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Documentation, Coding and Compliance Updates Mario Fucinari DC, CCSP, APMP, CPCO, MCS-P

Certified Professional Compliance Officer (CPCO)

Certified Medical Compliance Specialist (MCS-P)

Presented by ChiroHealthUSA

Disclaimer: The views and opinions expressed in this presentation are solely those of the author.

NCMIC and Mario Fucinari DC do not set practice standards. We offer this only to educate and

inform. The laws, rules and regulations regarding the establishment and operation of a healthcare

facility vary greatly from state to state and are constantly changing. Dr. Mario Fucinari does not

engage in providing legal services. If legal services are required, the services of a healthcare

attorney should be attained. The information in these seminar slides is for educational purposes

only and should not be construed as written policy for any federal agency.

NO RECORDING OF ANY TYPE ALLOWED

This Material is Copyright Protected

Unauthorized Audiotaping or Videotaping or Distribution of any presentation materials is illegal.

LEGAL NOTICE: The information contained in this workbook is for educational purposes

and is not intended to be and is not legal advice. Audiotaping and/or videotaping are strictly

PROHIBITED during the presentations. The laws, rules and regulations regarding the

establishment and operation of a healthcare facility vary greatly from state to state and are

constantly changing. Mario Fucinari DC does not engage in providing legal services. If legal

services are required, the services of a healthcare attorney should be attained. The information

in this class workbook is for educational purposes only and should not be construed as written

policy for any federal or state agency. All clinical examples are based on true stories. The

patient names in the clinical examples have been changed to protect the innocent. No part of

this workbook covered by the copyright herein may be reproduced, transmitted,

transcribed, stored in a retrieval system or translated into any language in any form by

any means (graphics, electronic, mechanical, including photocopying, recording, taping

or otherwise) without the expressed written permission of Mario Fucinari DC. Making

copies of this seminar workbook and distributing for profit or non-profit is ILLEGAL.

Mario Fucinari DC assumes no liability for data contained or not contained in this workbook

and assumes no responsibility for the consequences attributable to or related to any use or

interpretation of any information or views contained in or not contained in this seminar

workbook.

CPT® is a registered trademark of the AMA. The AMA does not directly or indirectly assume

any liability for data contained or not contained in this seminar workbook. This seminar workbook

provides information in regard to the subject matter covered. Every attempt has been made to

make certain that the information in this seminar workbook is 100% accurate, however it is not

guaranteed.

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About Dr. Mario Fucinari, CCSP®, APMP, CPCO, MCS-P

• Graduate of Palmer College of Chiropractic - 1986

• Currently in Full Time Practice in Decatur, Illinois

• Certified Chiropractic Sports Physician (CCSP) – Logan College of Chiropractic

• Certified Medical Compliance Specialist Physician – (MCS-P)

• Certified Professional Compliance Officer – CPCO (AAPC)

• Diplomate Academy of Integrative Pain Management (APMP)

• Post-graduate Faculty of Palmer College of Chiropractic, NYCC, D’Youville College, Life West and Western States Chiropractic College

• National Speaker’s Bureau for NCMIC, ChiroHealthUSA and Foot Levelers and many state associations

• Member Medicare Carrier Advisory Committee

• Past President of Illinois Chiropractic Society (ICS)

• Chairman, ICS Medicare Committee

• ICS Chiropractor of the Year 2012

• Member of ACA and ICS

New information posted regularly at

www.facebook.com/askmario “Like” us to get updates

Ethics and Compliance

Compliance Program Guidelines

In 1991, the United States Sentencing Commission Federal Sentencing Guidelines were

published. These guidelines were used by the United States government for the sentencing of

organizations.

The Sentencing Guidelines have been used by Federal courts in determining criminal fines for

corporations and organizations. The guidelines have provided the groundwork for compliance

programs ever since. A mitigating factor in this determination has been the existence of an

effective compliance program as defined in the Sentencing Guidelines. This is known as the

culpability score. The health care industry has used the Sentencing Guidelines as a framework

reference for establishing a compliance program and compliance guidance.

Federal Sentencing Guidelines

• Established in 1991 • Adopted by the OIG, FBI, DOJ • Controls sentencing of organizations for most federal criminal violations • Used as mitigating factor in sentencing • Credit for “effective programs to prevent and detect violations of the law.”

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Patient Protection and Affordable Care Act requires that you have the establishment of a

compliance program.

It has become quite clear that the adoption of the “Seven Elements of a Compliance Program”

have become a mainstay of compliance in the corporate world and in healthcare. To protect

oneself by showing a culture of ethics, it is recommended that these elements are adopted to

demonstrate the ethical culture of the organization.

Seven Elements of Your Compliance Program

1. Implement written policies and procedures; 2. Designate a compliance officer; 3. Conduct comprehensive training and education; 4. Develop accessible lines of communication; 5. Conduct auditing and internal monitoring;

a. Auditing ٠ Implement risk evaluation and auditing techniques ٠ Best if done by an outside entity so as not to be biased ٠ Must be independent and objective

b. Monitoring ٠ Based on assessment of risk ٠ Used as a management tool ٠ Day-to-day activities within the office ٠ Scalable to the risks and resources

6. Enforcing standards through well publicized disciplinary guidelines; and 7. Responding promptly to detected offenses and undertaking corrective actions.

Policies

“The set of basic principles and associated guidelines, formulated and enforced by the

governing body of an organization, to direct and limit its actions in pursuit of long-term goals.” *

Procedures

“A fixed step-by-step sequence of activities or course of action…that must be followed in the

same order to correctly perform a task.”

The Eighth Element added is that all employees must be checked against the OIG Exclusion

Database http://exclusions.oig.hhs.gov/ This is recommended to be done quarterly.

MEDICARE

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Revalidation Required with Medicare

The Medicare Card

CMS has released images of the newly designed and

renamed Medicare Beneficiary Identifier (MBI) card.

The new MBI card will be introduced on April 1,

2018. The card will go through a transition period

from April 1, 2018 through December 31, 2019 as

more than 44 million beneficiaries convert to the new

card with a new identification number. The Medicare

Beneficiary Identifier card will contain a unique,

randomly-assigned 11-character identification number

that replaces the current Social Security-based

number. Each MBI identifier will be randomly generated. An example of the new identifier

would be: 1EG4-TE5-MK73

CMS will begin mailing the new cards to people who receive Medicare benefits in April 2018.

The statutory deadline is to replace all the existing Medicare health insurance cards by December

31, 2019.

Medicare Part B

• In 2018 the deductible will be $183

• Only covered services are applied to the deductible

• Co-insurance: 20 percent.

• It is illegal to waive ANY part of the deductible or coinsurance

Filing of Medicare Claims

Medicare Processing Manual §70.8.6 – Time Limitation for Filing Part B Reasonable Charge

and Fee Schedule Claims (Rev. 170, 05-07-04)

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• Medicare law prescribes specific time limits within which claims for benefits may be

submitted with respect to physician and other Part B services payable on a reasonable

charge or fee schedule basis

• For these services, the terms of the law require that the claim be filed no later than the

end of the calendar year following the year in which the service was furnished…

“Opting out of Medicare is not an option for Doctors of Chiropractic. Note that opting out and

being non-participating are not the same things. Chiropractors may decide to be participating or

non-participating with regard to Medicare, but they may not opt out.”

MedLearn Matters SE0479

Did you do PQRS in 2016? _____ If no, subtract 2%

Did you do an attestation for Meaningful use in 2016? _____ If no, subtract 3%

This is the NEW amount charged to the patient. ____________________

In 2018, sequestration continues. An additional 2% will be deducted from your payment.

Medicare Updates! ▪ H.R. 2, SECTION 514 – Oversight of Medicare Coverage of Manual Manipulation of

the Spine to Correct a Subluxation

▪ Sequestration

▪ EHR Meaningful Use

▪ PQRS Penalty

▪ Value-Based Modifier

Medicare MIPS Program

Quality Payment Program (QPP)

In January 2017, the Medicare Access and CHIP Authorization (MACRA) took effect.

Medicare will begin payment based on the Quality Payment Program (QPP). The QPP structure

allows clinicians to follow one of two paths: the Merit-based Incentive System (MIPS) or

Advanced Alternative Payment Models (AAPMs). MACRA also addresses chiropractic

utilization of services. As a measure to meet MACRA requirements, it is recommended that all

physicians become knowledgeable in the implementation of the payment system and

requirements in its Medicare documentation.

2018 threshold for Medicare QPP < $90,000 AND

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Documentation must be legible

Medicare Documentation Requirements

The patient's medical record must contain documentation that fully supports the medical

necessity for manipulation. This documentation includes, but is not limited to, relevant medical

history, physical examination, and results of pertinent diagnostic tests or procedures.

“The Episode of Care”

Box 14:

Medicare –

Commercial Insurance –

PI/ Work Comp -

Medicare Initial Encounter Report

Symptoms causing patient to seek treatment

Family History

Past Health History

(Social History)

Mechanism of

Trauma

Quality and character of symptoms/problem

Onset, duration, intensity, frequency, location and radiation

Provoking and Palliative Factors

Prior interventions, treatments, medications, secondary complaints

Treatment Plan

− Frequency and duration − Treatment Goals − Care Plan

Chief Complaint – a concise statement describing the symptom, problem, condition, diagnosis,

or other factor that is the reason for the encounter, usually stated in the patient’s own words.

• Symptoms causing patient to seek treatment (Chief Complaint) – What brought the patient in?

• Acute injury/trauma? • Chronic condition…why now?

• Prior level of function

Family History – specific health related events in the patient’s family. Includes information about

the health status or cause of death of parents, siblings, and children and the following diseases:

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Orthopedic (arthritis, scoliosis) ______________

Neurologic ____________

Pathology (heart disease, cancer, diabetes)

Past Health history

Prior Illnesses and injuries

Type, date, treatment, current status

Prior Interventions Type, date, treatment, outcome

Prior Surgery Type, date, reason, results, current status

Hospitalizations

Prior trauma

Type, date, treatment, current status and extent of impairment

The most common mistake is not going back far enough when questioning

about trauma or injury.

Medications

Allergies

Immunization status

Dietary status

Social History

Marital status

Employment history

Occupational history

Use of drugs, alcohol, tobacco

Level of education

Sexual history and social factors

L, M, N, O, P,Q,R,S,T

Mechanism of Trauma

Onset, duration, intensity, frequency, location and radiation

Box 14:

Provoking and Palliative Factors

Prior interventions, treatments, medications, secondary complaints

Quality and character of symptoms/problem

Radiation of symptoms

Severity

Time

Review of Systems (ROS) – a series of questions of body systems that is used to clarify the

differential diagnosis (Ddx) , necessary tests, or for baseline data.

Code 99203: 3-8 out of 13 must be present. If NO ROS are present, then it is a 99201 code.

The Big Five

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ROS must document that you reviewed the systems with the patient. “Denies” or “Complains

of” should be listed

Nurse’s Code:

Example:

Cardiovascular: Denies: Shortness of breath, chest pain. Complains of: hypertension

Musculoskeletal: Denies: leg weakness or paresthesia. Complains of: right knee pain, right

leg pain into the great toe

The General Basics of a S.O.A.P. Note

Subjective – What’s going on? • Reporting of patient pain, limitations, concerns and problems.

• Information that cannot be verified or measured during the encounter.

• You may want to use a quote or summarize what the patient reported.

Medicare SOAP I. History (an interval history sufficient to support continuing need; document substantive

changes)

Review of chief complaints (is this in relationship to the initial visit or treatment for the

exacerbation)

Changes since last visit

System review if relevant

Railroad Medicare: Always address the following: ________________________

II. Physical Exam (interval; document subsequent changes; a full repeat of PART is not expected)

Exam of area of the spine involved in Dx.

Assessment of change in patient condition since last visit

Evaluation of treatment effectiveness

III. Evaluation of treatment effectiveness

In regard to the recommended level of care, duration, frequency and goals that were

developed at the initial visit or at the time of exacerbation.

IV. Documentation of how the day’s treatment fits within the plan of care (e.g. visit 4 of

planned 7 treatments) and any way the treatment plan is being changed

You must document the actual segments that you adjusted.

Document the response to the adjustment. “patient tolerated treatment without incident”

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• Changes in ADL?

• Are they compliant with their home care?

• New injuries or new conditions?

• Any questions or comments?

Objective – What did you find?

• Reporting of all measurable, quantifiable, and observable data obtained during the encounter.

• Present a picture by reporting anything that the provider used their senses (vision, hearing, smell, touch)

• Does not depend on patient reporting.

• Make certain that it is clear that you were not just a passive observer in the visit.

• Remember that your documentation may be read by those unfamiliar with the shorthand that health professionals use so freely.

• Use judgment when using abbreviations and keep them standard.

• Include functional status and the positive and significant negative tests that you performed.

Medicare P.A.R.T.

P.A.R.T.

Used to demonstrate a subluxation based on physical examination, two of the four criteria

mentioned under the above physical examination list are required, one of which must be

asymmetry/misalignment or range of motion abnormality. BE SEGMENT SPECIFIC.

P.A.R.T.

(2 of the 4 Required)

1. Pain/Tenderness - location, quality, intensity

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

observation, percussion, palpation, provocation, etc. Furthermore, pain intensity may be

assessed using one or more of the following: visual analog scales, algometers, pain

questionnaires, etc.

2. Asymmetry/misalignment - sectional or segmental level

Asymmetry/misalignment - Asymmetry/misalignment may be identified on a sectional or

segmental level through one or more of the following: observation (posture and gait

analysis), static palpation for misalignment of vertebral segments, diagnostic imaging, etc.

3. Range of Motion Abnormality

Range of motion abnormality (changes in active, passive, and accessory joint movements

resulting in an increase or a decrease of sectional or segmental mobility); and Range of

motion abnormality - Range of motion abnormalities may be identified through one or more

of the following: motion, palpation, observation, stress diagnostic imaging, range of motion

measurements, etc.

4. Tissue, tone changes in skin, fascia, muscle, ligament

Tissue, tone changes using descriptions pertaining to the characteristics of contiguous, or

associated soft tissues, including skin, fascia, muscle, and ligament. Tissue/Tone texture

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may be identified through one or more of the following procedures: observation, palpation,

use of instruments, tests for length and strength etc.

Evaluation and Management (E/M) CPT Codes

99201-99205/99211-99215

Seven Components of the E/M service

Key Components

• History

• Examination

• Medical decision making

Contributing Components

• Counseling

• Coordination of care

• Nature of presenting problem; and

• Time

The Examination:

On the initial examination or if significant, on

subsequent visits, note the following:

• Inspection

• Patient build

• Carriage and gait cycle

• Patient movement

• Examine the shoes

• Scoliosis

• Antalgia

• Skin appearance

• Biomechanical Inspection “Life in Balance”

In summary, the physical exam should include:

• Orthopedic and neurologic tests

• Palpation findings

• Pinprick sensitivity tests

• Reflexes

• Range of Motion - Give plane and degrees so it can be referenced later to show progress. The more specific the degrees, the better. Note pain.

• Muscle strength

• Outcome Questionnaires

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Evidence Based Outcomes Assessment Tools (OATs)

Measures Functional Impairment

Why Outcomes Assessment?

• An objective measure of the patient’s status

• Provides objective documentation regarding the patient’s condition.

• Helps the doctor, patient and insurer to make informed decisions

• A deterrent to malpractice

• Backed up by refereed journals (JMPT, Spine)

Outcomes Assessment Tools

• Have patient complete on initial exam, on re-exam or as clinically indicated and at any exacerbations.

• These tests quantify the amount of patient deconditioning present.

• A measure of the patient’s functional impairment of activities of daily living.

Outcome Assessment Tests

• Visual Analog Scale

• Pain Drawings

• Revised Oswestry Low Back Pain Disability Questionnaire

• Roland-Morris Disability

• Neck Pain Disability Index Questionnaire

• Headache Disability Index

• Bournemouth Questionnaire – Cervical and Lumbar. “Lifestyle illnesses”

• Zung Psychological Assessment Questionnaire

Neck Pain Disability Index Score

0-8% = None

10-28% = Mild

30-48% = Moderate

50-68% = Severe

>70% = Crippled

Revised Oswestry Score:

0-5% = None

6-20% = Mild

20-40% = Moderate

40-60% = Severe

60-80% = Crippled

80%+ Bed Bound

OATS → Tx Goals

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*If you compare the original score to the score at re-examination, there must be a minimum of a

30% decrease in score on re-evaluation to be clinically significant.

Re-Examination

• Formal re-examination should be done “to determine progress and need for further care”

• Should be done at least every 10-15 visits or every 30-45 days.

• Recheck all positive findings and significant negative findings.

A re-examination should include

• A brief consultation about current condition

• Repeat of significant orthopedic tests

• Visual Analog Scale or Borg Scale

• Outcome measures test repeated

After the re-examination, update record with an interim note or report. This will document and

explain the clinical significance of why you did the exam (rationale) and the results of the exam.

This then leads to your treatment plan and treatment goals.

– Any change in diagnosis – Treatment frequency/schedule – Treatment goals – Restrictions – Referrals or further tests – Exercise/rehabilitation

Re-evaluations

• Demonstrate the patients’ progress in objective, rather than conclusory terms • The evaluation elements, noted in the initial evaluation need not be documented at each

treatment; however, they must be present often enough to show measurable progress, or

failure to progress

– “Documentation of changes in the patient’s examination, status, progression must be recorded in the records at each visit.

– The evaluation process must be an ongoing procedure. Even if a complete and thorough examination can be completed during the first visit, signs and certain symptoms must be

rechecked during the course of treatment to determine the extent of the patient progress.

– The ongoing evaluation and assessment forming the basis for treatment modification is a key factor in total patient management.

– The initial examination, no matter how thorough, cannot be expected to provide all the answers.

– A treatment trial should be instituted with its effects assessed to determine whether it should be continued, or a different plan devised.

– It is the examination, that forms the foundation for treatment, guiding the doctor in selecting the appropriate treatment techniques, frequency, and the course of treatment.

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Assessment – What do you think? • Provider records their professional opinions and judgments as to the patient’s diagnosis, their

progress and/or their functional limitations.

• You interpret the data presented in the objective portion of the note.

• You may also point out inconsistencies, justify your goals, discuss emotional status or indicate progress in therapy.

• You may also present reasons why certain information was not obtained or deferred.

In your assessment, always answer:

How is the patient improved?

Why does the patient still need care?

Treatment Plan What are you going to do about it?

Treatment Plan:

1. Treatment Frequency AND DURATION include re-examination 2. Treatment Goals

a) Short-term Goals (2 Weeks) 1. Decrease pain, spasms, edema and increase range of motion 2. Resolution of any radicular pain in the lower extremity 3. Low back pain consistently less than or equal to 6/10 with all activities 4. Resting low back pain with less than or equal to 2/10 5. Independent with basic self-care ADL without increased low back pain

b) Long-term Goals (4+ Weeks) 1. Low back pain at worst less than or equal to 4/10 with all activities 2. Patient will ambulate 15 minutes at 2.0 miles per hour without increased low back pain 3. Bilateral hip flexion, multifidus and gluteal strength to 4+ to 5/5 4. Independent self-management 5. To prepare the patient for a home-based exercise program

3. Care Plan - an ordered assembly of expected/planned activities or actionable elements based

on identified deficiencies. These may include observations goals, services, appointments and

procedures, usually organized in phases or sessions, which have the objective of organizing and

managing health care activity for the patient, often focused on one or more of the patient’s health

care problems.

a) Acute b) Sub-acute c) Maintenance/Wellness

Medicare Medical Necessity NEW LCD ▪ The patient must have a significant health problem in the form of a neuromusculoskeletal

condition necessitating treatment, and the manipulative services rendered must have a direct

therapeutic relationship to the patient’s condition.

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▪ You must have a reasonable expectation of recovery or improvement of function. ▪ The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam.

A diagnosis of pain is not sufficient for medical necessity

▪ Acute subluxation - Acute subluxation - A patient’s condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical exam as specified

above. The result of chiropractic manipulation is expected to be an improvement in, or arrest

of progression, of the patient’s condition.

▪ Chronic subluxation - A patient’s condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute

condition), but where the continued therapy can be expected to result in some functional

improvement. Once the clinical status has remained stable for a given condition, without

expectation of additional objective clinical improvements, further manipulative treatment is

considered maintenance therapy and is not covered. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3)

An acute exacerbation is a temporary but marked deterioration of the patient’s condition that is

causing significant interference with activities of daily living due to an acute flare-up of the

previously treated condition. The patient’s clinical record must specify the date of occurrence,

nature of the onset, or other pertinent factors that would support the medical necessity of

treatment. As with an acute injury, treatment should result in improvement or arrest of the

deterioration within a reasonable period of time.

Maintenance Therapy

▪ Once MMI has been reached, Medicare will NOT pay for maintenance or supportive care.

___ Maintenance therapy includes services that seek to prevent disease, promote health and

prolong and enhance the quality of life, or ____ maintain or prevent deterioration of a chronic

condition. When further clinical improvement cannot reasonably be expected from continuous

ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature,

the treatment is then considered maintenance therapy. (CMS Publication 100-02, Medicare Benefit Policy

Manual, Chapter 15, Section 240.1.3A)

Maintenance Care:

1.

2.

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Episode of Care

Modifiers Medicare Modifiers GY - Used when an item or service is statutorily excluded or does not meet the definition of any

Medicare benefit. This modifier must be used when physicians, practitioners, or suppliers want to

indicate that the item or service is statutorily non-covered (as defined in the Program Integrity

Manual (PIM) or is not a Medicare benefit (as defined in the PIM). The use of this modifier will

automatically signal Medicare’s software to deny any service that is linked to this modifier.

• If the service is statutorily non-covered or is not a Medicare benefit, modifier GY may be used if the beneficiary insists on having Medicare billed.

GZ - Used when an item or service is expected to be denied as not reasonable and necessary. This

modifier must be used when physicians want to indicate that they expect that Medicare will deny

an item or service as not reasonable and necessary and they have not had an Advance Beneficiary

Notification (ABN) signed by the beneficiary.

If the beneficiary is not notified in writing that the provider expects that Medicare will deny the

item or service, she/he cannot be held liable for the charges. The GZ modifier must be used to

indicate that the provider expects that Medicare will deny an item or service as not reasonable

and necessary and there had not been an ABN signed by the beneficiary.

GA - This modifier is used to indicate that a waiver of liability statement is on file. If the

provider believes a service is likely to be denied by Medicare as not reasonable and necessary,

the beneficiary must be so advised, in writing, prior to rendering of the service. The GA modifier

must be used to indicate that the provider expects that Medicare will deny the service as not

reasonable and necessary and the beneficiary has a signed Advance Beneficiary Notification

(ABN) on file.

-AT Modifier

The –AT Modifier will be used with the CMT code in all acute and chronic subluxation (non-

maintenance) spinal CMT cases. If the AT modifier is not listed on the code, the CMT will be

considered to be for maintenance and automatically denied. The AT modifier is only to be

appended to services that are part of active/corrective treatment. The AT modifier should not be

appended to services that are part of maintenance therapy.

GX Modifier -

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25 – On the same day a procedure or service identified by a CPT code is performed, the patient’s

condition required a significant, separately identifiable E/M code.

example: 99203 25GYGX

98940 AT

Q6 - Locum Tenens

59 Modifier Updates

Modifier 59 - Distinct Procedural Service

• Modifier XE - Separate Encounter: A service that is distinct because it occurred during a separate encounter

• Modifier XS - Separate Structure: A service that is distinct because it was performed on a separate organ/structure

• Modifier XP- Separate Practitioner: A service that is distinct because it was performed by a different practitioner

• Modifier XU - Unusual Non-Overlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service

a. Ensure that you have clinical circumstances to justify the modifiers and please do not append to HCPCS and CPT codes to simply bypass the NCCI edits.

b. Medicare considers two physicians in the same group with the same specialty performing services on the same day as the same physician.

Episode of Care

The Advanced Beneficiary Notice Form

(June 21, 2017)

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.

See § 50.5 – Triggering Events.

1. One ABN for maintenance manipulation and one for non-covered services (“voluntary”) 2. Good for up to one year 3. Signed copy to patient

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4. Update as needed 5. Personally signed and dated by the patient

Red Flags of the ABN:

Name:

Identification

Number:

Options:

Signature and Date:

Offering Gifts and Other Inducements to Beneficiaries

A person who offers or transfers to a Medicare or Medicaid beneficiary any remuneration that

the person knows or should know is likely to influence the beneficiary’s selection of a particular

provider, practitioner, or supplier of Medicare or Medicaid payable items or services may be

liable for civil money penalties (CMPs) of up to $10,000 for each wrongful act. The statute

defines “remuneration” to include, without limitation, waivers of copayments and deductible

amounts (or parts thereof) and transfers of items or services for free or for other than fair market

value.

The OIG has interpreted the prohibition to permit providers to offer beneficiaries inexpensive gifts

(other than cash or cash equivalents) or services without violating the statute. For enforcement

purposes, inexpensive gifts or services are those that have a retail value of not more than $10

individually, and no more than $50 in the aggregate annually per patient.

Similarly, there is no meaningful statutory basis for a broad exemption based on the financial need

of a category of patients. The statute specifically applies the prohibition to the Medicaid program

– a program that is available only to financially needy persons. The inclusion of Medicaid within

the prohibition demonstrates Congress’ conclusion that categorical financial need is not a

sufficient basis for permitting valuable gifts.

This conclusion is supported by the statute’s specific exception for non-routine waivers of co-

payments and deductibles based on individual financial need. If Congress intended a broad

exception for financially needy persons, it is unlikely that it would have expressly included the

Medicaid program within the prohibition and then created such a narrow exception.

Why ChiroHealthUSA?

As benefits for chiropractic care dwindle, more families are forced to choose between needed

chiropractic care and other necessities. Because patients with insurance coverage have the benefit

of the carrier negotiating the fees with the doctor, cash-paying patients, or those with non-covered

services like Medicare beneficiaries, may have to pay MORE than insured patients.

ChiroHealthUSA allows patients to use the membership concept they are already familiar with to

access needed care for their immediate family.

Doctors are usually required to charge insurance companies and patients the same fees unless they

are under a network contract for a lower fee. ChiroHealthUSA is a contracted network that allows

doctors to set and accept discounts on their services for our members. When a patient joins

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ChiroHealthUSA, they are entitled to similar “in-network” discounts just like the insurance

companies.

• A single $49 annual membership includes everyone in your immediate family.

• Partially insured patients who have coverage for some services and not others, like

Medicare patients, may use their ChiroHealthUSA benefits to complement their existing

benefits, specifically for the non-covered services.

• Patients may use their membership cards at more than 3,900 doctors in the network.

Simple. Compliant. Profitable.

ChiroHealthUSA is a provider-owned network designed with doctors in mind. Our network model

allows you to offer legal, network-based discounts to cash, under-insured and “out of network”

patients who are members.

Members covered by Medicare and federal programs are eligible for discounts on non-covered

services. The network approach to discounts reduces the risks of compliance and OIG violations

related to inducements, improper down-coding, dual fee schedules, and potentially inappropriate

time-of-service discounts.

With ChiroHealthUSA, you can choose the level of discounts. The existence of a contract allows

you to set, offer, and accept these rates from our members. Our contract eliminates the “middle

man,” and solves a host of legal and regulatory problems for you and your patients.

ChiroHealthUSA only makes membership available to individuals, which means there is no

potential for “silent PPO” activity to lower your reimbursements.

Patients pay a low annual membership fee that includes them and their legal dependents. This fee

is often recovered through discounts received on their first visits. There is no cost to the clinic for

this program.

www.ChiroHealthUSA.com

Provider Signature Requirements (Effective January 1, 2010)

For medical review purposes, Medicare requires that the author authenticate services

provided/ordered. Medicare denies many claims due to the lack of an appropriate signature. Here

are some things to keep in mind on signature requirements:

1. The signature must be that of the provider of service. This means the person providing the service whether that is the physician or a non-physician practitioner (NPP). No one else

can sign for the physician; this includes another physician in a group, the senior nurse, etc.

2. The signature must be hand-written or electronic. Medicare does not accept stamped signatures.

3. The Centers for Medicare & Medicaid Services (CMS) 1995 and 1997 Documentation Guidelines (DG) for Evaluation and Management (E/M) services require that the provider's

signature be legible. If your signature is not legible, please provide a signature log or

authentication statement verifying the information.

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4. The signature of the transcriptionist is not the same as the physician signature. While your office may need or require this information, Medicare does not.

5. If you are using electronic medical records, please verify your system and software products protect against modification. Providers using electronic systems should recognize

the potential for misuse or abuse with alternate signature methods.

6. If you are splitting or sharing services between yourself and a NPP, then both parties must sign their portion of the service. The NPP cannot sign for the physician.

7. Physician offices should have a protocol in place to have physicians sign their records within a reasonable time, generally 48 to 72 hours after the encounter, but certainly prior

to submitting the claim to Medicare.

8. You cannot add a signature to a record later (this does not include the brief time to transcribe the record), instead use an attestation statement.

No signature on progress/treatment note submitted – attestation sample

“I, (name of doctor) , hereby attest that the medical records entry for the

date of service , accurately reflects signature/notations that I made in my capacity as

a D.C. when I treated/diagnosed .”

I do hereby attest that this information is true, accurate and complete to the best of my

knowledge and I understand that any falsification, omission, or concealment of material fact

may subject me to administrative, civil, or criminal liability.”

Signature: X Date Form Completed X___________________

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ICD-10 Coding and Documentation

Comparisons of ICD-9 to ICD-10

ICD-9 Diagnostic Codes ICD-10 Diagnostic Codes

3-5 Characters in length 3-7 Characters in length

Approximately 17,000 codes Approximately 70,000 available codes

First digit may be alpha; 2nd through 5th is numeric Character 1 is alpha; character 2 and 3 are

numeric; character 4 through 6 can be either

Limited space for adding new codes Flexible for adding new codes

Lacks detail Very specific

Lacks laterality Has laterality

Difficult to analyze data due to non-specific codes Specificity improves coding accuracy and quality

of data for analysis

Codes are non-specific and do not adequately

define diagnoses needed for medical research

Detail improves the accuracy of data used for

medical research

Does not support interoperability because it is not

used by other countries

Supports interoperability and the exchange of

health data between other countries and the U.S.

ICD-10-CM

• The increased specificity of the ICD-10 codes requires more detailed clinical documentation

in order to code some diagnoses to the highest level of specificity

• There are “unspecified” codes in ICD-10-CM for those instances when the health record

documentation is not available to support more specific codes

• The benefits of ICD-10 cannot be realized if non-specific codes are used rather than taking

advantage of the specificity ICD-10 offers

ICD-10 Updates: Example

• M48.061 Spinal stenosis, lumbar region without neurogenic claudication

• M48.062 Spinal stenosis, lumbar region with neurogenic claudication

Data Analysis

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• Aging Baby Boomers

• Increased Co-morbidities

• Complications to Care

• Patient Responsibility for Outcomes

• Population Health Management

• Past actions yield future payment adjustments

What are your local carriers telling you?

ICD-10 Step to UPDATE

1. Gather your last 40 new patient’s charts

2. Make a list of the ICD-10 diagnoses

3. You have your “Top 40 Playlist”

4. Check your EOBs

5. Identify Unspecified Codes and Deleted Codes

6. Convert to 2018 Code Usage

General ICD-10 Coding Guidelines: 1. ICD-10-CM codes should be listed at their highest level of specificity and characters.

a. ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6 or 7 characters. Use

three-character codes only if there are no four-character codes within the coding category.

These are the heading of a category of codes.

You will rarely use a three-character code, if ever.

b. Diagnosis codes are to be used and reported at their highest number of characters

available. Use the 4, 5, 6, or 7-digit code to the greatest degree of specificity available.

These provide further detail.

2. Codes that describe symptoms and signs are only acceptable if that is the highest level of

diagnostic certainty documented by the doctor. No other diagnosis has been established

(confirmed) by the provider. Codes that describe symptoms and signs, as opposed to

diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has

not been established (confirmed) by the provider.

3. Signs and symptoms that are associated routinely with a disease process should not be

assigned as additional codes, unless otherwise instructed by the classification.

www.Askmario.co

m

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a. As an example, you would not use a code for muscle spasm along with a strain code,

since the finding of spasms are routinely associated with a strain.

4. Additional signs and symptoms that are not routinely associated with a disease may be

reported.

5. Coding for diagnoses that are probable, suspected, likely or questionable are not to be

coded, because they indicate uncertainty.

• “Code what you know”

• Rule out and working diagnosis are not to be coded.

6. Code all documented conditions that coexist at the time of the visit that REQUIRE OR

AFFECT patient care. (complicating factors) Do not code conditions that no longer exist.

7. Coding for diagnoses that are probable, suspected, rule out, etc. are not allowed for

outpatients. You can write that you suspect a certain condition in your notes, but the code

for it will not go on the claim form.

8. The term “first-listed” diagnosis is now to be used instead of the term “principle” diagnosis.

“Code first” notes are also under certain codes that are not specifically manifestation codes

but may be due to an underlying cause. When there is a “code first” note and an underlying

condition is present, the underlying condition should be sequenced first.

“Code, if applicable, any causal condition first” notes indicate that this code may be

assigned as a principal diagnosis when the causal condition is unknown or not applicable.

If a causal condition is known, then the code for that condition should be sequenced as the

principal or first-listed diagnosis.

9. Multiple codes may be needed for sequela, complication codes and obstetric codes to more

fully describe a condition. See the specific guidelines for these conditions for further

instruction.

10. The acute condition should always be listed first.

a. The worst goes first!

10. Each unique ICD-10 diagnostic code may be reported only once. If you use a left and right

code, you only list the diagnosis with these sides once.

11. If the condition is bilateral and there is no bilateral code, then you have to list the left and

right code separately.

12. If a condition is borderline, then it is listed as confirmed.

13. An unspecified code should be reported only when it is the code that most accurately

reflects what is known about the patient’s condition at the time of that particular encounter.

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14. It is inappropriate to select a specific code that is not supported by the health record

documentation or conduct medically unnecessary diagnostic testing in order to determine

a more specific code.

Note: There are 21 chapters in the new ICD-10 Classification System. Some of the chapters will

never be used by the chiropractor. If you use functional medicine in your practice, I recommend

that you take classes that pertain to your area of expertise.

ICD-10-CM Conventions

The ICD-10 Characters

Placeholder “X” character - The ICD-10-CM utilizes a placeholder character “X” The “X” is

used as a 5th and /or 6th character placeholder at certain 6 and/or 7-character codes to allow

for future expansion.

S13.4xxA

Sprain of neck, initial encounter

7th Characters

Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is

required for all codes within the category, or as the notes in the Tabular List instruct. The 7th

character must always be the 7th character in the data field. If a code that requires a 7th

character is not 6 characters, a placeholder X must be used to fill in the empty characters.

Ordinality

• Is this the initial or subsequent visit for the complaint?

• Are these symptoms the sequela of the initial event?

7th Character Basic ICD-10 Coding Guidelines:

A – Initial encounter

D – Subsequent

encounter

S – Sequela

1. 7th character A:

• Initial encounter (Medicare says to use this during active care)

• Used when the patient is receiving active treatment for the condition

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- CMS says this is used as long as the patient is under active care (-AT

modifier)

While the patient may be seen by a new or different provider over the course of treatment

for an injury, assignment of the 7th character is based on whether the patient is undergoing

active treatment and not whether the provider is seeing the patient for the first time.

2. 7th character D:

– Subsequent encounter

– After treatment in the active phase of care and the patient is in the healing or

recovery phase of care

– Examples of this care are cast change, medication adjustment, or other aftercare

following treatment of the injury or condition.

– In chiropractic, this may be used in the phase when the patient is in rehabilitation.

3. 7th character S:

– Sequela also known as “late effects”

– For complication or conditions that arise as a direct result of a condition, such as

deconditioning of muscle after an injury.

– When using the Sequela codes, it is necessary to use both the injury code that

precipitated the sequela and the code for the sequela itself.

– The “S” is added to the injury code only, not the sequela code.

– The 7th character “S” identifies the injury responsible for the sequela.

– The specific type of sequela is sequenced first on the claim form, followed by the

injury code.

Simple Coding Examples:

ICD-10 Cervicalgia M54.2

Combination Coding Examples

M54.30 Sciatica unspecified side

M54.31 Sciatica Right

M54.32 Sciatica Left

M54.40 Sciatica with lumbago unspecified

M54.41 Sciatica with lumbago right

M54.42 Sciatica with lumbago left

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Spinal Coding is specified by ______________

Spinal Coding

0 Multiple sites in spine

1 Occipito-atlanto-axial region Occ-C1-C2

2 Cervical region C3-C6 Deleted

21 C4-5

22 C5-6

23 C6-7

3 Cervicothoracic region C7-T1

4 Thoracic region T2-T11

5 Thoracolumbar region T12-L1

6 Lumbar region L2-L4

7 Lumbosacral region L5-S1

8 Sacral and sacrococcygeal region

9 Site unspecified

Example:

• M50.320 Other cervical disc degeneration, mid-cervical region, unspecified level(M50.32) • M50.321 Other cervical disc degeneration at C4-C5 level (was M50.32) • M50.322 Other cervical disc degeneration at C5-C6 level (was M50.32) • M50.323 Other cervical disc degeneration at C6-C7 level (was M50.32) Sequencing of ICD-10 Codes • Numbers are reported on the insurance claim form because you are communicating to a

computer.

• Be sure to use the correct numbers, to the highest degree of specificity. This must be supported by the chart documentation.

• The diagnosis you provide directly relates to the level of care permitted by

the third-party payers.

Medicare Subluxation Complex – Segmental and somatic dysfunction

• M99.01 ... segmental and somatic dysf.- cervical region • M99.02 ... segmental and somatic dysf.- thoracic region • M99.03 ... segmental and somatic dysf.- lumbar region • M99.04 ... segmental and somatic dysf.- sacral region • M99.05 ... segmental and somatic dysf.- pelvic region Noridian Only Also Allows:

• M99.11 Subluxation complex (vertebral) of cervical region

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• M99.12 Subluxation complex (vertebral) of thoracic region • M99.13 Subluxation complex (vertebral) of lumbar region • M99.14 Subluxation complex (vertebral) of sacral region • M99.15 Subluxation complex (vertebral) of pelvic region

Proper Sequencing of Codes in ICD-10

Optimal sequencing of the codes:

• Neurological diagnosis

•

•

•

• Structural descriptor diagnosis

•

•

•

• Functional diagnosis

•

•

•

• Soft tissue

•

•

• Extremity

Sources:

• www.Askmario.com

• ICD-10 Coding of the Top 100 Conditions for the Chiropractic Office by Dr.

Mario Fucinari www.Askmario.com

www.facebook.com/askmario - for Free

http://www.askmario.com/http://www.askmario.com/

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New information posted regularly at

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Put us in your notifications

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G. OPTIONS: Check only one box. We cannot choose a box for you.

J. Date:

A. Notifier:

B. Patient Name: C. Identification Number:

Advance Beneficiary Notice of Noncoverage (ABN)

NOTE: If Medicare doesn’t pay for D. below, you may have to pay.

Medicare does not pay for everything, even some care that you or your health care provider have good reason

to think you need. We expect Medicare may not pay for the D. __ below.

D. E. Reason Medicare May Not Pay: F. Estimated Cost

WHAT YOU NEED TO DO NOW:

• Read this notice, so you can make an informed decision about your care.

• Ask us any questions that you may have after you finish reading.

• Choose an option below about whether to receive the D. listed above.

Note: If you choose Option 1 or 2, we may help you to use any other insurance that you

might have, but Medicare cannot require us to do this.

H. Additional Information:

This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or

Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).

Signing below means that you have received and understand this notice. You also receive a copy.

CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time

required to complete this information collection is estimated to average 7 minutes per response, including the time to review

instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you

have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS,

7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R-131 (Exp. 03/2020) Form Approved OMB No. 0938-0566

I. Signature:

□ OPTION 1. I want the D. listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for

payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.

□ OPTION 2. I want the D. listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.

□ OPTION 3. I don’t want the D. listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

mailto:AltFormatRequest@cms.hhs.gov

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