palpation, percussion, auscultation, and inspection.

99201 Problem Focused Exam1-5 Elements in 1 + Body Areas

Constitutional

1. 3-Vital Signs

2. General Appearance

Psychiatric

3. Awake, Alert, Oriented x 3.

4. Mood and Affect

Skin

5. Inspection rashes, lesions

6. Palpation nodules, tightness, (skin rolling)

Neck

7. Masses, appearance

8. Thyroid

Musculoskeletal

6 Body Areas:

• Head/Neck• Spine• Each Extremity

Musculoskeletal

9. Gait, station

Musculoskeletal

Inspection/palpation•Range of Motion•Stability (Orthopedic Tests)•Muscle Strength/

Tone (Muscle Testing)

Neurological

10. Cranial Nerves

11. Deep Tendon Reflexes

12. Sensation

99202 Expanded Problem 99202 Expanded Problem FocusedFocused6 Elements in 1 + Body Areas6 Elements in 1 + Body Areas

Constitutional

1. 3-Vital Signs


Psychiatric


4. Mood and Affect

Skin



Neck


8. Thyroid

Musculoskeletal

6 Body Areas:


Musculoskeletal

9. Gait, station

Musculoskeletal

•Inspection/palpation•Range of Motion•Stability (Orthopedic Tests)•Muscle Strength/•Tone (Muscle Testing)

Neurological

10. Cranial Nerves


12. Sensation

99203 Detailed Examination99203 Detailed Examination12 Elements in 2+ Body 12 Elements in 2+ Body AreasAreas

Constitutional

1. 3-Vital Signs


Psychiatric


4. Mood and Affect

Skin



Neck


8. Thyroid

Musculoskeletal

6 Body Areas:


Musculoskeletal

9. Gait, station

Musculoskeletal

•Inspection/palpation•Range of Motion•Stability (Orthopedic Tests)•Muscle Strength/•Tone (Muscle Testing)

Neurological

10. Cranial Nerves


12. Sensation

99204 Comprehensive99204 Comprehensive18 Elements18 Elements

Constitutional

1. 3-Vital Signs


Psychiatric


4. Mood and Affect

Skin



Neck


8. Thyroid

Musculoskeletal

6 Body Areas:


Musculoskeletal

9. Gait, station

Musculoskeletal

•Inspection/palpation•Range of Motion•Stability (Orthopedic Tests)•Muscle Strength/ Tone (Muscle Testing)

Neurological

10. Cranial Nerves


12. Sensation

Decision Making & Coding

Medical Decision Making

This is the thought process of the examiner, after obtaining information from the history and examination.


Medical decision making is arrived at by looking into three separate parameters:

The number of diagnosis and treatment options

The amount and complexity of data to review

The potential risk or complications, death, and morbidity


Medical decision making has four types:

1. Straightforward2. Low Complexity3. Moderate Complexity (rarely seen in a

chiropractic office)4. High Complexity (never seen in a chiropractic

office)

Complexity of Medical Decision Complexity of Medical Decision Making Making

(you must meet or exceed 2 out 3 (you must meet or exceed 2 out 3 parameters)parameters)

# of diagnoses or Treatment

options

Amount and/or Complexity of

Data to be Reviewed

Risk of Complications

Type of Decision Making

Minimal Minimal or None Minimal Straightforward

Limited Limited Low Low Complexity

Multiple Moderate Moderate Moderate Complexity

Extensive Extensive High High Complexity

Active rehabilitation

Passive Care versus Active Care

It is no longer acceptable to keep a patient on passive care for the entire treatment program especially over a 4 week duration.

You must transition the patient into active rehabilitation.

WHY?


The primary goal of your treatment plan must focus on functional capacity and increasing the patient’s activities of daily living.

Active Care

• Exercise: Document specific stretching or strengthening regimens that have or will be prescribed to the patient. (Active Care will be discussed later in this chapter, in much more detail, including billing parameters.)

• Home Care: Document all home care measures (i.e. most heat packs, icing instructions, orthopedic supports and rationale, positions of comfort or rest, etc.) including any type of activity modification.

Physical Medicine & Rehabilitation

97110—THERAPEUTIC PROCEDURE, 1 or more areas, each 15 minutes; Therapeutic exercises to develop strength and endurance, range of motion and flexibility, 1 or more areas, 15 minutes each

(See ChiroCode Deskbook page F78)


97112—NEUROMUSCULAR RE-EDUCATION of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, 1 or more areas, 15 minutes each


97530—THERAPEUTIC ACTIVITIES, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), 15 minutes each


All of these codes are time based

codes that require one-on-one supervision. It is important when documenting these codes that the specific exercises performed, sets, repetitions, and time spent must be noted in the patient’s

clinical record.

Time Requirements

When performing time requirement codes, I recommend following the CMS Manual Publication 100-04.

Time Requirements

Units

12345678

Number of Minutes

8 to 22 minutes23 to 37 minutes38 to 52 minutes53 to 67 minutes68 to 82 minutes83 to 97 minutes98 to 112 minutes113 to 127 minutes

Example

Example OneExample One• 24 minutes of neuromuscular re-

education 97112• 23 minutes of therapeutic exercise 97110• Total timed code treatment was 47

minutes

The 47 minutes falls within the range of 3 units. Correct coding would be:

97112 x 2 units97110 x 1 units

Example

Example TwoExample Two• 20 minutes of neuromuscular re-education

97112• 20 minutes of therapeutic exercise 97110• 40 total timed code minutes

The 40 minutes falls in the 3 unit range. Each code was billed for at least 15 minutes, so choose either code to be billed at 2 units and bill the other at 1 unit.

Modalities

A modality consists of applying physical agents to produce therapeutic change to tissue. These agents include:

Thermal Acoustic Light Mechanical Electrical Energy

Modalities

Modalities can be performed in two ways:

1. Supervised – Does not require direct (one-on-one) patient contact by the provider

2. Constant Attendance - Requires direct (one-on-one) patient contact by the provider

Hint: Hint: When selecting the most appropriate CPT modality code, be sure and read the description of the various modalities.

Supervised Modalities

97010 Application of hot or cold packs

97012 Traction, mechanical (one or more areas)

97014 Electrical Muscle Stimulation (unattended) (one or more areas)

Constant Attendance Modalities

• 97032 Electrical Stimulation (manual), each 15 minutes (one or more areas)

• 97035 Ultrasound, each 15 minutes (1 or more areas)

• 97124 Massage Therapy• 97140 Manual Therapy• All Active Rehabilitation Codes

97140 Manual Therapy

97140-- Manual therapy techniques (mobilization, manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

For a more in depth description and history of this code please visit F80 in the ChiroCode DeskBook.


Active Release Practitioners (ART Certified), please pay close attention. The CPT code book specifically prohibits this code when performed in the same anatomical areas as a chiropractic manipulation.

If you ART the cervical spine, then you cannot use a chiropractic manipulation code if you adjusted the cervical spine.


*Coding/Compliance Pearl: When performing along with Chiropractic Manipulation Treatment in other areas append with modifier 59. (97140-59)*


Doctors, even if you have been using this code with CMT codes and getting paid, you are at a higher risk for a negative post-payment audit if you are found to be performing in the same area as a CMT.

Basically, you’ve just been lucky so far; fix it now, before it comes back to bite you.

97124 Massage Therapy

• This is a time based code and cannot be used if a vibratory massager or percussion instrument is being utilized.

• This must be done by hand, and the technique used must be documented.


If the office employs a massage therapist, then the doctor must provide a prescription for the massage which includes the following instructions:


• Anatomical site to be worked on (specific muscles)

• Treatment frequency and duration (Three times per week for four weeks)

• Treatment time per session (30 to 60 minutes): I would advise no longer than 60 minutes.

• Diagnosis code that corresponds to the necessity 728.85 Muscle Spasms 729.1 Myofascitis

CMT Codes

98940: 1-2 Areas of Spinal Adjustment

The RVU data states work time to be estimated at 12 minutes: 2 minutes pre-service, 7 minutes intraservice and 3 minutes post service. (RVU .69)

98941: 3-4 Areas of Spinal Adjustment

The RVU data states work time to be estimated at 17 minutes: 3 minutes pre-service, 10 minutes intraservice and 4 minutes post-service. (RVU .96)

98942: 5 Areas of Spinal Adjustment

The RVU data states work time to be estimated at 21 minutes: 4 minutes pre-service, 12 minutes intraservice and 5 minutes post-service. (RVU 1.25)

98943: 1 or More Areas of Extraspinal Adjustment

The RVU data states work time to be estimated at 14 minutes: 3 minutes pre-service, 8 minutes intraservice and 3 minutes post-service. (RVU .65)

CMT

Includes: Pre- & Post-manipulation

Patient assessment

Usual (routine) evaluation & management (E/M) service

A variety of techniques

Use of hand held assistive devices

Spinal Regions

As Determined by CPT are Cervical, Thoracic, Lumbar, Sacral and Pelvic

Extraspinal Regions

As Determined by CPT are Head, Lower Extremities, Upper Extremities, Rib Cage and Abdomen

Full Spine Adjustments

In order to adjust full spine, there must be documentation of symptoms in the cervical, thoracic, and lumbar spines.

These symptoms can be anything from the patient stating there is stiffness or soreness, to minor aches and pains .

Full Spine Adjustment Rules

There should be documentation of symptoms in each area.

Do not perform full spine adjustments on every patient.

There should be a diagnostic impression to correlate with each area of treatment.

With improvement, the number of areas being adjusted should continually decrease.

Major Red Flag

A major red flag and the main reason for Medicare claim denials is not having the diagnosis match the areas of CMT.

Red Flag for Medicare? Give every patient a 98942 (5- region

CMT)

Modifiers

Modifiers

A modifier provides a way to report, or indicate, that a performed service or procedure has been altered by some specific circumstance.

But it does not change the actual definition or code.

Modifiers: Don’t forget them!

The five modifiers used in chiropractic care are:

GY : Non-covered service

GA : Properly delivered ABN

GZ : “Oops”. Use this on the rare occurrence that you should have gotten an ABN but, for some reason, did not.

GP : Therapy

AT : Active care (acute and chronic) spinal CMT.

Commonly Used Chiropractic Modifiers

1. 252. 263. 514. 525. 59

1. AT2. GA3. GY4. GZ5. LT6. RT7. TC

Advanced Beneficiary NoticeABN

Revised ABN

The revised Advanced Beneficiary Notice of Non coverage (ABN), form CMS-R-131 goes into effect January 1, 2012

Revised ABN

The revised ABN is issued by providers in situations where Medicare payment is expected to be denied.

General Information

The Financial Liability Protection provisions (FLP) of the Social Security Act, protects beneficiaries and healthcare providers under certain circumstances from unexpected liability for charges associated with claims that Medicare does not pay.

FLP Provisions

• Limitation On Liability (LOL) under §1879(a)-(g) of the Act;

• Refund Requirements (RR) for Non-assigned Claims for Physicians Services under §1842(l) of the Act; and

• • Refund Requirements (RR) for Assigned and Non-assigned Claims for Medical Equipment and Supplies under §§1834(a)(18), 1834(j)(4), and 1879(h) of the Act.

Limitation on Liability

A healthcare provider (herein referred to as a “notifier”) who fails to comply with the ABN instructions risks financial liability and/or sanctions.

The Medicare contractor will hold any provider who either failed to give notice when required or gave defective notice financially liable.

ABN Scope

The revised ABN is the new CMS-approved written notice that is issued by providers, practitioners, suppliers, and laboratories for items and services provided under Medicare Part A (hospice and regional non-medical healthcare institutes only) and Part B and given to beneficiaries enrolled in the Medicare Fee-For-Service (FFS) program.

ABN Scope

The revised ABN will now be used to fulfill both mandatory and voluntary notice functions.

The revised ABN replaces the following notices:

• ABN-G (CMS-R-131-G) • ABN-L (CMS-R-131-L) • NEMB (CMS-20007)

Voluntary ABN Uses

ABNs are not required for care that is either statutorily excluded from coverage under Medicare (i.e. care that is never covered) or fails to meet a technical benefit requirement (i.e. lacks required certification). However, the ABN can be issued voluntarily in place of the Notice of Exclusion from Medicare Benefits (NEMB) for care that is never covered such as:

Care that fails to meet the definition of a Medicare benefit as defined in §1861 of the Social Security Act;

Notifiers

Entities who issue ABNs are collectively known as “notifiers”.

ABN Triggering Events

Notifiers are required to issue ABNs whenever limitation on liability applies. This typically occurs at three points during a course of treatment which are initiation, reduction, and termination, also known as “triggering events”.

Initiations

An initiation is the beginning of a new patient encounter, start of a plan of care, or beginning of treatment.

If a notifier believes that certain otherwise covered items or services will be non covered (e.g. not reasonable and necessary) at initiation, an ABN must be issued prior to the beneficiary receiving the non-covered care.

Reductions

A reduction occurs when there is a decrease in a component of care (i.e. frequency, duration, etc.).

Terminations

Termination is the discontinuation of certain items or services.

Blank (G) Three Options

❏ OPTION 1.

This option allows the beneficiary to receive the items and/or services at issue and requires the notifier to submit a claim to Medicare. This will result in a payment decision that can be appealed.


❏ OPTION 2. This option allows the beneficiary to receive the non covered items and/or services and pay for them out of pocket.

No claim will be filed and Medicare will not be billed. Thus, there are no appeal rights associated with this option.


❏ OPTION 3. This option allows the beneficiary to receive the non covered items and/or services and pay for them out of pocket.

No claim will be filed and Medicare will not be billed. Thus, there are no appeal rights associated with this option.

Period of Effectiveness

An ABN can remain effective for up to one year. ABNs may describe treatment of up to a year’s duration, as long as no other triggering event occurs.

If a new triggering event occurs within the 1-year period, a new ABN must be given.

For More Information

Please visit the websitewww.arkfeldcompliance.com

Email:[email protected]: 989-448-8065

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