2/2013                                                                                       The Legal Stuff              ...
2/2013                   Practice Analysis of                    Chiropractic 2010            National Board of Chiropract...
2/2013www.kmcuniversity.com   (855) TEAM KMC
2/2013                                                                                        Clinically Appropriate Care ...
2/2013                     Subsequent Visits:                                                                             ...
2/2013                         Maintenance                                         Maintenance                CMS defines ...
2/2013                    Acute Exacerbaton                               Chronic Exacerbation                            ...
2/2013                   What is Compliance?        • As it relates to             • CERT Reviews Revealed          health...
2/2013            How does a Compliance Program                                                                           ...
2/2013                  Review the 7 Steps of the OIG                                                           Step 1- Im...
2/2013             An Example of Procedure (SOP)                                                  Know and Apply These Two...
2/2013         Step 2- Compliance Officer or Contact                                    • Review the role of this         ...
2/2013         Step 6-Internal Audits and Monitoring             Step 7- Open Lines of Communication        • More interna...
2/2013              Step 1- Implement Policies and                                                                       S...
2/2013              Step 3- Employ Comprehensive                                                    Step 4- Enforce Discip...
2/2013                                               Step 6-Internal Audits and Monitoring                                ...
2/2013          Treatment Plan & Goals     Measurable Functional Goals            Modalities & Rehab         Treatment Eff...
2/2013                            Dr. Finding                     Dr. Thinking        • Tests and                         ...
2/2013                   X-ray Policy                                            X-ray Report                         • To...
2/2013                   Donny Dreamboat ADL’s              Doctor Thinking                                               ...
2/2013        H + E = Dx −> Tmt Plan                                                       Diagnosis                      ...
2/2013      Positions 3 and 4 – Muscle/Disc/Other                         Positions 3 and 4 – Catch All        • For soft ...
2/2013          Sample: Morris Medicare                                                               Morris Medicare Hist...
2/2013          Treatment Plan & Goals                                                Functional Deficit Noted:           ...
2/2013                                                 Treatment Effectiveness                                            ...
2/2013                                                                Daily Assessment                                    ...
2/2013           Periodic Re-Assessment                                       Morris Medicare Ongoing                     ...
2/2013           Chiropractic Manipulative Treatment Codes:                                                               ...
2/2013             97530 Therapeutic Activities                                                97124 Massage              ...
2/2013             Evaluation and Mgmt. Coding       New patient vs.                                                      ...
2/2013                                           Patient-Doctor                                        80% Insurance Compa...
2/2013                                                                      Patient-Doctor                                ...
Spring 2013: Kathy Mills Chang Notes
Spring 2013: Kathy Mills Chang Notes
Spring 2013: Kathy Mills Chang Notes
Spring 2013: Kathy Mills Chang Notes
Spring 2013: Kathy Mills Chang Notes
Spring 2013: Kathy Mills Chang Notes
Spring 2013: Kathy Mills Chang Notes
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Spring 2013: Kathy Mills Chang Notes


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Spring 2013: Kathy Mills Chang Notes

  1. 1. 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. 2. 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 carewww.kmcuniversity.com (855) TEAM KMC
  3. 3. 2/2013www.kmcuniversity.com (855) TEAM KMC
  4. 4. 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)www.kmcuniversity.com (855) TEAM KMC
  5. 5. 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 patients 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 patients condition." Chronic Chronic • Not expected to CMS defines Chronic as: "A patients 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."www.kmcuniversity.com (855) TEAM KMC
  6. 6. 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."www.kmcuniversity.com (855) TEAM KMC
  7. 7. 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.www.kmcuniversity.com (855) TEAM KMC
  8. 8. 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 futurewww.kmcuniversity.com (855) TEAM KMC
  9. 9. 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.” Programwww.kmcuniversity.com (855) TEAM KMC
  10. 10. 2/2013 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.www.kmcuniversity.com (855) TEAM KMC
  11. 11. 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 Manualswww.kmcuniversity.com (855) TEAM KMC
  12. 12. 2/2013 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 effortswww.kmcuniversity.com (855) TEAM KMC
  13. 13. 2/2013 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 everyones 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 stepswww.kmcuniversity.com (855) TEAM KMC
  14. 14. 2/2013 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 incidentswww.kmcuniversity.com (855) TEAM KMC
  15. 15. 2/2013 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 effortswww.kmcuniversity.com (855) TEAM KMC
  16. 16. 2/2013 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 ASSESSMENTwww.kmcuniversity.com (855) TEAM KMC
  17. 17. 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…www.kmcuniversity.com (855) TEAM KMC
  18. 18. 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 patientwww.kmcuniversity.com (855) TEAM KMC
  19. 19. 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 Questionswww.kmcuniversity.com (855) TEAM KMC
  20. 20. 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 DIAGNOSISwww.kmcuniversity.com (855) TEAM KMC
  21. 21. 2/2013 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 Fracturewww.kmcuniversity.com (855) TEAM KMC
  22. 22. 2/2013 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.www.kmcuniversity.com (855) TEAM KMC
  23. 23. 2/2013 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.www.kmcuniversity.com (855) TEAM KMC
  24. 24. 2/2013 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 planwww.kmcuniversity.com (855) TEAM KMC
  25. 25. 2/2013 Treatment Effectiveness 30-Day Window to ‘Plan B’ Complicating Factors: Eval. Tx. Effectiveness Tools:www.kmcuniversity.com (855) TEAM KMC
  26. 26. 2/2013 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.www.kmcuniversity.com (855) TEAM KMC
  27. 27. 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%www.kmcuniversity.com (855) TEAM KMC
  28. 28. 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!www.kmcuniversity.com (855) TEAM KMC
  29. 29. 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 unitwww.kmcuniversity.com (855) TEAM KMC
  30. 30. 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 Initial Visit Routine Visit 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 Companywww.kmcuniversity.com (855) TEAM KMC
  31. 31. 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- Patientwww.kmcuniversity.com (855) TEAM KMC
  32. 32. 2/2013 Patient-Doctor Does my 0% ChiroHealth USA financial 100% Patient policy & discounts offered meet ALL layers of regulations? Initial Visit Routine Visit Exam: $120 CMT $65 X-Rays: $130 97110: $50 CMT: $65 97014: $35 97014: $35 97012: $35 Total: $350 Total: $185 Initial Visit Routine Visit Capped Fee: $150 Capped Fee: $65 Or 20% Discount Or 20% Discount Modalities: $10 Re-Exam s: $25 Procedures: $20 Each Film: $15 100% Poverty: 75% Discount 125% Poverty: 50% Discount 150% Poverty: 25% Discount 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 systemwww.kmcuniversity.com (855) TEAM KMC