Reimbursement and chiropractic billing can mostly seem to be simple at one moment, but then become suddenly gets complicated the next. The codes required for billing are recognized by the most chiropractors, but often aren’t complete aware of the complexities and nuances that lead to reimbursement or denial. In this post, let’s look at the 5 key problems chiropractic offices should watch out for in the year of 2014.
- 1500 Form Update
There is a latest update to the 1500 form for the year of 2014. This updated form permits twelve diagnoses in block 21. But frankly, I never understood why block 21 was restricted to 4 codes when there was obviously enough space to add more. Of course, this change is to accommodate the ICD-10 CM coding set; providers will likely use more codes, as this code system is more specific and granular.
According to CMS, the new form (2/12 revision) can be utilized on the day of Jan. 6, 2014, but that providers might sustain to use the existing 1500 (8/05) edition through the day of March 31, 2014. As a result, there can be dual use of either form during this time period. Although, beginning on the day of April 1, 2014, the new form is compulsory.
This is considered to be CMS timeline and it is expected that other carriers will follow the lead of Medicare. Although, determine and verify with your common payers as to their particular plans and time frame for use. Deployed on past experience with updates to the 1500, it is likely most, if not all, carriers will follow the time frame of Medicare.
While you require not change eventually, the change must be made. Verify that what will be needed to upgrade or purchase if a new program is required. If a billing service or clearinghouse is used, make sure that it is aware of the update and what changes, if any, you’re needed to make.
- The Expanded ICD
While ICD-10 doesn’t take effect until the day of Oct. 1, 2014, it is something you must be ready for early, as it alters and changes all the codes used for diagnosis. The ICD-9-CM codes number about 13,000 and are numerical in value. They range from 3 digits to as many as 5. ICD-10-CM contains more than 68,000 codes and range from 3 to 7 characters in length, but all have an alpha beginning. The codes are much more specific in the ICD-10 and providers will amuse a much higher capability to provide more exacting diagnoses.
It is a fact that 70% of claims are represented by the 5% of diagnoses codes. The average chiropractic office more than likely utilizes no more than twenty-five codes on a regular basis and selects from a code set of over 50-75 codes in most cases. But even this number of codes might triple and could increase as much as 10-fold for few codes sets.
Each office or provider must take it upon themselves to be ready for this transition. The most important is to make certain that there is a proper resource to change and add new codes to the office “cheat sheet” list. Additionally, any software or billing program should be upgraded to the new code set; ascertain either this can be done with the software straightly or if it is dependent upon the provider to make the modifications.
Obviously, there is likely little cost to this; either it is an update to the program or generally a new system. I would also recommend that you verify whether the update will have to be done a 2nd time if you change computer platforms at a later date, as the new system might have separate needs. If an outside billing service or clearinghouse is used, examine if it is updating its system, and either it’ll be supplying codes versus needing it to come from the provider.
In accordance to my belief, the use of these codes will help providers in demonstrating necessity for care more easily due their detailed nature, not to mention that problems of claim scrutiny, as explained in the next section, can be reduced by their use.
- Claim and Visit Scrutiny
Claim/visit scrutiny will reach a phase that has never been seen by the chiropractic profession. With 39 of 50 states having compulsory chiropractic advantages, clearly more individuals will likely find chiropractic care. This is considered to be very positive change for the chiropractic profession and frankly, for insurance companies as well. The reason it is positive for insurance carriers is chiropractic is a less-expensive expense in contrast to the traditional medical care involving medication, physical therapy and surgery, which means lower prices for claims.
Although, insurance plans like Blue Cross, Blue Shield (BCBS), CIGNA, et al., are utilizing the outside review sources like Optum Health, American Specialty Health, OrthoNet and others who observe chiropractic claims for necessity and mostly need authorization beyond some amount of visits. It isn’t that they won’t permit care, but that they’ll scrutinize more closely the number of services and visits.
Several chiropractic sufferers and chiropractic providers mostly languished in abundant benefits that were available.
Chiropractic care indicates remarkable efficacy for common spine and back ailments based on the evidence-based guidelines. But several of these sources show that the initial treatment plan intervention is adequate to resolve most cases. In fact, I’ve heard and read several studies and guides that show uncomplicated conditions require no more than 6-8 visits to sort out with chiropractic care.
When there are examples in which care goes beyond the “typical” needs, keep in mind the following:
- Is the provider utilizing objective measures on exams for “functional” change to show the necessity and ongoing requirement of care?
- Does the diagnosis correlate with the number of visits requested?
- Are there chronic factors that can be recognized, either by diagnosis or documentation in the chart, as chronic conditions by definition need increased care?
- Were functional outcome assessments utilized to further quantify the necessity and progress of the care plan?
- Does the treatment plan have a concentration on active care and rehabilitation? Note the following statement relating to active care, taken from the Chronic Pain Medical Treatment Guidelines: “There is powerful evidence that exercise programs, involving aerobic conditioning and strengthening is superior to treatment programs that don’t involve exercise.” This language is in all of the aforementioned carriers’ chiropractic treatment policy standards.
- Do your notes, under a crucial review, demonstrate functional improvement and a discharge when maximum therapeutic benefit has been acquired?
- Manual Therapy 97140
It must be appended with modifier 59, when billing this code to show that it is payable and separate from chiropractic manipulation. This modifier should merely be utilized in situations in which a different region of the body got the service. Obviously, several payers, upon seeing the 59, will pay, assuming the service was to a different region. Although, if the claim is later analyzed or audited, and it is enabled that the service wasn’t done to a separate region, it’ll outcome in a refund or deduction from future payments.
The CPT position paper on 97140 claims the following “Under few circumstances, it might be suitable to additionally report CMT/OMT codes in addition to code 97140.
The Aetna went so far as to not pay for 97140 done with chiropractic manipulation regardless of separate region. The policy of Aetna was made based on the following: “Aetna disclosed that their investigative audits discovered that 90% of the time that modifier -59 was utilized, manual therapy was conducted in the similar region as the CMT. They also discovered very poor or deficiency of documentation. The need of Aetna to make such a powerful policy change was due to what they believed to be excessive and inaccurate use of modifier -59.”
Luckily, with diligent battling by the chiropractic profession and the American Chiropractic Association, Aetna did change this and will permit the payment of 97140 with chiropractic manipulation when the medical necessity of separate regions is important and clearly documented.
Several carriers are making provisions with outside review agencies like American Specialty Health, OrthoNet and Optum, who are analyzing claims and chart notes more closely to be definite the 97140 services were given to a different body region from the chiropractic manipulation and medically necessary.
While this is a required and necessary service, the suggestion of evidence-based care plans shows reduction in the provision of passive care and increase in the provision of active care or simply exercise.
- Medicare 101
Medicare is here to stay and necessarily includes everyone over the age of 65. Keep it in mind that the baby boomer generation is changing Medicare age at a clip of 10,000 each day for the next fifteen years. That is too many individuals to avoid, specifically when Medicare pays more per visit than most of the managed care plans … even though it only pays for spinal manipulation.
It is also sarcastic how few consider Medicare is the strictest on medical necessity, still it is not unseal to have Medicare permit and pay for 20 to 30 visits when managed care plans, as noted above, are tightening. Although, let’s do remember the Medicare sufferers generally have more chronic and severe conditions that need greater care, which is most usually disc degeneration.
The providers who’re disillusioned with Medicare are mostly annoyed because of their deficiency of knowledge of Medicare requirements for billing and documentation, which surely has some nuances. Claims will be denied or when reviewed, will result in more denial or requests for refunds if these nuances are not followed.
For chiropractic, Medicare is straightforward: It pays for spinal manipulation merely and subluxation must be the primary diagnosis. Although, beyond the subluxation, there must be a secondary neuromusculoskeletal condition associated. The subluxation must be indicated in the file by an X-ray or physical examination and the particular vertebrae must be documented. It is not right to simply denote cervical subluxation.
The secondary diagnosis must also be demonstrated and it is imperative to have the most particular diagnosis or reason for the encounter indicated. While it is agreeable to use as simple a diagnosis as cervical pain 723.1, it is best to differentiate the causation of pain with myalgia 729.1, disc degeneration 722.4, disc displacement 722.0, strain and sprain 847.0, etc., whenever possible. Codes that have higher differentiation and severity obviously will result in a larger allowance of treatment, as the condition coded clearly warrants such.
Chiropractic manipulation codes must be appended with modifier AT to show the care is corrective or active. Omission of the modifier will outcome in an automatic denial of services with no sufferer responsibility.
If the sufferer selects to get care beyond what Medicare permits, he/she might do so and pay out of pocket for those services. What is needed is that the patient signs the Advance Beneficiary Notice (ABN), accepting responsibility; and that the chiropractic manipulation code be billed with modifier GA. Utilization of this modifier will outcome in a denial of payment from Medicare, but does permit and make the patient responsible for those services.
For services that are excluded for chiropractic, the chiropractic provider require not bill to Medicare. The sufferer is liable for those services and they can’t be offered at no charge or discount, as Medicare observes this as inducement.
This GY modifier shows that it is an excluded service and will outcome in patient responsibility for those services and permit payment from the secondary payer. Note that in most examples, Medicare will also forward the claim straightly to the secondary payer, meaning no extra work by the chiropractor. Also keep in mind that this secondary insurance information should be involved on the claim block 9a-d.
For Medicare aw well, there are claim form nuances. Block 11 should have “none” demonstrated, as this is the indication that there is no other insurance primary to Medicare. If this is left blank, Medicare will refuse the claim, demonstrating that it can’t ascertain the primary insurance.
Block 14 must have a date, and it is not essentially a date of injury or 1st symptom, but the date of the 1st visit for the present episode.
Medicare is also doing more review and audits of chiropractic providers and these are usual problems with provider documentation.
Some other billing considerations to keep in mind, specifically when it comes to Medicare:
- Missing signature: All notes need the signature, not initials, of the chiropractor.
- Unreadable notes: If you can’t read them, neither can anyone else. Make certain that if notes are requested, someone other than you can read them.
- Specific places of manipulation must be documented on each visit.
- The treatment plans must also be evident, demonstrating level of care involving frequency and length.
- Particular level of subluxation must be demonstrated in examination and treatment notes.
- If treatment sustains without the proof of betterment or the clinical status remains stable for a given condition, more manipulative treatment is considered maintenance therapy and is a non-covered benefit.