-Melani Crocker D.C. MCS-P
Welcome to 2014-The Year of Change.
WHEN YOU GET A REQUEST FOR RECORDS DO NOT IGNORE IT!!
!!! INSURANCE ALERT !!!
A recent report on chiropractic services that were reviewed by Railroad Medicare showed a 77% error rate. 50% of errors were because of failure to submit documentation, the rest of the errors were mostly for missing or insufficient documentation. There were some miscellaneous reasons of illegible notes, no signature, no key at the abbreviations and 170 of the 21,000 claims were down-coded. REMINDER: MAKE SURE TO ANSWER THESE REQUESTS FOR RECORDS IN A TIMELY FASHION, LET THE MSCA KNOW WHEN YOU GET RECORD REQUESTS FROM MEDICARE OR RAILROAD MEDICARE.
By now most of you have heard of all the changes that we are facing this year. All of these change are not bad, onerous, or downright difficult to comply with. The GOOD NEWS: MEDICARE HAS GIVEN US A RAISE!!! If you haven’t already looked at your 2014 Medicare Fee Schedule, I encourage you to do so and see what the new fee schedule is currently-UNTIL MARCH 31, 2014. We will be watching closely and will bring you news as fast as we can if/when this new fee schedule will be approved for the full year. Visit http://www.wpsmedicare.com/j5macpartb/fees/physician_fee_schedule/ for more information.
There are now 3 PQRS measures to report. Two that we should have been reporting this past year and 1 new measure we are to begin reporting this year. Remember if you have not been reporting PQRS correctly in 2013 you will be penalized and reimbursement taken out of your payments in 2015.
This is the easiest requirement we have this year. There is a NEW G CODE for measure #182 Functional Outcome Assessment – this code is G9227-
OUR NEW MEASURE IS #317
As you can see, it is dealing with blood pressure and it is what we do all the time so reporting the codes won’t be difficult at all.
PQRS really is the easiest requirement and it falls into the Value Based Care arena that we now find ourselves in along with any and all other types of providers. If you are not currently doing PQRS it is strongly urged that all DC’s begin. If you need help getting started, the ACA download is very user friendly and we at the MSCA are here to help you. Just contact us.
Care Improvement Plus:
Please comply with these requests as they are part of a risk adjustment review and not to be taken lightly. Also, I suggest you send these records certified, registered return receipt. This insures they get there on time and have been signed for by a person in case you need to prove timely receipt.
If you have questions please feel free to contact the MSCA and they will get you to the insurance department.
By now you should already have been studying and going to seminars on ICD-10 and increasing your knowledge on how to convert your most used diagnosis codes into ICD-10 codes. Dr. Evan Gwilliams presented to the 5th District relicensing seminar our first ICD-10 seminar and I want to let you doctors know that you CANNOT wait until the last minute to begin changing over to these new diagnosis codes. Dr. Gwilliams will be in Jefferson City at the MSCA presenting ICD-10 on May 8, 2014. Please sign up you and your support team to help you with this conversion. It is a VERY BIG endeavor to be taken in small bites daily to make up a whole code list for our offices. We posted a time-line in the January journal of where you should be as the year progresses. I hope this helps you and your team to plan and prepare implementing these codes.
WPS Medicare Seminars:
WPS Medicare Chiropractic Care seminars are being offered in Kansas in March and in Missouri in April. They will be offering a three-hour session designed specifically for those who wish to increase their knowledge of chiropractic care as it relates to Medicare. This seminar will help both new and experienced providers and billers understand chiropractic claim submissions, medical policy, medical documentation, medical necessity, and more. Please join us for this important seminar. Registration is available online, and space is limited. Visit http://events.r20.constantcontact.com/register/event?oeidk=a07e8ugual6db717ee1&llr=pipq86oab for more information.
CMS 1500 Form:
CMS-1500 form (02-12) is effective as of January 6, 2014, use of the revised form is optional until March 31, 2014. Please make sure you are using this new form.
These are just a few of the big issues facing us this year. HIPPA, A Compliance Manual, Self-Auditing or having a certified records auditor to review your files, OBAMACARE, just to name a few. The MSCA is always ready to help our members be proactive not reactive with these issues.
We all look forward to spring, sunshine and an office full of happy patient’s. Until next time….
FYI, please find the attached copy of Anthem’s “eUPDATE” released today with information concerning their recent temporary processing change. It offers a detailed explanation for their temporary processing change as well as notification of a letter to be mailed out “on or around March 1” to it’s network providers concerning underpayments.
PQRS: What You Need to Know About Participating in 2012
MSCA Insurance Alert!
We now know the results of the WPS SS Probe Review....
Planned Widespread Chiropractic Comparative Billing Report (CBR) Educational letters to be sent to Chiropractic Providers in J5 Jurisdiction
Chiropractic services remain a focus for the FY2012 Medical Review Strategy. Analysis of our errors for claims submitted 01/01/10 through 12/31/10 demonstrated there were 22 CERT errors for chiropractic services. Insufficient documentation made up 64 % of the CERT errors for chiropractic services in this time frame. Medically unnecessary services made up 27% of the CERT errors for chiropractic services in this time frame. Analysis of the results revealed the documentation did not support the requirements of the policy, the medical necessity of the service, and/or active corrective treatment.
Medical Review recently completed a series of Postpayment Probe Reviews of codes 98940, 98941, and 98942 billed with the AT modifier, which identified the following issue(s) in the jurisdiction:
In response to the CERT and review results, WPS performed further data analysis for chiropractic services for dates of service 6/1/2009 through 5/31/2010 to aid educational efforts. In J5 for this timeframe, there were 7,310 beneficiaries (274,519 claims) with 35 or more services billed per beneficiary. A high frequency of services per patient may indicate that some services are not for active corrective treatment (i.e. maintenance therapy) for which the AT modifier should not be applied. Due to this analysis and the results of these reviews, another concern is the appropriate use of the AT modifier. The CBR Report will contain data on the frequency of services per patient in comparison to peer norm.
Medical Review is utilizing a direct widespread educational approach to those Part B providers who bill a high volume of services per patient. Individual Comparative Billing Report (CBR) educational letters will be sent to those providers who bill only one of these Current Procedural Terminology (CPT) Codes 98940, 98941, or 98942 with the AT modifier 90% or more of the time and have greater than 1000 allowed services.
These providers will receive an educational letter along with a Comparative Billing Report comparing the individual provider to his/her peers in the J5 Jurisdiction. In addition, each provider will receive a Comprehensive Error Rate Testing (CERT) Program and Chiropractic Services Resources attachment to utilize.
Several doctors have asked what is an ABN Form.
An ABN (Advance Beneficiary Notice) is a standard Medicare form that is to be used to let a patient know what may not be covered. In order to fill them out properly, it is best that you go to Medicare's website and print out the instructions. Here is the link to that information: http://www.acatoday.org/pdf/abn_2011.doc
Non-covered services can be listed on the ABN form but it is not mandatory. Covered services are manipulations only. Maintenance manipulations are considered a covered service that is not medically necessary, and the correct way to put it on your claim form is to not put an AT modifier behind your manipulation code. You are required to have the patient sign an ABN form each visit that you are doing a manipulation that is maintenance care.
One of the questions I received was that the patient needs the care to prevent deterioration of their condition. If you treat them, and it is maintenance care, you must have an ABN signed and filled out properly; and you are required to bill it and not use the AT modifier for it. It is covered but not medically necessary. (NOT my verbiage)
This email is for Nebraska doctors on my list. If you are getting this email and you are in one of the other J5 MAC States (WPS Medicare) this information pertains to you also, however you should be getting a state specific email from your association and/or your CCAC Representative.
Attached are four documents/forms that we have worked on to help with the self audits, as well as other types of audits/reviews you receive from any of the Medicare contractors. I want to thank Denise Hoffman and Vicki Stoffer for helping draft these documents. These forms were produced by us and do not reflect endorsement of any contractor or CMS itself.
I also highly recommend you go to these Internet links (below), download and print them. Use them for auditing your initial visit and subsequent visit documentation and for further reference. (members may read the entire letter by clicking here)
MSCA Insurance Update: Medicare
Most of you may already be aware, on September 5, 2007, the Centers for Medicare & Medicaid Services (CMS) announced that the Wisconsin Physicians Service Insurance Corporation (WPS) had been awarded the Medicare contract to provide Part A and Part B administrative services for the states of Iowa, Kansas, Missouri and Nebraska.
In an effort to provide you with more details about the Wisconsin Physicians Service, and their plans for implementation, here is a link to their website (below). It has implementation information, dates, contact information and more. This link will also be available on the MSCA website at www.mscainfo.com .
Click Here: http://www.wpsmedicare.com
THE MSCA INSURANCE COMMITTEE IS TRYING TO COMPILE A FULL LIST OF ALL MISSOURI CHIROPRACTORS WHO HAVE EITHER BEEN TERMINATED OR PUT ON PERFORMANCE IMPROVEMENT AGREEMENTS WITH ACN.
PLEASE, EMAIL THE NAMES TO: firstname.lastname@example.org
Provider Types Affected
Provider Action Needed
MISINFORMATION #1: There is a 12 visit cap or limit for chiropractic services.
MISINFORMATION #2: If you are a non-participating (non-par) provider, you do not have to worry about billing Medicare
MISINFORMATION #3: If you are a non-participating (non-par) provider, you will never be audited nor have claims reviewed, etc.
MISINFORMATION #4: You can opt out of Medicare
MISINFORMATION #5: You should get an Advance Beneficiary Notification (ABN) signed once for each patient, and it will apply to all services, all visits.
MISINFORMATION #6: Maintenance care is not a covered service under Medicare.
MISINFORMATION #7: Non-par providers do not have the same documentation requirements as par providers.
This letter is for demonstrative purposes only and members should consult their legal counsel as individual situations may vary.
On January 4, 2006, several Missouri Chiropractors joined to file a class action lawsuit against United Healthcare Corporation (UHC) and American Chiropractic Network (ACN) in the Western Division of the federal court of the United States. The lawsuit alleges UHC/ACN created a way to cut healthcare costs that affects the quality of healthcare available to patients. UHC/ACN profiles the doctors and uses these profiles to determine the level of care patients need. They send out notification to doctors that places them on probation, and gives them six (6) months to improve or face possible termination from the UHC network. Many doctors across the country have received these notifications called Performance Improvement Agreements, and many have been terminated.
The performance Improvement Agreements gave doctors criteria they should fall under, according to ACN. It limits the doctors to an average patient visit number not to exceed 6.2 visits per 6 months. Some states have reported these averages were 2.7 patient visits per year. There are approximately 29,000 providers in the ACN network.
The Missouri Division of Insurance (MDOI) is also looking into the matter after many complaints have been filed with them concerning ACN and UHC.
When you feel an insurance company has violated your patient's right to chiropractic care, or your fair and timely reimbursement, there is a place to file your complaint. The Department of Insurance provides forms for patient and provider complaints. As a convenience, the MSCA is adding a link to its web page, on the "Forms/Links" page, for easy access to the DOI web page and complaint form.
The report of the Office of the Inspector General (OIG), the study of whether chiropractic benefits were paid appropriately for claims paid in 2006, was released in May, 2009. The objective of the study was to determine the extent to which: 1) chiropractic claims were appropriate, in 2006, for beneficiaries receiving more than 12 services from the same chiropractor; 2) controls ensured that chiropractic claims were not for maintenance therapy; 3) claims data could be used to identify maintenance therapy; and, 4) chiropractic claims were documented as required.
The review was based on 200 claims where the AT modifier was used with more than 12 visits from the same chiropractor. For each treatment episode, the medical records were reviewed to identify the initial visit and subsequent visits to determine whether each sampled claim was active/corrective treatment or maintenance therapy; the extent to which chiropractors supported their use of the AT modifier with proper documentation indicating active/corrective treatment; whether claims were coded properly; and whether documentation met the Manual requirements.
The findings were: 1) Medicare inappropriately paid $178 million for chiropractic claims in 2006, representing 47% of claims meeting the study criteria. The breakdown was $157 million were maintenance visits, $11 million were miscoded, $46 million were undocumented, and $36 million were for multiple errors; 2) Efforts to stop payments for maintenance therapy have been largely ineffective; 3) Claims data lacked initial visit dates for treatment episodes, hindering the identification of maintenance therapy; and 4) Chiropractors often do not comply with the Manual documentation requirements. The medical reviewers indicated that treatment plans are an important element in determining active/corrective care in achieving specified goals. Of the 76% of records that reviewers indicated contained some form of treatment plan; 43% lacked treatment goals, 17% lacked objective measures, and 15% lacked the recommended level of care.
The Recommendations made by the OIG to CMS due to these “high error rates and poor documentation” were 1) Implement and enforce policies to prevent future payments for maintenance therapy 2) Review treatment episodes rather than individual chiropractic claims to strengthen the ability of the CERT to detect errors in chiropractic claims 3) Ensure that chiropractic claims are not paid unless documentation requirements are met and 4) Take appropriate action regarding the undocumented medically unnecessary, and miscoded claims indentified in the sample.
The above comments are taken from the Department of Health and Human Services Office of the Inspector General titled, “Inappropriate Medicare Payments for Chiropractic Services,” dated May, 2009. For the full text and more detailed explanations, you can get the actual document and review it.
This report reiterates how imperative it is for our profession to continue to work aggressively to improve our documentation. The 2009 work plan for the Department of Human Services Office, Office of Inspector General, includes chiropractic again. Please let the MSCA know if you get an OIG record request.
National Health Care
Legal Action Fund