Spring 2013: Kathy Mills Chang Notes

2/2013

The Legal Stuff

Please be reminded that CPT code descriptors and
compliance and coding policies do not reflect all coverage
and payment policies. The existence of a CPT code does
Get Squeaky Clean with Medicare, not ensure payment for any service. The coverage and
payment policies of governmental and commercial payers
Documentation and Compliance may vary. Questions regarding coverage and payment for
an item or service should be directed to particular
payers. Any coding advice in this seminar reflects the
With Kathy Mills Chang, MCS-P opinions of Kathy Mills Chang in her role as a certified
medical compliance specialist and is not a substitute for
Certified Medical Compliance individual consultation with the appropriate authority (
CMS, legal counsel, malpractice insurance company, etc.).
Specialist KMCU disclaims responsibility for any consequences or
liability attributable to the use of the information
contained in this seminar.

LOCAL MEDICAL REVIEW POLICY
(LMRP)
Medicare Guidelines
• LMRP is an administrative and educational tool to
assist providers, physicians and suppliers in submitting
correct claims for payment.
• Local policies outline how contractors will review
claims to ensure that they meet Medicare coverage
requirements.
• CMS requires that LMRPs be consistent with national
guidance (although they can be more detailed or
specific), developed with scientific evidence and
clinical practice, and are developed through certain
specified federal guidelines.

Medical Review Policies Risk Management / Records
Warning Signs of Improper Documentation
• Global Indications (i.e.) – Different levels of record
Aetna BCBS
– Illegible Records for different accounts
– Dates Incomplete / Absent – Lack of objective language,
metrics
– Absent Signature or Initials
– Remarks about other
– Informed Consent Absent
providers
– Documentation in pencil
– Blanks on forms indicate
– Follow – Up Exam Absent “Not performed.” Note:
– Patient Name / File Blanks do not indicate NAD
number absent / WNL
– Made up abbreviations
(Have Legend)

www.kmcuniversity.com (855) TEAM KMC

2/2013

Practice Analysis of
Chiropractic 2010
National Board of Chiropractic Examiners

• The typical practitioner now spends more
than a quarter (25.2%) of his or her work time
documenting patient care; this amount has
almost doubled since 1998 (13.8%)

Medically Necessary vs. Clinically
Appropriate Care
Medically Necessary Clinically Appropriate

• Significant • Life Enhancing
improvement in clinical • Symptom relieving
findings and patient’s • Wellness care
functionality
• Supportive Care
• Maintenance care


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2/2013

Clinically Appropriate Care

Medically Necessary Care

Subsequent Visits Documentation Subsequent Visits Documentation
Requirements Requirements
• History: (29% Documentation Error Rate)
– Review of Chief Complaint
• Subjective: (PART)
Location of Symptoms
– Changes since last visit
– System review if relevant
Subjective (P) Quality of Symptoms • Question:…Salutations, Please tell me…..
Intensity of Symptoms
– Where the low back pain is today…what is the
• Physical exam: (43% Documentation Error Rate)
– Exam of area of spine involved in diagnosis – Objective (A, R, T)
quality and intensity?
– Assessment of change in patient condition since last – Has there been a change in your ability to lift Since
visit (PE, OA, ADL, QVAS) (Same, Better, Worse)
– Evaluation of treatment effectiveness (Same, Better,
Assessment objects? (Function) Last
Worse, How and Why) – How is your ability to garden? (Function) Visit

• Documentation of treatment given on day of visit: (15%
Plan
• Record finding(s) in Progress / SOAP note
Documentation Error Rate)
– Failure to document the medical necessity of the chiropractor’s
manual spinal manipulation(s) may result in denial of claim(s)


2/2013

Subsequent Visits:
Must Have
According to Medicare

• SOAP for each condition (area of the spine)
• Patient History you are treating
• Congruency between treatment plan and
• Physical exam of the area of the
notes
diagnosis
• Listing of services performed
• Documentation of the treatment • Patient assessment and doctor’s assessment
provided in the visit
• Objective tests in the areas of the spine being
treated

Acute
Acute
• New injury, identified
by x-ray or physical
• CMS defines Acute as: "A patient's condition is exam
considered acute when the patient is being • Expected improvement
treated for a new injury, identified by x-ray or in, or
physical exam as specified above. The result of • Expected arrest of
chiropractic manipulation is expected to be an progression of, the
improvement in, or arrest of progression of, condition
the patient's condition."

Chronic Chronic
• Not expected to
CMS defines Chronic as: "A patient's condition is significantly improve or
considered chronic when it is not expected to resolve with treatment
significantly improve or be resolved with further
treatment (as is the case with an acute • BUT continued therapy
condition), but where the continue therapy can can result in some
be expected to result in some functional functional improvement.
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."


2/2013

Maintenance Maintenance
CMS defines Maintenance Therapy as:
"Chiropractic maintenance therapy is not • Wellness
considered to be medically reasonable or
necessary under the Medicare program, and is – Prevent disease
therefore not payable. Maintenance therapy is – Promote health
defined as a treatment plan that seeks to prevent – Prolong/enhance the
disease, promote health, and prolong and quality of life
enhance the quality of life; or therapy that is
performed to maintain or prevent deterioration of • Supportive
a chronic condition. When further clinical – Maintain or prevent
improvement cannot reasonably be expected deterioration of a
from continuous ongoing care, and the
chiropractic treatment becomes supportive rather chronic condition
than corrective in nature, the treatment is then
considered maintenance therapy."

P.A.R.T. S=P
• Refresh your knowledge • P = Pain • The patient shares the
of P.A.R.T and how it • A = Alignment information about their
effortlessly fits within • R = Range of Motion Subjective complaints,
your traditional S.O.A.P. or their Pain
format to easily confirm • T = Tissue Changes
medical necessity.

O = ART Acute Exacerbation
CMS defines Acute Exacerbation as: "An acute
• The Doctor observes the exacerbation is a temporary but marked
information about the deterioration of the patient’s condition that is
patient’s status, through causing significant interference with activities of
provocative testing, daily living due to an acute flare-up of the
measurable outcomes, or previously treated condition. The patient’s
clinical record must specify the date of
their Objective findings occurrence, nature of the onset, or other
• Range of Motion, Tissue pertinent factors that would support the medical
Changes and Asymmetry necessity of treatment. As with an acute injury,
are noted as part of the
treatment should result in improvement or
arrest of the deterioration within a reasonable
patient’s progress period of time."


2/2013

Acute Exacerbaton Chronic Exacerbation
• New injury, identified • CMS defines Chronic Exacerbation as:
by x-ray or physical "An acute exacerbation of a chronic
exam subluxation must represent an acute
• Expected improvement change that is a marked deterioration of
in, or the patient’s condition and is causing
• Expected arrest of significant interference with activities of
progression of, the daily living. “Active treatment” may only
condition
occur as long as the patient is achieving
significant clinical improvement."

Daily Treatment Notes
Chronic Exacerbation
• Not expected to
significantly improve or
resolve with treatment
• BUT continued therapy
can result in some
functional improvement.


2/2013

What is Compliance?
• As it relates to • CERT Reviews Revealed
healthcare, has to do the following error rates
with privacy, security, in 2011
coding, billing,
documentation, and – 61% insufficient
utilization documentation
• Active compliance – 26% lack of medical
program necessity
• Dedicated compliance – 7% incorrect coding
officer

Fraud includes obtaining a benefit through Compliance Program: Defined
intentional misrepresentation or concealment of
material facts
• An operational
structure that will assist
Waste includes incurring unnecessary costs as a the physician’s practice
result of deficient management, practices, or controls
in preventing fraudulent
or erroneous conduct
Abuse includes excessively or improperly using or behavior
government resources

The purpose of a compliance program
Is it Mandatory?
is:
• To integrate policies and • Came out of the
procedures into the sentencing guidelines
physician’s practice that • Affordable Care Act:
are necessary to Mandatory Compliance
promote adherence to Plans Coming Soon
federal and state laws • CMS has NOT finalized
and statutes and the requirements
regulations applicable • CMS will advance specific
to the delivery of proposals at some point
healthcare services. in the future


2/2013

How does a Compliance Program
Let’s Start at the Very Beginning…
Work?
• An effective compliance • Decide that the time is
program establishes an
atmosphere of compliance NOW!
that permeates the entire
organization. • Take the first step by
• A compliance program should declaring that this is the
be tailored to the specific TIME!
circumstances of the provider.
• The program should also feed • Bring your team
and grow on itself. together and simply get
• As problems are detected started.
appropriate changes should be
made to the program and • Initial compliance
related policies and meeting gets you going.
procedures.

Initial Compliance Meeting Initial Compliance Meeting
• Sets the tone • Be prepared
• Introduces new rules • Have Code of Conduct
and compliance ready for each team
concepts to entire team member
at once • If the Compliance
Officer will assist with
• Doesn’t make wrong this meeting, divide the
• Clean slate to begin presentation
• Introduces Compliance • Explain the “why”
Officer behind the changes

Sample Introductory Scripting Initial Compliance Meeting
“You may be aware that many changes are occurring in • Next, explain there are
healthcare and the business of healthcare. Practices are
being audited, rules are changing and here at (insert practice different kinds of
name) we want to stay ahead of the curve and show our Compliance
commitment to an environment of the utmost compliance.
For this reason, you may see some changes coming down the • OIG, HIPAA, Regulatory
pike to procedures and systems we’ve had in place. There boards, financial policy
may be changes necessary to certain processes that we have
learned need to be updated. We’re constantly learning and compliance, etc.
growing as we strive to stay on top of the changes as they • Then review the 7 steps
happen. This meeting is meant to get all of us on the same
page about the culture of compliance that we will be of the OIG Compliance
enforcing going forward.” Program


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Review the 7 Steps of the OIG Step 1- Implement Policies and
Compliance Program Procedures
• Understand the
difference between the
two
• Assess what existing
policy and procedure is
in place that needs
attention

Why You Need Both Build As You Go
• Policy: This is how and • The most efficient way
why we do things here to accomplish this
• Procedure: Standard daunting task is to build
Operating Procedure both manuals as you go.
(SOP)—It’s how we • As you work through
implement the policy each area of focus or
we’ve decided upon. lesson, appropriate SOP
and Policy will be
developed and
implemented.

An Example of Procedure (SOP)
An Example of Policy PROCEDURE:
It is the responsibility of the Compliance Officer to:
Sample Policy: Physician Education Policy • Conduct provider education with the frequency necessary to ensure compliance with
applicable federal and state laws, statutes and regulations.

PURPOSE: • Schedule, direct and document an annual base-line medical record audit for all physicians
The purpose of physician and other practitioner education is to ensure all providers and other practitioners. Refer to Medical Record Audit Policy.
understand and comply with federal and state laws, statutes and regulations
applicable to the delivery of health care in a clinical environment. • Provide physicians with information regarding new or changes in existing federal and state
healthcare laws, statutes and regulations.

POLICY: • Develop the content of materials used for educational purposes. Medical record audit
Physicians and other practitioners are required to attend all agreed upon and findings and other identified risk-areas will be included in the training materials.
scheduled educational programs designed for providers. Education will be
conducted subsequent to medical record audit activity and with a frequency to • Conduct Compliance Program education at least annually.
meet the needs of the provider. Provider compliance education will be conducted
at least annually. • Conduct coding, billing and reimbursement education at least annually.

• Provide the Compliance Committee with a quarterly report of provider education activities.


2/2013

An Example of Procedure (SOP) Know and Apply These Two Important
Procedure for Conducting Post Audit Provider Education:
Concepts
1) Compliance officer (CO) selects two dates for possible training, within one
month of the audit, and sends email to all providers to select the date that • A clear knowledge of
works best for them. both policy and
2) CO compiles training materials for the meeting based on identified errors in procedure ensures a
the audit. Power point presentations, handouts and other training
materials are prepared for the meeting. proper compliance
3) Upon selecting the best date, CO sends training announcement to all program.
providers, secures the location and arranges for agenda, refreshments, and
files to be reviewed in training.
• Every issue may not need
4) CO sends reminder email 2 days before scheduled training to all providers. both
5) The day of the training, CO conducts the training and review. • Less is not more in this
6) Minutes of the meeting are kept and added to the compliance manual. instance!
7) An employee training log is filled out and signed by all in attendance, and
added to the compliance manual. • It’s a journey, not a
8) The next audit date is calendared at this time, based on the error rate destination.
determined by the previous audit.

Physical Manuals

Digital Manuals


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Step 2- Compliance Officer or Contact
• Review the role of this
person
• Everyone is responsible
for compliance
• Officer is responsible
for overseeing all
manner of compliance,
but doesn’t work alone

Step 3- Employ Comprehensive
Education and Training
• Training is going to be
tracked and
documented
• Webinars, seminars,
conventions, and other
on the job training
should always be
recorded when relative
to a compliance related
issue

Step 5- Respond Swiftly to Detected
Step 4- Enforce Disciplinary Standards
Offenses
• Review the code of • Everyone’s eyes and ears must be open and
conduct watching at all times
• Explain why everyone • Overpayments to Medicare must be within 60
must commit to
compliance
days of the detection
• Get the Code of • Internal processes and audits will assist with
Conduct signed after all the practice finding these occasional missteps
7 steps have been • Everyone must participate in supporting the
reviewed compliance officer’s efforts


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Step 6-Internal Audits and Monitoring Step 7- Open Lines of Communication
• More internal audits • Insist on an Open Door
will take place now Policy
• Four types of audits • Everyone must report
– Documentation things they don’t
– E/M Coding Audits understand or are
– Coding Audits curious about
– EOB Audits • Create the system that
• Calendar of routine you’ll use for reporting
audits will be set

Sample Scripting Get Code of Conduct Signed
• Now that all 7 steps are
“We all recognize that the accumulation of reviewed, go back to the
Code of Conduct, pass it
unspoken, unanswered problems, grievances, out and get everyone’s
complaints and questions can result in agreement.
dissatisfaction and can impact the working • Collect the signed
documents, make 3
relationship. It is to everyone's advantage to copies of each at the end
bring these matters out in the open. If you have of the meeting
a problem or complaint, or a compliance • Original: Employee’s file
related concern, please review it with your • Copy: To employee
supervisor, the doctor, or compliance officer as • Copy: Behind “Code of
Conduct” tab in
soon as possible.” Compliance manual

Fill Out Training Sheet for this Meeting Install Compliance in Your Office
• None of this matters if
you only talk and don’t
act
• Installation of
compliance programs
can take time
• Set aside appropriate
time to do a little at a
time for each of the 7
steps


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Step 1- Implement Policies and
Step 2- Compliance Officer or Contact
Procedures
• Assess what policy and • Once assigned as a
procedure exists
compliance officer, the
• Make an action list of the
most important policies journey begins
first • Calendar a year’s worth
• Documentation, of events
Medicare, Financial, and
Coding policies take • Always keep an eye out
precedent for compliance related
• KMCU clients have issues
sample policy for each
lesson

Daily, Weekly, Monthly, Annual and As
Needed Duties
As Needed Duties
• Daily: Ongoing monitoring • Annually: Complete audit • Initial compliance
• Weekly: Team meeting of 5-10 charts per provider;
complete coding audit; training for new team
training; review
recommended concerns review all provider members, within 10 to
• Monthly: Compliance contracts; review existing 90 days of employment
meeting with doctor; spot policy and procedure;
annual compliance meeting • Ongoing, and remedial
check 1-4 notes per
provider; random EOB with the team; renew the training based on audit
review practice’s Code of Conduct; findings or spot check
confirm key team members
have completed annual findings
training; conduct formal • Ongoing case work for
compliance training with
the entire team compliance incidents


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Step 3- Employ Comprehensive
Step 4- Enforce Disciplinary Standards
Education and Training
• Always document every • Lay out a sliding scale of
training with a training
log signed and added to discipline to be
compliance manual enforced
• Every webinar, free or • Range from verbal
otherwise should be
included, if appropriate warning and retraining
• All outside seminars up to referral to law
should be documented enforcement
• CO should lay out a • Document, document,
training plan early in the
year according to the document
calendar

Other Items to Include in Sanction
Policy
• Negligence
• Incompetence
• Disorderly conduct
• Fraud or falsification on employment
application
• Unsuitability to job requirements
• Insubordination
• Violation of applicable statutory requirements

Step 5- Respond Swiftly to Detected
Offenses
• Be ready to take action
on detected offenses
• Document time lines in
writing on incident
reports
• Everyone must
participate in
supporting the
compliance officer’s
efforts


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Step 6-Internal Audits and Monitoring
• Consider an outside
entity to conduct a
baseline audit on your
behalf
• Use error rates to
determine what is next
• Coding audits
conducted by KMCU as
part of PPP or ISP/PhD
programs

Step 7- Open Lines of Communication Just Do It!
• Set a goal.
– By when will you take
the first steps?
– By when will you have
your meeting?
– By when will you get the
basics in place?
• Don’t put it off again.
• Action gets results.

ESSENTIAL ELEMENTS OF
ASSESSMENT


2/2013

Treatment Plan & Goals Measurable Functional Goals

Modalities & Rehab Treatment Effectiveness

30-Day Window to ‘Plan B’ Dr. Listening
• Listen closely to effect
on a patient’s life
• Ask thoughtful
questions about
paperwork
• O-P-P-Q-R-S T
• After gathering...poof…
we transform to…


2/2013

Dr. Finding Dr. Thinking
• Tests and • This is assessment
measurements • S + O = Assessment
• Distinguish between • Enter important
important nuances comments and
• Record everything in diagnoses that helps to
the patient’s record show the picture of
what you found

Dr. Fixing What I learn in the HISTORY
• Listening + Findings+ • History means • What regions or areas
Thinking = Treatment everything you learn as of Chief Complaint are
Plan Dr Listening what the involved?
• Foundation now exists patient tells you - both • What ortho/neuro tests
to deliver the treatment on verbally and on their are coming to mind as
• Medical necessity is paperwork appropriate?
shown • What risk factors or
• It’s logical to expect the contraindications may
treatment you chose be present?

What I learn in the EXAM Exam Helps
• Dr. Jeff Miller
• Be a great detective, • Exam Doc
during the examination extraordinaire
process • Flash Cards Available
• You want to be focused this weekend: Special
• QUANTIFY your findings Seminar Price: $40
• MEASURE your results includes shipping (first
come-first served)
• OBSERVE your patient


2/2013

X-ray Policy X-ray Report

• To x-ray or not x-ray that • Proper documentation
is the question. is key in diagnostic
• Imaging and diagnostic imaging: you must have
testing are for a solid rationale, and a
documentation …not report showing clinical
education. outcome, otherwise the
• There should never be a test is not considered
blanket x-ray policy in medically necessary.
any office.

X-ray Indications MRI Indications

• Trauma • Lingering pain beyond 4
weeks
• Red flags for infection
• Progressive or worsening
or cancer neurological symptoms
• Scoliosis evaluation • When fracture is strongly
(when clinical indicators suspected/not seen on film.
are present) • Painful or progressive
structural deformity
• Unstable segment
• Persisting signs and
symptoms

Time to sow those wild OATs!

OATs = Outcome Assessment Tools
• Visual Analog Scale
• Revised Oswestry
• Pain Drawings
• Roland-Morris Disability
• Neck Pain Disability Index
• Headache Disability Index
• Bournemouth
• Zung Psychological
Assessment Questions


2/2013

Donny Dreamboat ADL’s Doctor Thinking
• HISTORY:
• What the patient tells
you
• What the patient puts
on their paperwork
• E/M:
• Your exam findings
• What any additional
testing tells you
H + E = Assessment • What the OATs tell you

H + E = Dx −> Tmt Plan CCGPP Prognostic Factors

History Exam
Clinical • Older age
Decision • History of Prior Episodes
Making • Severity of initial episode
of injury
• Number of exacerbations
• Duration of current
episode longer than 1
month
• Psycho-social factors

CCGPP Prognostic Factors

• Pre-existing pathology
• Nature of employment
• Waiting more than 7
days to seek treatment
• Congenital Anomalies
• Patient compliance ASSESSMENT LEADS TO DIAGNOSIS


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H + E = Dx −> Tmt Plan Diagnosis
Clinical • The diagnosis that you choose to represent
History Exam

Decision your patients’ conditions directly relates to
the level of care permitted by third-party
Making payors when you submit your claims.
• Use an order that will accurately represent the
patient’s condition on the claim form and
describe his or her clinical presentation, as
well as support the plan of care that you have
prescribed

Position 1 – Nerve Position 2: Bone/Joint/Disc
• The pain can be biomechanically reproduced.
• When a patient has a radicular symptom, include • “I can make your body do something that makes
radiculitis as your first position code. you recreate the pain”
• Radiculitis is the radiation of pain down a nerve, • Disc Degeneration or Degenerative Joint Disease
typically into an extremity. (DJD) are musculoskeletal: 722.4 Cervical DJD
• The radiation of pain away from its site of origin 722.52 Lumbar DJD
provides justification for the diagnosis of radiculitis. • Other musculoskeletal codes include a broad
• Quality of pain: burning or shooting range of anomalies from scoliosis to
spondylolisthesis.
• Will correlate with positive neurological findings
• An excellent pediatric diagnosis is 781.9
– Radiation, weakness, numbness, positive nerve tests
Abnormal Posture

MRI Required Must Have Viable X-Ray

• 722.0: Intervertebral • Degenerative joint
disc disorders disease
• Muscle tears • Degenerative disc
• Rotator cuff disease
• Other ligamentous • Spondylolisthesis
damage or tears • Compression Fracture


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Positions 3 and 4 – Muscle/Disc/Other Positions 3 and 4 – Catch All

• For soft tissue and extremity treatment, it’s best to • The 3rd and 4th positions can also serve as a
point the diagnosis to the code.
catch-all location for any other diagnosis that
• If you provide tx to the soft tissues, you must include
a soft tissue diagnosis. is descriptive of your patient’s condition.
• This includes Manual Therapy 97140. • Soft Tissue DX should be easily defendable:
• Functional Diagnosis must have correlating findings: true myofascitis, carpal tunnel, adhesive
– Restricted ROM, Positive Muscle Testing capsulitis
• Myalgia is an excellent supporting diagnosis to use:
muscle pain: 729.1 Myalgia 728.2 Deconditioning
Syndrome

When Using Exam Findings Diagnosis Made Easy
• You must be able to
defend your diagnosis
• Kemp’s test is positive
in most facet
syndromes, but in some
facet syndromes are not
• Be able to tell a third
party what your
thought process was
using what’s written in
your patient record

Sample: Bettye Blue Cross

• 27 YO Female, neck, mid & low back pain of 3
years. LBP aggravated with moving her
household last week. LBP constant aching,
throbbing, and stiffness with 8/10 pain scale.
Interferes with sleep, sitting, lying down,
standing. Personal and family health histories
are unremarkable.


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Sample: Morris Medicare Morris Medicare History
• Let’s see how it all comes Morris states that that since that time he has had worsening
together… neck and right shoulder pain. He has also been having
burning pain, tingling and numbness in his left arm all the
way to his fingers.
• Morris Medicare is a 67 year
old male who presents for care Nothing seems to make it better or worse and the symptoms
today related to an injury are constant. He reports he cannot sleep comfortably. He
verbally rates the neck pain at an 8/10, the left arm
sustained while gardening & symptoms at a 7/10, and the right shoulder pain a 5/10.
hoeing by hand in very rocky
ground 2 weeks ago. He worked Morris denies any prior injuries or complaints involving this
for 8-10 hours and frequently area. His family and personal medical histories are non-
needed to use a pick axe. contributory.

Morris Medicare Findings/Exam Morris Medicare Assessment
Examination revealed Morris Medicare to be alert and oriented to person, Upon consideration of the information available I have
place and time. He appears well developed, well nourished, and well kept. diagnosed Morris Medicare with Cervical-brachial
His blood pressure was 124/75 and he is at 5’11, 175 lbs.
He was tender to touch throughout her cervical spine and in her right syndrome, cervical strain, and AC joint sprain.
shoulder. Moderate swelling was palpated in the right shoulder region. His Morris is of good health and is expected to make good
cervical ranges shoulder ranges of motion were restricted (see exam form progress and recovery with few residuals, however due to
for measurements).
In the cervical spine foraminal compression test and Jacksons test was positive
his advanced age, the length of the current episode, and
on the left were positive for aggravation of radiating symptoms and the amount of time that passed before he sought care it is
O’Donoghues was positive for pain on passive ranges of motion. His right reasonable to believe that his recovery may take longer
shoulder Superspinatus press test was positive for shoulder pain, and than an average patient with an uncomplicated case.
Appley’s scratch tests were positive for restricted motion. Myotomal
muscle testing was performed and all upper extremity muscles test +5 It is my recommendation that he be seen 3 times per week
bilaterally, with pain in the right shoulder. Grip and pinch strength tests for four weeks at which time barring any unforeseen
were equal bilaterally.
complications or changes a re-evaluation will be
Cervical and right shoulder films were ordered to evaluate for possible loss of
joint integrity. Neck Disability Index test was performed the patient scored performed to determine progress and further care.
a 35% which is a moderate level of disability.

Morris Medicare DX and TX plan Nasty-Gram
Morris will need to be seen 3 times per week for 4 weeks for
treatment to his cervical spine and right shoulder. He has been
diagnosed with cervical-brachial syndrome, cervical strain, and AC
joint strain.
His treatment will consist of CMT with diversified technique to the
cervical spine. Trigger point therapy will be performed to the
upper trapezius musculature for 15 minutes. Pre-modulated e-
stim will be performed on the right shoulder for 15 minutes and ice
will be applied. Ultrasound therapy will be performed for a total of
10 minutes to the cervical spine and superspinatus musculature.
Range of motion exercises will be prescribed to the patient initially
and strengthening exercises will be added as progress is
appropriate. The goals of his treatment are to reduce pain and
discomfort with ADLs including dressing, sleeping, and day to day
activities.


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Treatment Plan & Goals

Functional Deficit Noted:
Inability to:_______________

Functional Treatment Goal:
Able to __________________

Measurable Functional Goals

Functional Deficit Noted:
Personal Care, Lifting, Walking,
Sitting, Standing, Work,
Driving, Other:____________

Goal Setting: The Secret to Medical
Modalities & Rehab
Necessity
• Find out the patient’s
goals
• Don’t allow pain relief
only
• Combine patient goals
with exam functional
deficiencies to produce
treatment goals
• Use goals to drive
treatment plan


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Treatment Effectiveness

30-Day Window to ‘Plan B’

Complicating Factors:

Eval. Tx. Effectiveness Tools:


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Daily Assessment

• A brief assessment of
Projected Completion of Tmt the patient’s response
to treatment should be
Plan: _________ noted after each
treatment is completed,
an recorded in the
Functional Treatment Goal: progress notes (ie SOAP
By _________(when) notes)

Ongoing Assessment Function, Function, Function
• Get to the root of how
patients are REALLY • In relationship to
doing at each visit treatment goals
• Patients will always
report on pain. • HOW is the patient
• On an ongoing basis the improving?
assessment should
answer two questions. . .

OATs Determine Course Accuracy
Function, Function, Function
• Mid-point of a trial of
• WHY does the patient need care
more care? (week 2 of 4-week trial)
• Practitioner should re-
assess whether the
• What is left to accomplish? current course of care is
continuing to produce
satisfactory clinical
gains using commonly
accepted OATs.


2/2013

Periodic Re-Assessment Morris Medicare Ongoing
Assessment
After an initial course of Visit 3 Assessment: Morris is improving as he states he is able to sleep more
comfortably now and can dress more easily. Gross ranges of motion are
treatment has been concluded slightly improved. The numbness and tingling in his fingers before now only
• Re-examination reached his forearm. Continued care is necessary to continue to reduce
pain, strengthen the shoulder complex, and increase range of motion.
• 25-modifier worthy
• Repeat the last exam Visit 8 Assessment: Morris continues to improve- he states that he
• Re-perform all positive tests sleeps through the night and has no pain with dressing. He states
that he is able to carry light weights like some groceries with his right
• RE-do OATs arm now. He states that the numbness and tingling in his left arm
has subsided. Tissue swelling in the right shoulder and tenderness in
• How far have they come the shoulder and cervical spine are reduced.

H + E = Dx −> Tmt Plan CMT Codes

History Exam
Clinical • 98940-3 the basic building
Decision blocks and best description
Making of the DC’s work.
• Most comprehensive
physician code to describe
chiropractic services.
• Basic service around which
everything else is built.

Coding The CMT Extra Spinal Adjustment

• Full Spine Adjustment: The • 98943-Extra spinal
treating doctor should adjustment
prioritize the level of
adjustment and code for • 5 regions:
the primary area(s) of – Head, including TMJ
concern. – UE
• 98940: 30-60% – LE
– Anterior ribs
• 98941: 40-60%
– Abdomen
• 98942: 1-10%


2/2013

Chiropractic Manipulative Treatment Codes:
Supervised Modalities
Extra Spinal Code
• 98943, 1 or more • 97010-97028 do not require
one-on-one contact by the
extra spinal regions provider.
• Correlate: • Billed only once per
– Symptoms encounter.
– Exam findings • Code 97012 Mechanical
Traction
– Diagnosis
• Code 97014 Electrical
– Treatment
Stimulation
– Documentation

Constant Attendance Modalities Therapeutic Procedures Coding:
Active Care

• 97032-97039 require • Therapeutic Procedures
direct one-on-one are time-based codes.
patient contact by • The patient is active in
provider. the encounter.
• These are timed codes. • Require direct one-on-
• Code 97032 manual one patient contact by
electrical stimulation provider of the service.
• Code 97035 ultrasound

97110 Therapeutic Exercises 97112 Neuromuscular
Re-education
• Develop one functional • Used to describe those
parameter: strength,
endurance, range of motion, activities that affect
or flexibility proprioception
• Treadmill for endurance • Balance
• Isokinetic exercise for ROM
• Coordination
• Lumbar stabilization exercises
for flexibility • Kinesthetic sense
• Stability ball to stretch or • Posture
strengthen
• Per KMC: DON’T USE
THIS PLEASE!


2/2013

97530 Therapeutic Activities 97124 Massage

• Used when multiple • Massage is a passive
parameters are trained procedure used for
including balance, strength, restorative effect.
and range of motion. • Used for effleurage,
• Must be related to a petrissage, and/or
functional activity with tapotement, stroking,
direct functional
compression, and/or
improvement expected.
percussion.
• An independent
• Use Outcomes Assessment procedure from CMT
Tools. and is considered
separate and distinct.

97140 Manual Therapy 97150 Group Therapy

• When supervising more
• Includes soft tissue and than one individual, for a
joint mobilization, service that requires direct
manual traction, trigger supervision, use code 97150
for each patient.
point therapies, passive
range of motion, and • For example, if NMR is
performed in a group
myofascial release. setting, use code 97150 —
do not use 97112 and
• When billed with a 97150 at the same time.
CMT, must be in a • Billed once per session.
separate body region.
• Requires a -59 modifier.

Timed Treatment Codes Timed Treatment Codes

• Timed codes are • Check with each carrier • For a single timed code • For multiple timed
counted per 15 minutes and document being billed in a visit: codes billed on the
• Up to 15 minutes is not appropriately. – 8 up to 23 min = 1 same visit, use this
a full unit, under the • Use of the -52 modifier – 23 up to 38 min = 2 standard, but count
CPT guidelines could negate the service – 38 up to 53 min = 3 TOTAL time spend on
• Some carriers may have – 53 up to 68 min – 4 each timed code
you use the Medicare
– And so on
standard of 8 minutes
for the 1st unit


2/2013

Evaluation and Mgmt. Coding
New patient vs.
Initial Visit Routine Visit
established patient coding Exam: $120 CMT $65
X-Rays: $130 97110: $50

History CMT: $65
97014: $35
97014:
97012:
$35
$35

Total: $350 Total: $185
Examination
Clinical Decision Making Exam: $95 CMT $35
X-Rays: $75 97110: $30

Components and CMT: $35
97014: $15
98940: $25.15
98941: $34.86
97014:
97012:
$15
$15
98942: $42.75
subcomponents Total: $220 Total: $95

Build your way to the 100% Poverty: 75% Discount

correct code 125% Poverty: 50% Discount
150% Poverty: 25% Discount

Decide If You Want to Discount You Are Likely Already Discounting
When a patient that has insurance enters your office for care – they
are bringing another “person” to the relationship
• Use federal prompt pay discount guidelines
for hardship policy
• Never discount on copay or deductible for
insurance patients
• Never make side deals with the patient
• Remember, charge correctly, bill correctly,
then COLLECT according to your policy
• Easiest Fix: join a DMPO

Insurance Company - Patient

Doctor-Insurance Company


2/2013

Patient-Doctor

80% Insurance Company
20% Patient

IMPLEMENT ANY DESIRED DISCOUNTS
FOR CASH PAYING PATIENTS

ChiroHealthUSA

• Designed by a Chiropractor to benefit Chiropractors
AND Chiropractic!
• ChiroHealthUSA is a DMPO – Discount Medical Plan
Organization
Doctor-ChiroHealthUSA
• A DMPO can stand in the corner the Insurance
Company occupies in the Triangle…
• Look at how the story changes!

Patient-Doctor ChiroHealthUSA- Patient


2/2013

Patient-Doctor
Does my
0% ChiroHealth USA
financial
100% Patient policy &
discounts
offered meet
ALL
layers of
regulations?

Exam: $120 CMT $65
X-Rays: $130 97110: $50
CMT: $65 97014: $35
97014: $35 97012: $35

Total: $350 Total: $185

Capped Fee: $150 Capped Fee: $65
Or 20% Discount Or 20% Discount

Modalities: $10 Re-Exam s: $25
Procedures: $20 Each Film: $15

EVALUATE AND IMPLEMENT DESIRED
HARDSHIP POLICY

Clear Understanding of Hardship and
Mistakes and Blunders
Discounted Fees
• Your hardship • What may NOT be
agreement can co-exist financial hardship?
with other fee – No insurance
schedules.
– High deductible
• You must set the – I don’t wanna pay that
standard up front, have much
qualifying factors, and
– My other doctor didn’t
verify eligibility.
charge my copays
• Utilize a standardized – Pulse and a spine
form and system


2/2013

Co-Pay or Deductible Waivers for
BCBS Policy on Hardship
Hardship
• The waiver is not offered as
part of any advertisement
or solicitation;
• Waivers are not routinely
offered to patients;
• The waiver occurs after
determining in good faith
that the individual is in
financial need;
• The waiver occurs after
reasonable collection
efforts have failed.

Bettye Blue Cross CHARGE Recap
• Bettye must be charged actual fees
• If you participate with her carrier, you can
find out if she can always qualify for
contracted fees
• If Bettye is Under-Insured, she can qualify for
CHUSA
• If Bettye has a high deductible or co-
payment, she can “elect to self pay”.
• Bettye may qualify for hardship if her carrier
will allow it.

Morris Medicare CHARGE Recap Morris Medicare CHARGE Recap
• Morris must be charged actual fees for
excluded services • It’s still very confusing about what to
• Morris COULD enjoy a 5-15% charge Morris when he’s on
• Morris can join CHUSA for all non-CMT Maintenance care.
• CMT Medicare PAR: Actual Fee, then write • There are three differing opinions that
off to Regulated Fee have been put into writing:
• CMT Medicare Non-Par: Limiting Fee – We don’t’ care what you charge!
• Morris may qualify for hardship if you – You can’t charge more than the limiting
follow the rules carefully, including trying fee!
some payment plan first.
– You have to charge the actual fee!


Spring 2013: Kathy Mills Chang Notes

Spring 2013: Kathy Mills Chang Notes

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