PHYSICAL MEDICINE MANAGEMENT PROGRAM

PROVIDER TIPS & REMINDERS

Chiropractic Services

PresenterPresentation NotesWelcome to the Physical Medicine Management Program webinar on Provider Tips and Reminders for Chiropractic Services. This webinar is an informational resource and is intended for chiropractic providers and their staffs. During this webinar the viewer will be able to stop, pause, move forward, and move back within the presentation, as needed. Since it is not interactive, however, any questions or suggestions should be referred to the appropriate provider representative.

AGENDA

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• Purpose

• Program Review

• Documentation

• Medicare Advantage

• Routine and Non-Routine Chiropractic Services

PresenterPresentation NotesThis webinar includes 4 main topics for discussion: Program review, documentation, Medicare Advantage requirements, and routine versus non-routine chiropractic services.

PURPOSE

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To review important features of the Physical Medicine Management Program, as well as requirements specific to Medicare Advantage members, in order to facilitate, and minimize unnecessary delays in, the delivery of medically necessary chiropractic care.

PresenterPresentation NotesThe purpose of this webinar is to review important features of the Physical Medicine Management Program, as well as requirements specific to Medicare Advantage members, in order to facilitate, and minimize unnecessary delays in, the delivery of medically necessary chiropractic care.

PROGRAM REVIEW

PresenterPresentation NotesHighmark developed the Physical Medicine Management Program to ensure that our members receive medically appropriate physical medicine treatment in the proper setting. The program is designed to track and monitor utilization of physical medicine services to assure members receive high-quality care that is aligned with evidence-based guidelines. Highmark has contracted with Healthways to administer the registration process and provide medical necessity review and authorization, when applicable, for these services under the program.The next 7 slides represent a summary of the basic elements of the program. A thorough review of the program is available online in the Physical Medicine Management Program Administrative Guide via the Provider Resource Center.

CARE REGISTRATION

• A registration is required for physical medicine services provided by physical therapists (PTs), occupational therapists (OTs), and allopathic and osteopathic physicians (MD’s and DO’s)

• A separate registration is required for manipulation services provided by doctors of chiropractic (DCs).

*For participating PEBTF members, separate registrations are required for each of the three disciplines (physical therapy, occupational therapy, and manipulation services).

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PresenterPresentation NotesA care registration is required for physical medicine services provided by physical therapists, occupational therapists, and allopathic and osteopathic physicians. A separate registration is required for manipulation services provided by doctors of chiropractic. For participating PEBTF members, separate registrations are required for each of the 3 disciplines.

CARE REGISTRATION

• Patients are registered annually beginning with their first visit each calendar year

• Care registration is used to document the initial visits in the calendar year in order to determine when medical management is needed

• Once the member is registered, an “auto-approval” is entered that allows eligible claims for the initial eight (8) visits in a calendar year to process according to the member’s benefit plan (6 visits for PEBTF members)

• The provider submits claims to Highmark and the member’s benefit is applied

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PresenterPresentation NotesPatients are registered annually beginning with their 1st visit each calendar year. Care registration is used to document the initial visits in the calendar year in order to determine when medical management is needed. Once the member is registered, an “auto-approval” is entered that allows eligible claims for the initial 8 visits in the calendar year to process according to the member’s benefit plan. The provider submits claims to Highmark and the member’s benefit is applied.Please note: The number of auto-approved visits for PEBTF members is six.

CARE AUTHORIZATION

If the member needs more than 8 visits in the calendar year… • Prior to the 9th visit, the treating provider must obtain a care authorization

from Healthways

• Upon request, the provider’s office will submit clinical information, including current functional status, objective progress, and treatment plan.

*An authorization is a determination of medical necessity only and is not a guarantee of coverage or payment

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PresenterPresentation NotesIn the event a member requires more than 8 visits in the calendar year, a care authorization must be entered prior to the 9th visit. Upon request, the provider’s office will submit clinical information, including the member’s current functional status, objective progress, and the specific treatment plan for that member. Please note: An authorization is a determination of medical necessity only and is not a guarantee of coverage or payment.

REQUEST SUBMISSION

Care registration and authorization requests may be submitted to Healthways in one of several ways. The most expeditious methods of submission are: • NaviNet (Rapid Response System) and • Telephone (IVR-RRS) In the event the provider does not have telephone or computer access, or is having problems using the RRS or NaviNet, Fax or mail may be used.

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PresenterPresentation NotesProviders and staff are reminded that care registration and authorization requests may be submitted to Healthways in one of several ways, including NaviNet and telephone. In the event the provider does not have functional Internet or telephone access, care registration and authorization requests may be submitted via fax or mail.

NAVINET

NaviNet is the preferred method for submission of requests This electronic submission process provides: • A single portal of entry and access • Immediate responses, in some cases auto-authorizations • Greater efficiency • Claim and Authorization status • Eligibility status • Benefit Accumulator

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PresenterPresentation NotesNaviNet is the preferred method for submission of requests. NaviNet offers the provider a single portal of entry and access, as well as immediate decision responses. In addition to its efficiency, NaviNet also provides claim and authorization status, member eligibility status, and a benefit accumulator.

RAPID RESPONSE SYSTEM (RRS)

NaviNet serves as the portal to Healthways’ Rapid Response System • Following member evaluation, the provider prepares a treatment plan and

completes the Treatment Authorization Template

• The proposed treatment plan is routed through RRS, processed along specific clinical decision support pathways, and benchmarked against nationally accepted, evidence-based treatment guidelines for specific conditions

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PresenterPresentation NotesOne of the many benefits of NaviNet is access to Healthways’ Rapid Response System, or RRS. Once the member has been evaluated and determined to require additional treatment, the provider prepares a treatment plan and completes the Treatment Authorization Template. The treatment plan is then routed through RRS, processed along specific clinical decision support pathways, and benchmarked against nationally-accepted, evidence-based treatment guidelines for the member’s specific condition.

RAPID RESPONSE SYSTEM (RRS)

• Provider is immediately aware of the pre-screening outcome in the case. There are three possible outcomes:

• Approval

• Opportunity to modify the proposed treatment plan to meet guidelines

• Pended for peer clinical review; Relevant clinical information will be requested for submission and review

• Written notification is faxed to provider’s office within the hour

The program’s clinical guidelines and protocols are continually reviewed and updated annually by Healthways’ Clinical Oversight Committee and are reviewed and approved by

Highmark’s Care Management Committee

All decisions regarding medical necessity are governed by Highmark medical policy

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PresenterPresentation NotesThe provider is immediately aware of the prescreening outcome in the case. Based upon the clinical information submitted by the provider, there are 3 possible outcomes: Approval Opportunity to modify the proposed treatment plan to meet guidelines; and Pended for peer clinical review. For requests that are pended, relevant clinical information will be requested for submission and review. Written notification is faxed to the provider’s office within the hour.Please note: The program’s clinical guidelines and protocols are continuously reviewed and updated annually by Healthways’ Clinical Oversight Committee and are reviewed and approved by Highmark’s Care Management Committee. All decisions regarding medical necessity are governed by Highmark medical policy.

PROVIDER DOCUMENTATION

PresenterPresentation NotesProvider Documentation

DOCUMENTATION

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Of all requests for chiropractic services that are partially or fully denied, the #1 reason is incomplete or missing documentation.

PresenterPresentation NotesOf all requests for chiropractic services that are partially or fully denied, the #1 reason is incomplete or missing documentation.

DOCUMENTATION

Problem Oriented Medical Record (POMR)

• The nationally accepted standard for medical record keeping in the US

• POMR Components: • Problem List • Diagnoses • Treatment Goals for Each Condition • Goal-Oriented Treatment Plan • S.O.A.P. Notes • Dates of Resolution by Diagnosis or Complaint

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PresenterPresentation NotesThe Problem Oriented Medical Record is the nationally accepted standard for medical record keeping in the US and is the standard against which provider record submissions are compared. The components of the POMR include: The problem list, diagnoses, treatment goals for each condition, goal-oriented treatment plan, SOAP notes, and dates of resolution by diagnosis or complaint.

DOCUMENTATION

Proper documentation is:

• Accurate

• Relevant

• Complete

• Timely

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PresenterPresentation NotesProper clinical documentation is accurate, relevant, complete, and timely

DOCUMENTATION

The Importance of Proper Documentation

PROPER DOCUMENTATION: • Is an important component of high quality health care delivery, and

promotes member safety

• Minimizes errors and facilitates ongoing quality care between episodes of care and between providers (continuity of care)

• Helps prevent medically necessary services from being denied

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Poor documentation, including illegible and incomplete entries, may delay necessary care, claims submission, and payment

PresenterPresentation NotesProper documentation is an important component of high-quality health care delivery, and promotes member safety. It minimizes errors and facilitates ongoing quality care between episodes of care and between providers. Furthermore, proper documentation helps prevent medically necessary services from being denied. Poor documentation, including illegible and incomplete entries, may delay necessary care, claims submission, and payment

DOCUMENTATION

Minimum Documentation Requirements

• Chief complaint and history of present illness, including relevant past medical history and prior treatment for same condition

• Evaluation of musculoskeletal/nervous system through physical examination including:

• Specific objective findings

• Presence of a subluxation

• Level of dysfunction

• Functional status

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PresenterPresentation NotesAt a minimum, the following components are required for proper documentation of chiropractic care:Chief complaint and history of present illness, including relevant past medical history and prior treatment for the same condition.Evaluation of the musculoskeletal and/or nervous system through physical examination including specific objective findings, the presence of a subluxation, the specific level of dysfunction, and the functional status of the patient.

DOCUMENTATION

Minimum Documentation Requirements – cont.

• Diagnosis • Is a subluxation present? (CMS requirement)

• What specific level?

• Acute? Chronic? Exacerbation? • Treatment plan

• Long and short term goals

• # of visits requested

• Reasonable estimation of treatment duration

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PresenterPresentation NotesDiagnosis, including the presence of a subluxation (a CMS requirement), the specific level of dysfunction, and the nature of the dysfunction (acute, chronic, or exacerbation).Next, a treatment plan is required that includes both long and short-term goals, the number of visits requested, and a reasonable estimation of the treatment duration.

DOCUMENTATION

Current Functional Status

• Subjective (patient description of condition)

• Objective physical findings

• Use of the Patient Specific Functional Scale (PSFS) or other relevant tool for the assessment of functional status

• PSFS is preferred

• Utilize the same assessment tool throughout the episode of care

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PresenterPresentation NotesThe current functional status of the patient must be documented and must include the patient’s description of the condition, relevant objective physical findings, and the findings of a validated instrument for the assessment of functional status. The Patient Specific Functional Scale (or PSFS) is the preferred tool, but the provider may use any validated instrument, as long as the same tool is used throughout the episode of care.

DOCUMENTATION

Objective Progress

• Use objective, verifiable, and reproducible measures

• Compare to previous values

• Update functional status (PSFS or other tool – same tool throughout episode of care)

• Document need for additional visits and the basis for that determination, if

applicable

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PresenterPresentation NotesIn order to properly document patient progress, the provider must:document objective, verifiable and reproducible measuresthe results of these measures must be compared to previous valuesthe functional status must be updated and the need for additional visits and the basis for that determination must be clearly stated

DOCUMENTATION

Most Common Reasons for Partial or Full Denial Related to Documentation

• No documentation of initial examination

• Daily clinical notes do not include all visits within the episode of care since the previous submission

• No documentation of objective measures to evaluate treatment effectiveness, visit to visit (pain scores, ROM, ADL clinical measures, PSFS)

• No documentation of treatment effectiveness, visit to visit

• No documentation of care plan (duration and frequency of visits)

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PresenterPresentation NotesAs stated previously, improper documentation is the #1 reason for partial or full denials of chiropractic service requests. The top 10 most common documentation errors are listed on the next 2 slides and include:No documentation of initial examinationDaily clinical notes do not include all visits within the episode of care since the previous submissionNo documentation of objective measures to evaluate treatment effectiveness from one visit to the next (for example, missing pain scores, range of motion measurements, activities of daily living clinical measures, and PSFS)No documentation of treatment effectiveness from one visit to the nextNo documentation of the plan of care, including the duration and frequency of the visits requested

DOCUMENTATION

Most Common Reasons for Partial or Full Denial Related to Documentation

• No documentation of re-examination every 30-45 days during the

episode of care

• Illegible chart

• Use of atypical abbreviations

• The number of visits requested does not match the proposed treatment plan

• No revision of the treatment plan based upon the patient’s progress

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PresenterPresentation NotesNo documentation of reexamination every 30-45 days during the episode of careIllegible chart entriesUse of atypical abbreviationsMismatch between the number of visits requested and the proposed treatment planNo revision of the treatment plan Ace to upon the patient’s progress

DOCUMENTATION

Illegible Chart Entries

• Total legibility is an absolute MUST, whether handwritten or typewritten

• If chart entries are only decipherable by office staff, they are too illegible for submission

• “Passed Away Office” principle: If everyone in the provider’s office “passed away” who would be left to decipher the provider’s chart entry that is not legible to outside observers?

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*Colored or shaded documents do not copy well or transmit well via fax *Use white paper and use only black or dark blue ink for chart records.

PresenterPresentation NotesThe importance of a legible chart entry cannot be overstated. Total legibility is an absolute must, whether the entry is written by hand or typewritten. If chart entries are only decipherable by office staff, they are sufficiently legible for submission.The so-called “Passed Away Office” principle bears consideration and asks: if everyone in the provider’s office passed away, who would be left to decipher the provider’s chart entry that is not lePlease keep in mind that colored or shaded documents do not copy well or transmit well via fax. All chart entries should be on white paper and made with black or dark blue ink only. gible to outside observers?

DOCUMENTATION

Lack of Demographic Information

• Patient records must contain complete information that identifies the patient and the office encounter

• The patient’s full name and the complete date of the encounter must be on every page supplied and be clearly visible to the reader.

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PresenterPresentation NotesPatient records must contain complete information that identifies the patient and the office encounter. To that end, the patient’s full name and the complete date of the encounter must be on every page supplied and be clearly visible to the reader 

DOCUMENTATION

Extraneous Information

• In order for an outside party to most appropriately and expeditiously review a patient’s chart, information relevant to the current condition and request is necessary

• The submission of multiple pages of information that is clinically irrelevant to the patient encounter serves to distract the reviewer from the germane facts of the case and delay the medical necessity determination

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PresenterPresentation NotesIn order for an outside party to most appropriately and expeditiously review a patient’s chart, information that is relevant to the current condition and service request is necessary. The submission of multiple pages of information that is clinically irrelevant to the patient encounter serves to distract the reviewer from the germane facts of the case and delay the medical necessity determination.

DOCUMENTATION

Use of Subjective Descriptors

• Using phrases such as “Doing well” or “No change” does not tell anyone what happened during that encounter

• Proper documentation must be unambiguous in order to be properly interpreted and requires the use of objective physical measures that are verifiable and reproducible

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PresenterPresentation NotesUsing phrases such as “doing well” or “no change” does not tell anyone what happened during that encounter. Proper documentation must be unambiguous in order to be properly interpreted and requires the use of objective physical measures that are verifiable and reproducible.

DOCUMENTATION

Incomplete Chart Entries

Incomplete chart entries:

• May be mistakenly interpreted as gaps in care

• Make the condition, findings, and management of the patient more difficult to understand

• “If it’s not documented, it didn’t happen.”

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PresenterPresentation NotesIncomplete chart entries may be mistakenly interpreted as gaps in care and may make the condition, findings, and management of the patient more difficult to understand. It is important to heed the old adage: “If it’s not documented, it didn’t happen.”

MEDICARE ADVANTAGE

PresenterPresentation NotesAnd now a few important words about documentation of chiropractic encounters for Medicare Advantage members.

MEDICARE ADVANTAGE

Medicare Advantage Medial Policy Z-6 (Chiropractic Services)

• The primary diagnosis must be an ICD-9 spinal subluxation diagnosis code (739.x)

• The secondary diagnosis must be an ICD-9 neuromuscular diagnosis code

• Components required to establish medical necessity

• Presence of a subluxation

• Documentation of the subluxation by x-ray or exam (PART)

• Documentation of initial and subsequent visits

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PresenterPresentation NotesMedical necessity criteria and documentation requirements for chiropractic services under Medicare Advantage are outlined in Highmark Medicare Advantage Medical Policy Z-6 (Chiropractic Services). Some of the more important points to remember are:The primary diagnosis must be an ICD-9 spinal subluxation diagnosis code (739.x).The secondary diagnosis must be an ICD-9 neuromuscular diagnosis code.The following components are necessary in order to establish medical necessity:The presence of a subluxationDocumentation of that subluxation by x-ray or examinationDocumentation of initial and all subsequent visits

MEDICARE ADVANTAGE

Medicare Advantage Medial Policy Z-6 (Chiropractic Services)

The acronym “PART” must be used to describe the exam components indicating that the patient is suffering from a spinal condition amenable to manipulation

PART

• P Pain/tenderness • A Asymmetry/misalignment • R Range of motion abnormality • T Tissue/tone changes

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At least 2 of the 4 PART criteria must be met, with at least one of them being the “A” or “R” component

PresenterPresentation NotesThe acronym “PART” must be used to describe the exam components indicate that the patient is suffering from a spinal condition amenable to manipulation.The components of “PART” include:“P”Pain/tenderness“A”Asymmetry/misalignment“R”Range of motion abnormality“T”Tissue/tone changesAt least 2 of the 4 components must be addressed, with at least one of them being the “A” or “R” component.

ROUTINE & NON-ROUTINE CHIROPRACTIC CARE

PresenterPresentation NotesRoutine and Non-Routine chiropractic care refers to a Medicare Advantage benefit only, and does not apply to commercial products.

ROUTINE CHIROPRACTIC CARE

When a member’s plan offers Routine Chiropractic Care as a benefit: • Depending upon the type of plan, the member has 8 routine chiropractic

visits to use per calendar year (*Security Blue HMO Deluxe members have 6 routine visits)

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Routine visits DO NOT require an authorization and can be used at any time throughout the calendar year.

PresenterPresentation NotesWhen a member’s plan offers routine chiropractic care as a benefit, the member has 8 routine chiropractic visits to use her calendar year.Please note: Security Blue HMO Deluxe members have 6 routine visits per calendar year.Routine chiropractic visits do not require an authorization and can be used at any time throughout the calendar year.

NON-ROUTINE CHIROPRACTIC CARE

When the member has an acute condition or exacerbation of a chronic condition Non-Routine chiropractic visits must be used

Non-Routine Chiropractic Care DOES require an authorization

• The participating provider then contacts Healthways to request an

authorization for the medically necessary visits, up to 8 visits if approved, to be used in a 60 day time-frame (These are the registered visits that are auto approved)

(Note: Claims coming through BlueCard do not require authorization) • Once the 8 Non-Routine registered visits are exhausted or the 60 day time-

frame has expired, if additional visits are needed, the provider then requests authorization for the additional Non-Routine visits up to a total of 30 in a calendar year.

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PresenterPresentation NotesWhen a member has an acute condition or exacerbation of a chronic condition non-routine chiropractic visits must be used.Non-routine chiropractic care does require an authorization.The participating provider contacts Healthways requesting authorization for the medically necessary visits, up to 8 visits if approved, to be used in a 60 day timeframe. These are the registered visits that are auto-approved.Please note: Claims coming through BlueCard do not require authorization.Once the 8 non-routine registered visits are exhausted or the 60 day timeframe as expired, if additional visits are needed, the provider must request authorization for the additional non-routine visits, up to a total of 30 and a calendar year.

ROUTINE & NON-ROUTINE CHIROPRACTIC CARE

Member Responsibility The member is responsible for… • Knowing their benefits and any required co-pays or coinsurance as listed in

their Evidence of Coverage manual • Contacting Customer Service with any questions regarding their benefits

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PresenterPresentation NotesWith regard to routine versus non-routine chiropractic care, the member is responsible for:Knowing their benefits and any required co-pays or coinsurance as listed in their Evidence of Coverage manual and Contacting customer service with any questions regarding their benefits.

ROUTINE & NON-ROUTINE CHIROPRACTIC CARE

Participating Provider Responsibility The participating provider is responsible for… • Contacting Provider Services to verify member eligibility and benefits via

phone or Navinet

• Requesting any authorizations that may be required

• Utilizing and billing procedures codes correctly

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PresenterPresentation NotesThe participating provider is responsible for: Contacting provider services to verify member eligibility and benefits via NaviNet or telephoneRequesting any authorization that may be required, andUtilizing and billing procedure codes correctly

TAKE-AWAY POINTS

• Complete information on the PMMP is available online via the Provider Resource Center

• Contact your Provider Representative if additional assistance is needed

• NaviNet is the most efficient and the preferred method for submission of requests

• Proper documentation is required and helps ensure that medically necessary treatment is not improperly delayed or denied

• There are important differences between commercial and Medicare Advantage members in terms of physical medicine benefits and documentation requirements

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PresenterPresentation NotesImportant take away points from this webinar include:Complete information on the Physical Medicine Management Program is available on line via the Provider Resource Center;Your provider representative is your most important resource if additional assistance is needed;NaviNet is the most efficient and the preferred method for submission of requests;Proper documentation is required and helps ensure that medically necessary treatment is not improperly delayed or denied; and lastlyThere are important differences between commercial and Medicare Advantage members in terms of physical medicine benefits and documentation requirements

PROVIDER RELATIONS REPRESENTATIVES

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Justin Crousey Joanne Kramer Kim Mitchell Armstrong Allegheny Bedford

Beaver Blair

Butler Cambria

Cameron Clearfield

Clarion Fayette

Crawford Greene

Elk Huntingdon

Erie Indiana

Forest Somerset

Jefferson Washington

Lawrence Westmoreland

McKean

Mercer

Potter

Warren

Venango

PresenterPresentation NotesPlease take a moment to locate your county on the chart. The column title is the name of your provider relations representative. The chart is being provided as the Provider Resource Center territories are currently being updated.

Thank you for your time today!

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