Fall 2012: Arkfeld Notes

Indiana State Chiropractic
Association
Fall Convention 2012

Ted A. Arkfeld, DC, MS, CPC

Disclaimer
Advanced Compliance Technologies, PLLC, and Genius Solutions,
Inc., denies responsibility or liability for any erroneous opinions,
analysis, and coding misunderstandings on behalf of individuals
undergoing this independent study program.
The coding topics taught here are for the sole purpose of the
chiropractic profession, any transference to other healthcare
disciplines are at the risk of the individual coder’s discretion.
We have based the majority of this program on the guidelines set
forth by the CPT Code Book, ICD-9, and HCPCS information found in
the ChiroCode DeskBook, and in The Medicare Manual, as it relates to
Chiropractic practice.
No legal advice is given in this manual, and we encourage you to refer
any such questions to your healthcare attorney.

2009 Report
After the 2006 OIG review, it was found
that Medicare inappropriately paid $178
million for chiropractic claims in 2006.
This documents us as showing no real
improvement in our documentation. This
will lead to increasing audits and other
methods to enforce that inappropriate
payments are not paid out to us, including
further possible caps and cuts in the near
future.

Documentation Problems

“Chiropractors
often do not comply
with the Manual
documentation
requirements.”
Pg 16 of the 2009 OIG report

**See “AT” modifiers and “wellness care” as examples.**

Separate from the undocumented claims
already mentioned,
83 % of chiropractic claims failed to meet
one or more of the documentation
requirements.
Consequently, the appropriate use of the
AT modifier could not be definitively
determined through medical review for 9
percent of sampled claims, representing
$39 million.

2009 Report
“Efforts to stop
payments for
maintenance therapy
have been largely
ineffective.”
Pg ii of the 2009 OIG report

1. The medical reviewers indicated that
treatment plans are an important element
in determining whether the chiropractic
treatment was active/corrective in
achieving specified goals (therefore
allowable or not).
2. Another important element was a
documented Initial Visit Date for each
episode.

Of the 76 % of records that reviewers
indicated contained some form of
treatment plan:
 43 % lacked treatment goals
 17 % lacked objective
measures
 15 % lacked the
recommended level of care

Use the OIG Report for Your Good

1. Use this report to begin improving the
policies and procedures in your practice.
2. Use this report to check and enhance
your documentation skills.
3. Use this report as an opportunity to
become compliant and create your own
healthcare stimulus and reform.

Medicare Program

Medicare, which is the Nation’s largest purchaser of health
care (and, within that, of managed care), processes over 1
billion fee-for-service claims per year.

The Medicare program is funded through the Hospital
Insurance (HI) and Supplementary Medical Insurance (SMI)
trust funds and is composed of four parts:

Medicare Program

Medicare Part A:
Pays for hospital, skilled nursing facility
(SNF), home health, and hospice care for the
aged and disabled. It is financed through the
HI trust fund, which is funded primarily by
payroll taxes paid by workers and employers.

Medicare Program

Medicare Part B:
Pays for physician and outpatient hospital services,
laboratory tests, medical equipment, and other
items and services not covered by Part A. It is
financed through the SMI trust fund, which is funded
primarily by transfers from the general fund of the
U.S. Treasury and by monthly premiums paid by
beneficiaries.

Medicare Program

Medicare Part C:
Known as Medicare Advantage (MA),
provides health care coverage choices for
Medicare beneficiaries through private health
care companies that contract with Medicare
to provide benefits. Part C is funded by both
the HI and SMI trust funds.

Medicare Program

Medicare Part D:
the prescription drug benefit program created
by the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003
(MMA)

High Risk

The size and scope of the Medicare program
place it at high risk for payment errors

The Top 10
Misconceptions
about Medicare

Misconception #1
There is a 12 Visit Cap on
Chiropractic Services
Truth: There are no caps in Medicare for
chiropractic at this time.

However, there may be periodic review
screenings, or intervals at which the carrier may
require a review of documentation to allow
continued service.

Misconception #2
I can treat Medicare patients without
being registered.
Truth: It is illegal to treat Medicare patients and
not be registered with Medicare.
You may choose to be a “participating” or “non-
participating” provider, but you must register. If
you treat a Medicare patient with a spinal CMT
code, you MUST submit a claim.

Misconception #3
If you are a non-par provider, you will
never be audited or have claims
reviewed
Truth: Any Medicare claim submitted can be
audited/reviewed despite provider status.

The status of the physician does not affect
the probability of this occurring.

Misconception #4
If you are a non-participating provider (non-
par), you do not have to worry about billing
Medicare
Truth: Being non-par does not exempt you
from having to bill Medicare.

ALL Medicare-covered services must be
billed to Medicare or the provider could face
penalties.

Misconception #5
Non-par providers do not have the same
documentation requirements as par
providers

Truth: Chiropractic care has documentation
requirements to show medical necessity.

The participation status of the provider is
irrelevant.

Misconception #6
You can ‘opt out’ of Medicare.
Truth: Opting out is NOT an option for Doctors
of Chiropractic.
If you treat Medicare patients, you must
register as ‘participating’ or ‘non-participating’.
If you don’t want to deal with Medicare, then
don’t treat Medicare patients. It is illegal to
treat Medicare patients and not submit a claim.

Misconception #7
Maintenance care is NOT a covered
service under Medicare.
Truth: Spinal manipulation is a covered service
under Medicare, no matter which phase of care
you may be in; however, maintenance care is not
REIMBURSABLE.
Acute, and Chronic conditions are all ‘covered’,
under Medicare if medically necessary.

Misconception #8
Medicare requires unreasonable record keeping
and documentation to receive reimbursement

Truth: Medicare has specific documentation
requirements, but nothing extraordinary.
Whether a Medicare patient or not, chiropractors
should be exercising specific standards in their
chart notes with thorough documentation for
every encounter.

Misconception #9
Chiropractors can make special offers to
Medicare patients.
Truth: Inducements of any kind are strictly
forbidden for Medicare patients. Free exams, x-
rays, even chicken dinners could lead doctors to
accusations of fraud.
An exception to this rule is if you waive a portion
of the patient’s fee due to documented financial
hardship. “Smallness” is another exception; this is
where you can write off the amount being
collected if it is less than your cost to try to collect
it. This would apply to very small dollar amounts
such as $2.86.

Misconception #10
An Advance Beneficiary Notice (ABN) should be
signed once for each patient and it will apply to all
services, and all visits

Truth: The decision to deliver an ABN must be
based on a genuine reason to expect that
Medicare will deny payment for the service due to
lack of medical necessity.

Medicare Benefit Policy Manual Chapter 15 –
Covered Medical and Other Health Services
Table of Contents
(Rev. 109, 08-07-09)

Medicare Documentation

CMS Manual System, Pub 100-02, Chapter
15, Section 240.1.2

What is Medical Necessity?
Medicare’s Definition
The patient must have a significant health
problem, in the form of a neuromuscular
skeletal condition, necessitating treatment,
and the manipulative services rendered must
have a direct therapeutic relationship to the
patient’s condition and provide reasonable
expectation of recovery or improvement of
function.

Medicare Requirements for
Chiropractic Claims
Under Medicare Chiropractors are limited to
three reimbursable codes.

 98940 (CMT; spinal, one to two regions)
 98941 (CMT; spinal, three to four regions)
 98942 (CMT; spinal, five regions)

AT Modifier

The AT modifier should follow the CMT
code on claims submitted to Medicare. This
will identify that the patient is in acute
treatment for either an acute for chronic
subluxation.

Acute Treatment

Your documentation must reflect that the
patient is in active/corrective treatment.

Medicare Article: Part II
Essentials of Documentation
Medicare does have specific requirements
for documentation, but nothing
extraordinary.
Whether a patient is covered by Medicare,
or not, all chiropractic encounters should be
represented by appropriate, specific,
record-keeping that adheres to a basic
standard.

D. Documentation Requirements: Initial Visit - the following documentation
requirements apply whether the subluxation is demonstrated by x-ray or by
physical examination:
1.History as stated above.
2.Description of the present illness including:
- Mechanism of trauma;
- Quality and character of symptoms/problem;
- Onset, duration, intensity, frequency, location, and radiation of symptoms;
- Aggravating or relieving factors;
- Prior interventions, treatments, medications, secondary complaints; and
-Symptoms causing patient to seek treatment.
These symptoms must bear a direct relationship to the level of subluxation. The symptoms
should refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo or osteo), rib
(costo or costal) and joint (arthro) and be reported as pain (algia), inflammation (itis), or as
signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause
headaches, arm, shoulder, and hand problems as well as leg and foot pains and numbness. Rib
and rib/chest pains are also recognized symptoms, but in general other symptoms must relate
to the spine as such. The subluxation must be causal, i.e., the symptoms must be related to
the level of the subluxation that has been cited. A statement on a claim that there is "pain" is
insufficient. The location of pain must be described and whether the particular vertebra listed
is capable of producing pain in the area determined.

Medicare Documentation Requirements

Documentation must meet the following criteria:
• Be legible
• Clearly identify patient, date of service, and service
provider
• Accurately report all pertinent facts, findings, and
observations
• Use standardized medical abbreviations or include
a key of the abbreviation scheme
• Include appropriate diagnosis for the service
provided

Initial Visit Must-Have’s
The initial visit should,
at minimum include:
1.Patient History
2.Description of the Presenting Complaint
3.Evaluation Findings
4.Diagnosis
5.Treatment Plan
6.Initial Visit Date

History
Statement of Health
 Past Health History
Social/Family History
Description of the Presenting
Complaints
Any Secondary Complaints

Presenting Complaint
 Symptoms
 Mechanism of Trauma
 Quality and Character of the Pain
 Onset, Duration, Intensity, Frequency,
Location, and Radiation of Symptoms
 Aggravating/Relieving Factors
 Prior Interventions
 Treatments
 Medications

Documentation of Subluxation

Subluxation may be demonstrated by:

 X-ray
 Physical Examination

Demonstrated by X-ray
The x-ray analysis to demonstrate
subluxation must be taken at a time
reasonably proximate to the initiation of a
course of treatment.

An x-ray is considered reasonably
proximate if it was taken no more than 12
months prior to or 3 months following the
initiation of a course of chiropractic
treatment.

In certain cases of chronic subluxation
(e.g., scoliosis), an older x-ray may be
accepted, provided the beneficiary’s
health record indicates the condition
has existed longer than 12 months
and there is a reasonable basis for
concluding that the condition is
permanent.

Demonstrated by
CT or MRI
A previous CT scan and/or MRI is
acceptable evidence if a subluxation
of the spine is demonstrated.

Demonstrated by Physical Exam
(P.A.R.T.)
Subluxation demonstrated by Physical
Examination Evaluation of the
neuromusculoskeletal system to identify:
P.A.R.T.
 Pain
 Asymmetry
 Range of Motion and
 Tissue tone changes

Evaluation
Physical examination and evaluation
of the musculoskeletal/nervous
system.
Document everything you do and
detail your findings.

PAIN/TENDERNESS

Pain/tenderness is evaluated in terms
of location, quality, and intensity.

PAIN/TENDERNESS
Pain and tenderness findings
may be identified through on
or more of the following:

1. Observation
2. Percussion
3. Palpation
4. Provocation

PAIN/TENDERNESS
Pain intensity may be assessed using
one or more of the following:

1. Visual Analog Scales
2. Algometers
3. Pain Questionnaires

Asymmetry Misalignment
Asymmetry/misalignment is identified
on a sectional or segmental level.

Asymmetry/misalignment may be
identified through one or more of the
following:
 Observation
(posture and gait analysis)
 Static Palpation
 Diagnostic Imaging

Range of Motion Abnormality
Range of motion abnormalities may be
following:
1. Motion Palpation
2. Observation
3. Stress diagnostic imaging
4. Range of Motion Measurements

Tissue/Tone
Tissue and or tone texture may be
following procedures:

1. Observation
2. Palpation
3. Use of Instruments
4. Tests for length and strength

To demonstrate a subluxation based
on physical examination, two of the
four criteria mentioned are required,
one of which must be
asymmetry/misalignment or range of
motion abnormality.

Treatment Plan
Include the recommended level of care
with duration and frequency of visits
Specific treatment goals
Objective measures to evaluate
treatment effectiveness
Always include the date of the initial
treatment and sign it

Sample Treatment Plan
05-05-06
• CMT and adjunctive modalities daily for 1 week and 3x/wk
for the following 2 weeks. Re-eval at that time; L MRI may
be indicated. Off work 2 wks. Home care: Cryo q 2 hrs x 15
mints; avoid strenuous activity; LS supports to be worn
when standing.
• Short-term goals: Minimize pain (<3) and spasm; increase
pain-free LS flexion (>45 degrees).
• Long-tern goals: Restore ability to tie shoes w/o pain,
sit/stand for prolonged periods (>2 hrs.), and get in/out
vehicles w/o difficulty; return normal sleep patterns.
Dr. C. My Signature

Subsequent Visits
Subsequent visits should be documented and
should include no less than the following:
 Subjective comment on patient’s progress and
changes since last visit
 Physical exam findings including changes since
last visit
 Documentation of the treatment given on the day
of the visit
(Don’t just refer back to the plan from the initial
visit without also documenting today’s findings!)

Subjective
S: Review of chief complaint, note any
changes since the last visits, system
review if relevant (any surgeries, illness,
trauma, or medications since last visit?)

Objective
O/A: Physical/regional exam
 Examine the area of the spine involved in the
diagnosis and note findings. Assess change in
the patient’s condition since the last visit.
 Evaluate the treatment for effectiveness.
(Note, listings and type of technique are not
currently required by CMS or CPT in reporting;
however, for the thoroughness of the record
we’d recommend these details.)

Plan
P: Document the treatment given on
the day of the visit and any adjunctive
therapy

Documentation of Subluxation

Subluxation may be
demonstrated by:
X-ray
Physical
Examination

The x-ray analysis to demonstrate subluxation
must be taken at a time reasonably proximate
to the initiation of a course of treatment.
An x-ray is considered reasonably proximate if
it was taken no more than 12 months prior to or
3 months following the initiation of a course of
chiropractic treatment.

In certain cases of chronic subluxation (e.g.,
scoliosis), an older x-ray may be accepted,
provided the beneficiary’s health record
indicates the condition has existed longer than
12 months and there is a reasonable basis for
concluding that the condition is permanent.

Demonstrated by
CT or MRI
A previous CT scan and/or MRI is
acceptable evidence if a subluxation of
the spine is demonstrated.

PAIN/TENDERNESS
Pain & Tenderness are evaluated in
terms of location, quality, and intensity.

PAIN/TENDERNESS
Pain and tenderness findings may be
following:
1. Observation
2. Percussion
3. Palpation
4. Provocation

PAIN/TENDERNESS
Pain intensity may be assessed using one
or more of the following:

1. Visual Analog Scales
2. Algometers
3. Pain Questionnaires

Asymmetry/Misalignment is identified
on a sectional or segmental level.

Tissue/Tone
Tissue and or tone texture may be
following procedures:

1. Observation
2. Palpation
3. Use of Instruments
4. Tests for Length and Strength

To demonstrate a subluxation based on
physical examination, two of the four
criteria mentioned are required, one of
which must be asymmetry/
misalignment or range of motion
abnormality.

Subsequent Visits
Subsequent visits should be documented and should
include no less than the following:
Subjective comment on patient’s progress and
changes since last visit
Physical exam findings including changes since
last visit
Documentation of the treatment given on the day
of the visit
(Don’t just refer back to the plan from the
initial visit without also documenting today’s
findings!)

Subjective

S: Review of chief complaint, note any
changes since the last visit, system
review if relevant (any surgeries, illness,
trauma, or medications since last visit?)

Objective
O:
 Examine the area of the spine involved in the
diagnosis and note findings. Assess change in
the patient’s condition since the last visit.
 Note, listings and type of technique are not
currently required by CMS or CPT in reporting;
however, for the thoroughness of the record
we’d recommend these details.

Assessment

A:Evaluate the treatment for
effectiveness.

Plan
P: Document the treatment given on
the day of the visit, and any adjunctive
therapy

10/28/2009 Basic Exam

PATIENT DEMOGRAPHIC INFORMATION:
Name: Mr. Low Back Pain
Gender: M
Date of Birth: 5/29/1970
Race: Caucasian
Mr. Low Back Pain complains of low back pain.

CAUSATION DETAILS:
Mr. Low Back Pain related to me that his chief complaint was brought about by raking leaves. His
date of onset was 10/28/2009. Mr. Low Back Pain indicated that he has had this complaint
multiple times previous to this episode. The primary complaint is getting worse since the onset.
This onset of the primary complaint started as follows:
The patient stated he was raking leaves yesterday for a prolonged period of time and began to
have low back complaints shortly after. He stated he was turned to the side raking from left to
right and bent over somewhat for about two hours when he began to have pain in the right L4-S1
areas. This morning when waking up he had pain on both sides of his lower back area.

SUBJECTIVE:
Mr. Low Back Pain indicated on his visit today that he has been feeling constant moderate pain
in the lower back area. This is restricted movement as well as stiffness and sore pain generalized
in the left lumbar, left sacroiliac area, right lumbar and right sacroiliac area. Mr. Low Back Pain's
low back pain feels worse due to arising from a chair, bending and repetitious movements. He
states that nothing reduces the severity. The patient was asked to rate his pain and severity on a
scale of 1 to 10. He estimated his low back pain at 4

REVIEW OF SYSTEMS:
GU: Denies polyuria, nocturia, incontinence, or hematuria
GI: Denies nausea, vomiting, diarrhea, constipation, incontinence.
PAST MEDICAL HISTORY:
Low Back Pain has not taken any prescription medications to treat these symptoms. The patient
has no history of surgical procedures used to treat this problem.
FAMILY HISTORY:
He has no family history of problems.
SOCIAL HISTORY
A social history was obtained from Mr. Low Back Pain. Mr. Low Back Pain's social history was
reviewed and was found to be consistent with previous findings.
Mr. Low Back Pain is married. He has two children. He has a bachelor's degree. He usually
exercises. Low Back Pain stated that he occasionally drinks alcohol. He never uses tobacco
products.
OSWESTRY ASSESSMENT:
The Oswestry Daily Living Assessment was used to indicate Mr. Low Back Pain's perceived pain
and disability. It is a valid indicator since he rated his condition as it affects his daily living
activities, thus avoiding interviewer interference. The patient related his capability in the
activities of daily living as follows:
Pain Intensity: "The pain comes and goes and is moderate."
Personal Care: "Washing and dressing increases the pain and I find it necessary to change my
way of doing it."

Lifting: "Pain prevents me from lifting heavy weights off the floor."
Walking: "Pain prevents me from walking more than 1/2 mile."
Sitting: "Pain prevents me sitting more than 1/2 hour."
Standing: "I cannot stand for longer than 1/2 hour without increasing pain."
Sleeping: "Because of pain, my normal night's sleep is reduced by less than one-quarter."
Traveling: "I get some pain while traveling, but none of my usual forms of travel make it any
worse."
Degree of Pain: "My pain is gradually worsening."
On 10/28/2009, the patient's revised oswestry pain score was 52. The patient's score fell into
the 40 - 60% range indicating a severe disability.
GENERAL APPEARANCE:
This patient is a well-appearing 68 year old male in mild distress. The patient was awake, alert
and oriented and in moderate pain. He demonstrated appropriate illness behavior. Mr. Low
Back Pain showed spasticity. The patient appeared comfortable. The patient showed normal
grooming and appropriate dress.
VITAL SIGNS:
Pulse Rate 82
Sitting Pressure/Systolic L: 120
Sitting Pressure/Diastolic L: 80
Temperature 98.6
Height 5'6"
Weight 150

ORTHO/NEURO:
Minor's Sign was present bilaterally. The patient was seated and was asked to stand. The
examiner noted that the patient supported their weight on the uninvolved side by balancing on
the uninvolved leg, placing the hand on the back and flexing knee and hip on the involved side.
This was done on the other side following a repeat of the test.
Tripod Sign was present bilaterally. The patient was seated with their legs dangling off the
table at the knees. They were instructed to extend their knees. This caused the patient to lean
backward in order to perform this test.
Kemp's Standing Test elicited localized pain in the right L4-S1 facet joints. With the patient
standing, the examiner stood behind and anchored the pelvis and sacrum with one hand while
grasping the opposite shoulder with the other hand. The shoulder was then forced obliquely
back, down, and medial. The patient experienced localized low back pain on the right side.
Bechterew Sitting Test was negative bilaterally. With the patient seated and legs dangling over
the edge of the table, the examiner instructed the patient to extend one knee straight out then
repeat with the other knee. Then, the patient repeated the maneuver with both knees. The
patient was able to do this without any pain and without leaning backwards.
Valsalva's Test was negative. The examiner instructed the patient to bear down as if having a
bowel movement. This increased the intrathecal pressure. Bearing down did not cause any
significant pain.
Straight Leg Raise Test was negative bilaterally. With the patient lying supine on the examining
table, the examiner lifted the leg upward by supporting the patient's foot around the
calcaneus. In order to make sure the knee remained straight, the examiner placed the free
hand on the anterior aspect of the knee. The patient did not experience significant pain. When
the test was performed on the other leg, the same results were obtained.

Lasegue Test was negative bilaterally. With the patient supine and knee fully extended, the
examiner placed one hand under the patient's heel and the other hand over the knee to prevent
flexion. The examiner then slowly flexed the patient's thigh at the pelvis to 90 degrees. The
patient did not experience any significant pain.
Patrick's Test was negative bilaterally. With the patient supine, the examiner placed the foot of
the patient's involved side on the opposite knee. This made the hip joint flexed, abducted, and
externally rotated. In this position, the patient did not experience any significant pain. The
same result was obtained on the other side.
Ely Heel to Buttock Test was positive bilaterally. This two stage test was performed with the
patient lying prone. The examiner flexed the patient's knee approximating the heel to the
opposite buttock. From this position, the examiner hyperextended the patient's thigh. The test
was positive if the patient was unable to do the test, unable to extend the thigh, if femoral
radicular pain was produced, and/or if upper lumbar discomfort was present. The positive was
obtained on the other side.
Nachlas Test was positive bilaterally. The examiner stood on the side of the patient ipsilateral
to the pain while the patient lay prone. With one hand, the examiner raised the foot of the
involved side and maximally flexed the knee. With the other hand, the examiner pushed
downward on the patient's pelvis. The patient experienced pain in the joint. The same result
was obtained on the other side.
Yeoman's Test was positive bilaterally. The patient was prone on the examination table. With
one hand the examiner stabilized the sacroiliac joint being tested. The examiner flexed the knee
of the leg tested to 90 degrees. The examiner then hyperextended the thigh of the leg tested by
lifting it off of the examining table. Pressure was maintained over the sacroiliac joint being
tested. This test was also done on the other side. This test was positive as demonstrated by
sacroiliac pain over both of the sacroiliac joints.

RANGE OF MOTION:
Spinal ROM:
Lumbar:
Pelvic Sacral Angle Decreased
Flexion Decreased
Extension Decreased
Right lateral flexion Decreased
Left Lateral Flexion Decreased
OBJECTIVE:
On examination of the spinal joints, a severe amount of restricted joint function at T10 - T12, L1 -
L5 and the left ilium - sacrum was detected. On palpation of the spinal segments there was a
moderate pain level at T10 - T12, L1 - L5 and the ilium - sacrum bilaterally. There is severe
spasticity of the lower trapezius, latissimus and sacrospinalis and gluteus maximus bilaterally
found on palpation.
DIAGNOSIS:
739.3 Segmental Dysfunction, Lumbosacral Region
724.8 Lumbar Facet Syndrome
739.5 Nonallopathic Lesions of Pelvic Region, not elsewhere classified
728.85 Spasm of Muscle
739.4 Nonallopathic Lesions of Sacral Region, not elsewhere classified
724.2 Lumbar Spine Pain

ASSESSMENT:
The patient will remain on acute care status.
The patient has experienced an exacerbation which is defined as an increase in the severity of a
disease or any of its signs or symptoms. This is typically due to a significant irritation or flare-up
of the patient's complaint without a specific incident. May be secondary to performing the
activities of daily living (ADL).
DISCUSSION:
The patient stated he was raking from left to right which would place a repetitive rotary
movement on the lumbar spine, with compressive forces loading on the right lumbar facet
joints and tensile forces on the left paraspinal muscles. The patients past x-rays clearly indicate
degenerative joint disease in the facet joints, however he was asymptomatic prior to raking of
the leaves. This new activity resulted in a mechanism of trauma to the right L4-S1 facet joints
and straining of the left paraspinal muscles. This is validated by the history of the event and the
examination findings of decreased range of motion, pain being elicited on Kemp’s Testing, and
palpatory spinal tenderness and muscle spasms in the lumbar spine.
The mechanism of trauma satisfies the definition of exacerbation of a neuromusculoskeletal
condition. The definition per Medicare guidelines state:
Necessity for Treatment:
1. 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 and provide 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, as described above.

Necessity for Treatment: (continued)

- 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.
PLAN: The patient is rescheduled for tomorrow.
1) Office/Op Visit, New Pt, 3 Key Components: Expand Prob Focus Hx; Expand Prob Focus Exam;
Strtfwd Dec:
1) Lumbar Spine
2) Adjustment 3-4 Areas:
1) Lumbar Spine
2) Left Sacroiliac
3) Right Sacroiliac
4) Sacrum
3) Mechanical Traction:
1) Lumbar Spine

Signed Iama Doctor, DC

Medicare
When a Medicare patient returns with new
symptoms or a flare up of previous
symptoms, you must document if it was due
to one of the following:

1. Exacerbation
2. Aggravation
3. Insidious

Exacerbation
Exacerbation:
An increase in the severity of a disease or any
of its signs or symptoms. This is typically due
to a significant irritation or flare-up of the
patient’s complaint without a specific incident.
May be secondary to performing the activities
of daily living (ADL).

Aggravation
Aggravation:
Significant irritation or flare-up of the patient’s
condition due to a specific incident.

Insidious
Insidious:
Denoting a disease/lesion that progresses
gradually with unapparent symptoms. Implies
no actual traumatic event. The pain is
typically described as developing without
cause or reason. Repetitive micro trauma
disorders (i.e. carpal tunnel syndrome) are
often described this

What is a Treatment Plan

Review 42 CFR s 410.61

Review Medicare Carriers Manual 2251.2

Why is a Treatment Plan so important?

• Medicare requires “extended care”
providers to have a treatment plan
• CPT, E/M Service require a treatment plan
• Boards of Examiners require treatment
plans
• Insurance Carriers require a treatment plan
• Treatment plans make daily notes much
more effective and easier

Mechanics – How do I Actually Create a
Treatment Plan?
Plan

• Does it have to be on paper?

• How do I combine this treatment plan in my medical
documentation software?

• What payers are really looking for …

– Do you even have a treatment plan in the first place?

.

Major Elements of a Treatment Plan
 Diagnoses (write them out)
 Specific Procedures
 Target – Site / Organ System
 Frequency / Times per Week & Duration / # of weeks
 Amount/Reps
 Goal / Rationale (consider both long and short-term
goals)
 Signed by the provider
 Passive / Active Stages (interpretation)
 Let’s review the sample

Date of Plan: 10/6/2009
Patient Name: Tony Romo
Patient ID#: 002628
Doctor Name: Ted Arkfeld, DC

Based on a detailed New Patient Examination Level 2 (99202), performed on
10/6/2009, the following Care Plan was created for Patient Tony Romo:

Diagnoses: 739.1 Cervical subluxation
723.1 Cervicalgia

Contributing Conditions: Emotional stress

Aggravating Conditions: Work

Diagnostic Tests: No diagnostic tests were performed.

Based on the findings, there will be 2 stages of care; Passive / acute and
Active or Rehabilitative. The long-term goals are restoring tolerance to
normal activities of daily living and enhance flexibility. Based on the
patient's condition, re-evaluations are planned, for each stage of care, to
assess the benefits of care and ensure functional improvement.

During the Passive / acute stage, the following services will be provided:
98940 - CMT 1-2 Regions consisting of diversified technique will be
performed to the Neck, specifically to the Cervical Vertebrae, to decrease
pain and facilitate healing of inflamed and injured neurological and
musculoskeletal tissues. This will be provided 3 times per week for 4 weeks.
97012 - Mechanical Traction consisting of static traction pull will be
performed to the Neck, specifically to the Cervical Vertebrae, to facet
distraction. This will be provided 1 time per week for 1 week.
99213 - Level 3 Re-evaluations will be performed once every 4 weeks.
During the Active or Rehabilitative stage, the following services will be
provided:
98940 - CMT 1-2 Regions consisting of diversified technique will be
performed to the Neck, specifically to the Cervical Vertebrae, to correct
body mechanics. This will be provided 1 time per week for 1 week.
97110 - Therapeutic Exercise (Ea. 15 Min) consisting of Thera-Band exercises
will be performed to the Neck, specifically to the Cervical, to correct body
mechanics, increase mobility/range of motion, increase strength, and re-
establish neuromuscular control. 1 unit will be provided 3 times per week
for 4 weeks.
99213 - Level 3 Re-evaluations will be performed once every 4 weeks.
The patient will be re-evaluated at the end of care, with Level 2 (99212), at
which time a Wellness Care Plan will be discussed.

Treatment Goals
A treatment plan should have two
goals:
1. Reducing or eliminating the patient’s
pain.
2. Increasing or restoring their functional
activities.

They Do Not Care
 Insurance companies do not care about
individual chiropractor’s treatment
philosophy.
 They care about profit.

Symptom Based
 We can still have maintenance visits,
they just cannot be billed to insurance
companies.
 Chiropractors must treat on a
symptom basis in order to submit
insurance claims that are medically
necessary.

Compliance Tip of the Day
Base everything on the presenting
complaints of the patient and you
will always be compliant.

Is it really that easy?

Proper Coding
1. Proper coding identifies the reason for the
patient’s visit.

2. Proper coding is required for your office to
get paid.

Coding

Very Simply:
The Diagnosis Code indicates the patient’s
condition.
The Procedure Code indicates what was
performed.
Both must be linked together in order to
establish medical necessity.

Translate Clinical Findings With the

With the new ICD-10-CM language, doctors of
chiropractic will now be able to translate their true
clinical findings into a code set that allows for
specificity.

Diagnosing Problems

Unfortunately, the lack of specificity (and
accuracy) possible with the ICD-9-CM codes
resulted in our profession becoming
somewhat lazy in our ability to diagnose.

The Problem
• Cheat Sheets (lists of old time favorites that they have
been reimbursed for in the past)
• A false belief that diagnosis codes “do not change that
much” or “but I only use a small number of codes”
• Some strange belief, as a profession, that we are
DOCTORS of chiropractic, but are somehow exempt from
being proficient in examination, diagnosis determination,
and proper coding

ICD-10-CM Adoption
The adoption of ICD-10-CM will require the chiropractic
profession to enhance their
documentation of clinical care in order to be reimbursed
more accurately.

ICD-10-CM will change the landscape of chiropractic
coding for years to come.

Offices that become proactive now in educating their staff
will see only minor bumps in the road with their insurance
reimbursements come October 2013.

Implementation Challenges of ICD-10-CM

How difficult would it be for your office if a
mandate came down from the government
requiring that only French could be spoken
in your office by October 2013?

Clinical Impressions

Coding/Compliance Pearl:
The diagnosis must support the patient's subjective
symptomatology, mechanism of injury (if applicable),
objective findings and radiographic evaluations (if
necessary).

The diagnosis should be as accurate as possible
and express the etiology of the patient's condition.

1500 Health Insurance Claim Form

• Industry Standard

• Required by Medicare & Third-party Payers

Date of Onset

Another important element was a
documented Initial Visit Date for each
episode.

Box 14

Insert the date of first treatment or date
of exacerbation.

Note: The date of first treatment is NOT
the first time they entered your office, but
is the first visit for this occurrence of the
current condition.


The 1500 claim form allows you to post
four (4) diagnoses in box 21.

The primary diagnosis in the #1 slot
should directly correlate with the chief
complaint.


Even though there are only four slots,
do not limit your diagnoses to just
these slots.

For every area of treatment, there
must be a corresponding diagnosis
code.

1500 Claim Form

 The 1500 claim form allows for up to four (4)
diagnoses in box 21.
 The primary diagnosis goes into the number 1 slot
and should directly correlate with the chief
complaint.
 The remaining slots should have conditions
associated with the chief complaint, or a
secondary complaint listed.
 Even though there are only four slots, do not limit
your diagnoses to just these slots.

1500 Claim Form
For every area you are treating, there must be a
corresponding diagnosis.
This always begs the question, “if there are only four slots
and I have ten diagnoses, where do I put the other six?”
For Medicare, Auto, and Worker’s Compensation cases,
you use box 19 of the claim form.

For most Blue Cross Blue Shield and other commercial
carriers, they only want four diagnoses, so make sure those
correlate to the chief complaint and any secondary
complaints.

However, all diagnoses must be in your documentation.

Documentation Examples
for Procedure & DX Codes

Patient presents to the office with a chief
complaint of neck pain.
The objective findings reveal decreased
cervical spine range of motion, palpatory
muscle spasms, and articular dysfunction at C5
and C6.
1. 739.1 Segmental Dysfunction Cervical
2. 728.85 Muscle Spasms
3. 723.1 Cervical Spine Pain

Patient presents to the office with a chief complaint of neck pain with a
secondary complaint of right arm pain.
The objective findings reveal decreased cervical spine range of motion most
noticeable with right rotation and extension causing increased pain with
duplication of the radiating pain into the right arm. There is a positive cervical
compression, right and left shoulder abduction for increasing the radiating
pain. Cervical distraction was positive for decreasing the right arm pain.
Muscle strength testing was 4/5 in the right middle deltoid, and biceps, all
testing on the left was normal. Sensory findings were significant for
hypesthesia in the right C5-C6 dermatomes, left negative. Deep tendon
reflexes were 1+ in the biceps and brachioradialis tendons on the right.
Palpatory tenderness and muscle hypertonicity were found in the cervical and
upper thoracic musculature, along with subluxations at C5-C6.
1. 739.1 Segmental Dysfunction Cervical 3. 729.1 Myofascitis
2. 723.4 Brachial neuritis 4. 723.1 Cervical Spine Pain

Patient presents to the office with an acute flare up of a chronic condition to her neck and
upper back. The patient has recently been gardening with her head bent down for
prolonged periods of time. She is now experiencing a deep dull ache in the cervical spine
made worse with extension and moving her head right and left to check for traffic.
The objective findings reveal bilateral rounding of the shoulders forward with an anterior
head translation. Decreased cervical spine range of motion especially on extension where
she points to the C5-C7 facet joints bilaterally as painful. All orthopedic tests were
negative for a radiating component, but did elicit localized pain in the C5-C7 facet joints
bilaterally. Cervical Distraction was positive for relieving the pain. All motor and sensory
findings were normal. Moderate palpatory tenderness was found in the cervical
paraspinals and C5-C7 facet joints, where subluxations were also present.
Radiology Report was reviewed and revealed cervical degenerative disc disease with facet
hypertrophy at the C5-C7 spinal areas.

1. 739.1 Segmental Dysfunction Cervical 3. 724.8 Facet Syndrome
2. 722.4 Degeneration of Cervical Disc 4. 723.1 Cervical Spine Pain

Patient presents with a chief complaint of low back pain secondary to riding in a car for a 6 hour
drive. The pain is described as a deep dull ache that becomes sharp when leaning back and to
the left. Patient also states he is having mid-back and neck complaints as well.
The objective findings reveal a positive minor’s sign and difficulty in transitioning from a sitting
to a standing posture. Lumbar range of motion actively and passively perform is restricted on
all planes of testing with pain being centralized in the L4-S1 areas bilaterally. Kemp’s Test is
positive for localized pain in the L4-S1 facet joints bilaterally. Straight leg raise, Valsalva’s,
Bechterew’s and Patrick’s tests all are negative. Motor testing reveals 4/5 in the quadriceps,
and hamstrings on the left. Sensory findings indicate hypesthesia in the left L4-S1
dermatomes. Palpatory findings indicate tenderness and moderate muscle spasms in the
lumbar spine and paraspinals bilaterally. Subluxations were found in the L4, L5, Right and Left
S/I joints and the Sacrum. Cervical and Thoracic subluxations were present.
An MRI taken 6 weeks prior reveals L4-L5 left posterior disc herniation and L5-S1 central disc
protrusion.

1. 739.3 Segmental Dysfunction Lumbar 6. 728.85 Muscle Spasms
2. 724.4 Lumbosacral radiculitis 7. 739.4 Segmental Dysfunction Sacrum
3. 722.10 Lumbar IVD w/out 8. 739.1 Segmental Dysfunction
4. 724.2 Lumbar Spine Pain 9. 739.2 Segmental Dysfunction Thoracic
5. 739.5 Segmental Dysfunction Pelvis 10. 724.1 Thoracic Spine Pain

What are they looking for?

1.Health Care Fraud

2.Health Care Abuse

Medicare Fraud

Medicare Fraud / Civil Money Penalty
42 U.S.C. § 1320a-7a(a)(1)(E)

“Any person… that knowingly presents or
causes to be presented…a claim… for
items or services that a person knows or
“should have known” are not medically
necessary has submitted a “False Claim”.

Examples of Fraud

 Billing for services that were not rendered
 Billing for services using another provider’s
NPI number
 Violating anti-kickback statutes and Stark
Laws
 Upcoding to higher levels when the
provider knew the criteria had not been
“met or exceeded”

Health Care Abuse

Health Care Abuse
Abuse may, directly or indirectly, result in
unnecessary costs to the Medicare program,
improper payment, payment for services that
fail to meet professionally recognized
standards of care, or services that are
medically unnecessary.

Examples of Abuse

Charging in excess for services or
supplies
Providing medically unnecessary
services

Medicare Reviews

Medicare can review
your files at any time
for any reason.

Who can Initiate a Review?

1. OIG (Office of the Inspector General)
2. CMS (Centers for Medicare & Medicaid
Services)
3. Local Carrier WPS (Wisconsin Physicians
Service), or MAC (Medicare
Administrative Contractors)

Types of Reviews

Automated Reviews: performed by
computers at the carrier level
Routine Reviews: by Non-Medical Staff
Complex Reviews
Once you have received a request
for records, you are officially
under review.

The OIG

 Is concerned with fraud
 Has their own inspectors and auditors
 Does not need a warrant to come into
your office and review your files
 Can impose civil monetary penalties

CMS

Is concerned with Abuse
They use Contractors and
Subcontractors

– Comprehensive Error Rate Testing
(CERT)
– Recover Audit Contractors (RAC)

What Triggers an Audit?

Disgruntled Employee
Profile is the same for all patients
 Everyone receives a 98941 or 98942 CMT
Cookie Cutter Chiropractic
Upcoding
Canned Notes
Failure to do Re-Exams

What Triggers an Audit?

Ghost Billing
Improper ICD-9 Coding
Improper Exam Sequence
Irrelevant Exam Findings
Down Coding
Waiving Deductibles and Co-pays

What should I do if I’m Audited?

 Don’t bury your head in the sand thinking it will all just go
away
 Carefully review what they are asking for and the time
frame for submission
 Retain a DC who is a CPC to audit your files
 Respond in a timely fashion
 Do not send originals
 Always send information by Certified Mail
 No excuses (i.e. the clinic did not burn down, the dog did
not eat the files)
 Once sent, return your focus to treating your patients

What if I get a Negative Outcome?

Do Not Just Pay!

Get Help!
→ A DC who is a CPC
→ A Healthcare Attorney

Start the Appeals Process
Immediately!

Medicare Appeals Process

1. First Level— Redetermination at the Carrier Level
You have 120 days from the date of the notification letter to start the
appeals process.
2. Second Level— Reconsideration by a Qualified Independent Contractor
(QIC)
First Coast Services Options Jacksonville, Florida
You have 180 days from the redetermination findings to move to this
level.
3. Third Level— Administrative Law Judge (ALJ)
You have 120 days from the reconsideration findings.
4.Fourth Level— Departmental Appeals Board (DAB)
You have 60 days from the ALJ findings.
5. Fifth Level— Judicial Review the amount must be at least $1,800.00
You have 60 days from the DAB findings.

Prevention

Education
→ Compliance Program

Electronic Medical Records
→ Encounter Specific Verbiage
→ Clinical Assessment Outcomes
→ Efficiency
→ Peace of Mind

Billing & Coding Traps Audit
Triggers
Six High Risk Areas that Lead to Problems
1. NPI number problems
2. Inaccurate Evaluation & Management coding
3. Not coding to the highest level of specificity
4. Improper coding and documentation of time
based codes
5. Inaccurate billing and coding to Medicare
6. Payment (care package/family package) Plans

Evaluation & Management
Coding

E/M Coding

How to correctly bill and code for each
E/M level for New and Established
Patient Visits

Learn how to increase your revenue with
appropriate coding

E/M Coding

You will learn how to avoid common
mistakes and billing errors that lead to
denials, and possibly post-payment audits.

Under-coding for E/M Services is costing
your clinic MONEY. Get paid for the
services your doctor renders.

E/M Codes

Account for about 90% of
family practitioners’
revenue
Account for about 10% to
15% of chiropractic
revenue

Proper evaluation & management (E/M)
coding
will get you paid, and will get you paid more!

Evaluation & Management Coding

• The most important aspect of all new
and established patient encounters is
E/M code selection.
• Proper E/M coding drives medical
necessity.

Proper E/M Coding Gets you Paid, Correctly!

E/M Services Must be Performed

They are crucial for the
determination of:

1. Mechanism of Injury
2. Objective Findings
3. Diagnostic Impressions
4. Treatment Plans

Terminology

New Patient
A new patient is one who has not received any
professional services from a physician, or
another physician of the same specialty who
belongs to the same group practice, within the
past three years.

Terminology

Established Patient
An established patient is one who has
received professional services from the
physician, or another physician of the same
specialty who belongs to the same group
practice, within the past three years.

Who is Not a New Patient?

VERY IMPORTANT
Any patient who has been under your care, or
another physician in your group, within the
past three years, no matter if they have a new
injury or new insurance, IS NOT A NEW
PATIENT.

NOT a New Patient,

Would Therefore Also Include
• Someone who has seen another physician in
a group practice of a different specialty, but
all physicians use the same tax
identification number

• A patient who was previously under care,
but who is currently, now, involved in either
an auto or worker’s compensation case also

E/M CPT Codes
Level History Exam Decision Time

99201 Prob Focus Prob Focus Straight For 10 Minutes

99202 Expanded Expanded Straight For 20 Minutes

99203 Detailed Detailed Low 30 Minutes

99204 Comprehen Comprehen Moderate 45 Minutes

99205 Comprehen Comprehen High 60 Minutes

E/M Established Patient
Codes

99211 Physician Physician Physician 5 Minutes
Presence Not Presence Not Presence Not
Required Required Required

99212 Prob Focus Prob Focus Straight 10 Minutes
Forward

99213 Expanded Expanded Low 15 Minutes

99214 Detailed Detailed Moderate 25 Minutes

99215 Comprehensive Comprehensive High 40 Minutes

Components of a Proper E/M Service

There are seven (7) components to each of
the E/M codes.
These components translate into the work
necessary to properly document a code, or
to help you determine the actual code you
should be selecting.

E/M Components

History Key
Examination Key
Medical Decision Making Key
Counseling Contributory
Coordination of Care Contributory
Nature of Presenting Problem Contributory
Time Contributory

Key Components

The three key components in choosing
an appropriate level of E/M service
are:
1. History
2. Examination
3. Medical Decision Making

Key Components

For new patient E/M codes, all three key
components must be met or exceeded.
 (3 out of 3 rule)

For established patient E/M codes, two out
of three must be met or exceeded.
 (2 out of 3 rule)

E/M CPT Codes

Forward
99202 Expanded Expanded Straight 20 Minutes
Forward

99203 Detailed Detailed Low 30 Minutes

99204 Comprehensive Comprehensive Moderate 45 Minutes


E/M Established Patient Codes

99211 Physician Physician Physician 5 Minutes
Presence Not Presence Not Presence Not
Required Required Required

Forward

99213 Expanded Expanded Low 15 Minutes

99214 Detailed Detailed Moderate 25 Minutes


History
Let’s Start at the Beginning

Patient History

The AMA lists the following as
components of a history:
Chief Complaint

History of Present Illness (HPI)

Review of Systems (ROS)

Past, Family, and Social histories

The Intake Process

This process has now become VERY
important because:
It determines the chief complaint of the
patient
It determines the correct evaluation &
management code selection
It provides a key component of medical
necessity

History

Not all histories are the
same, which is especially
true in auto and worker’s
compensation cases.

Terminology

Patient History
The AMA CPT Code Book states the chief
complaint, history of present illness (HPI),
review of systems (ROS), and the past
medical, family and social histories are all
components of the patient’s history.

Terminology

Chief Complaint
A chief complaint is a concise statement
describing the symptoms, problem, condition,
diagnosis, or other factor that is the reason for
the encounter. It is usually stated in the
patient’s own words.

Chief Complaint

The chief complaint should be the first
notation in all medical records and is
required for all levels of history.

It needs to be documented by the service
provider.

History of Present Illness (HPI)

1. Location
2. Quality
3. Severity
4. Duration
5. Timing
6. Context
7. Mod. Factors
8. Signs/Symptoms

Review of Systems (ROS)

The Review of Systems is often either not obtained or
the relevance of information that was documented is
not problem pertinent.
For many offices the intake forms that have ROS
information is lacking questions relating to the
fourteen (14) systems recognized by the AMA CPT
Code Book, or too many questions that do not provide
any useful information to the provider.
Many times, this portion of the history is considered
too tedious and time consuming for the physician and
is omitted even though higher level E/M codes require
a ROS.


The 14 systems as per the AMA CPT Code Book:

1 Constitutional 8. Musculoskeletal
2. Eyes 9. Integumentary
3. Ears, Nose, Mouth, Throat 10. Neurological
4. Cardiovascular 11. Psychiatric
5. Respiratory 12. Endocrine
6. Gastrointestinal 13. Hematologic/Lymphatic
7. Genitourinary 14. Allergic/Immunologic


A complete Review of Systems (ROS) is not
necessary for each new or established
patient encounter and should always be
problem pertinent for the chief complaint.


Example 1
For patients presenting with neck pain, a
problem pertinent ROS would obtain
information about the following systems:
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Musculoskeletal


Example 2
For patients presenting with low back
pain, a problem pertinent ROS would
obtain the following:
Gastrointestinal
Genitourinary
Musculoskeletal

Past Medical, Family & Social History

(PFSH)
Past History
A review of the patient’s past medical history
should include information on previous
occurrences of the chief complaint,
surgeries, fractures, traumas, treatments,
medications, and home therapies.


Family History
A review of the patient’s family history to
include any conditions or cause of death of
parents, siblings, or children. This should
include asking about diabetes,
hypertension, cancer, or any other disease
related to or that may delay recovery of the
chief complaint.


Social History
 This should include information on marital status,
occupation, educational level achieved, and
current/previous use of alcohol, tobacco, and drugs.
 It is important not to overlook the musculoskeletal
system review for previous episodes of neck, or back
pain. This is a very simple method of obtaining the
necessary information for the various E/M
requirements.

99201 (Problem Focused History)

HPI 1-3 Elements, Brief

ROS No ROS Needed

PFSH No Past Medical, Family or
Social History Needed.

99202 (Expanded Problem Focused History)

HPI 1 - 3 Elements, Brief

ROS 1- ROS Needed

PFSH No PFS History Needed

99203 (Detailed History)

HPI 4+ Elements, Extended

ROS 2 - 9 ROS Pertinent

PFSH 1 Relevant Review of PFS

99204 to 99205 (Comprehensive History)

HPI 4+ Elements, Extended

ROS 10+ ROS

PFSH 3 Relevant PFS

Examples of the History Section
99202 Adult
7/23/2009

CAUSATION DETAILS:
Mr. Joe Doe believes his symptoms were caused by a sports injury while playing
softball. His date of onset was 7/23/2009 for the lumbar spine discomfort. Prior to
this episode Mr. Doe stated that he has never experienced this problem before.
This onset of the primary complaint started as follows:
The patient presents today with a chief complaint of left sided low back pain secondary
to a knee injury that will require surgery. For the past two weeks he has been on
crutches which are resulting in the lower back complaints.
SUBJECTIVE:
Mr. Doe presented today and indicated that he is experiencing intermittent mild pain
in the area of the lumbar spine. This is achy and dull pain left lumbar, left sacroiliac
area and left lower lumbar area. Mr. Doe states that nothing makes him feel better
while his low back pain is made worse by walking. A 1 to 10 pain scale was used for
Mr. Doe to assess his current status. He assessed his low back pain at 2.

99202 Jane Doe
7/24/2009

PATIENT DEMOGRAPHIC INFORMATION:
Name: Ms. Jane Doe
Gender: F
Social Security Number: 123-45-6789
Date of Birth: 4/7/1955
Race: Caucasian
Marital Status: Married
CAUSATION DETAILS:
Ms. Jane Doe related to me that her chief complaint was brought gradually and cannot
pinpoint a mechanism of injury. Jane was unsure of the exact date of onset, but
indicated that it was over a year ago. Prior to this episode, Ms. Doe stated that she
has never experienced this problem before.
The patient presents today with a chief complaint of anterior ASIS pain with radiation
into the left S/I joint.


SUBJECTIVE:
Ms. Doe enters the office today and states she is feeling frequent
mild to moderate pain in the lower back. This is sharp pain
generalized in the left hip, left upper-medial thigh, and the
left sciatic region. Ms. Doe stated that massaging by hand
makes her more comfortable but her low back pain is a lot
more uncomfortable due to arising from a chair and getting
out of bed. The patient was asked to rate her pain and severity
on a scale of 1 to 10. She estimated her low back pain at 4.

REVIEW OF SYSTEMS (ROS)
General: Denies fever, chills, fatigue, and no major weight loss or gain
Psych: Denies depression, anxiety, insomnia, irritability
GU: Denies polyuria, nocturia, incontinence, or hematuria
Eyes: WORK GLASSES/CONTACTS
CVA: Denies chest pain, palpitations, fainting, shortness of breath, or ankle swelling
Resp: Denies cough, wheezing or shortness of breath.
GI: CONSTIPATION
M/S: Refer to HPI
Integ: Denies rashes, lesions, infections, and change in hair or nails
Neuro: Refer to HPI, denies seizures and loss of memory problems.
Endocrine: THYROID DISORDER
Hematologic: No history of anemia, abnormal bleeding, bruising, heat or cold
intolerance
Immune: Denies hives, hay fever, persistent infections or enlarged lymph nodes


PAST MEDICAL HISTORY
Medication taken for these symptoms includes
acetaminophen. The patient has no history of
surgical procedures used to treat this problem.


FAMILY HISTORY
Her family history is positive for high blood
pressure.

Examination
The Middle & Main Body

Examination

Examination
The collection of diagnostic information
discovered through physical applications such
as palpation, percussion, auscultation, and
inspection.

99201 Problem Focused Exam
1-5 Elements in 1 + Body Areas
Constitutional Psychiatric Skin Neck
1. 3-Vital Signs
2. General 3. Awake, Alert, 5. Inspection 7. Masses,
Appearance Oriented x 3. rashes, lesions appearance
4. Mood and Affect 6. Palpation 8. Thyroid
nodules,
tightness, (skin
rolling)

Musculoskeletal Musculoskeletal Musculoskeletal Neurological
6 Body Areas:
Inspection/palpation Cranial Nerves
9. Gait, station 10.
• Head/Neck •Range of Motion
11. Deep Tendon
• Spine •Stability (Orthopedic Reflexes
• Each Extremity Tests) 12. Sensation
•Muscle Strength/
Tone (Muscle Testing)

99202 Expanded Problem Focused
6 Elements in 1 + Body Areas

1. 3-Vital Signs
nodules,
tightness, (skin
rolling)

6 Body Areas: 10. Cranial Nerves
9. Gait, station •Inspection/palpation
11. Deep Tendon
• Head/Neck •Range of Motion Reflexes
• Spine •Stability (Orthopedic 12. Sensation
• Each Extremity Tests)
•Muscle Strength/
•Tone (Muscle Testing)

99203 Detailed Examination
12 Elements in 2+ Body Areas

1. 3-Vital Signs
nodules,
tightness, (skin
rolling)

11. Deep Tendon
•Muscle Strength/
•Tone (Muscle Testing)

99204 Comprehensive
18 Elements

1. 3-Vital Signs
nodules,
tightness, (skin
rolling)

11. Deep Tendon
•Muscle Strength/
Tone (Muscle Testing)

Medical Decision Making

This is the thought process of the examiner,
after obtaining information from the
history and examination.

Medical decision making is arrived at
by looking into three separate
parameters:

 The number of diagnosis and treatment options
 The amount and complexity of data to review
 The potential risk or complications, death, and
morbidity

Medical decision making has four
types:

1. Straightforward
2. Low Complexity
3. Moderate Complexity (rarely seen in a chiropractic office)
4. High Complexity (never seen in a chiropractic office)

Complexity of Medical Decision Making
(you must meet or exceed 2 out 3 parameters)

# of diagnoses or Amount and/or Risk of Type of Decision
Treatment options Complexity of Data Complications Making
to be Reviewed
Minimal Minimal or None Minimal Straightforward

Limited Limited Low Low Complexity

Multiple Moderate Moderate Moderate Complexity

Extensive Extensive High High Complexity

Passive Care versus Active Care

It is no longer acceptable to keep a patient on
passive care for the entire treatment program
especially over a 4 week duration.
You must transition the patient into active
rehabilitation.

WHY?


The primary goal of your treatment plan must
focus on functional capacity and increasing
the patient’s activities of daily living.

Active Care
• Exercise: Document specific stretching or
strengthening regimens that have or will be prescribed to
the patient. (Active Care will be discussed later in this
chapter, in much more detail, including billing
parameters.)

• Home Care: Document all home care measures (i.e.
most heat packs, icing instructions, orthopedic supports
and rationale, positions of comfort or rest, etc.) including
any type of activity modification.

Physical Medicine & Rehabilitation

97110—THERAPEUTIC PROCEDURE, 1 or
more areas, each 15 minutes; Therapeutic
exercises to develop strength and
endurance, range of motion and flexibility,
1 or more areas, 15 minutes each
(See ChiroCode Deskbook page F78)


97112—NEUROMUSCULAR RE-
EDUCATION of movement, balance,
coordination, kinesthetic sense, posture,
and/or proprioception for sitting and/or
standing activities, 1 or more areas, 15
minutes each


97530—THERAPEUTIC ACTIVITIES, direct
(one-on-one) patient contact by the
provider (use of dynamic activities to
improve functional performance), 15
minutes each


All of these codes are time based codes that
require one-on-one supervision. It is
important when documenting these codes
that the specific exercises performed, sets,
repetitions, and time spent must be noted
in the patient’s
clinical record.

Time Requirements

When performing time requirement
codes,
I recommend following the CMS Manual
Publication 100-04.

Time Requirements

Units Number of Minutes
1 8 to 22 minutes
2 23 to 37 minutes
3 38 to 52 minutes
4 53 to 67 minutes
5 68 to 82 minutes
6 83 to 97 minutes
7 98 to 112 minutes
8 113 to 127 minutes

Example

Example One
• 24 minutes of neuromuscular re-education 97112
• 23 minutes of therapeutic exercise 97110
• Total timed code treatment was 47 minutes

The 47 minutes falls within the range of 3 units. Correct
coding would be:
97112 x 2 units
97110 x 1 units

Example

Example Two
• 20 minutes of neuromuscular re-education 97112
• 20 minutes of therapeutic exercise 97110
• 40 total timed code minutes

The 40 minutes falls in the 3 unit range. Each code
was billed for at least 15 minutes, so choose either
code to be billed at 2 units and bill the other at 1 unit.

Modalities

A modality consists of applying
physical agents to produce therapeutic
change to tissue. These agents
include:  Thermal
 Acoustic
 Light
 Mechanical
 Electrical Energy

Modalities

Modalities can be performed in two ways:
1. Supervised – Does not require direct (one-on-one)
patient contact by the provider
2. Constant Attendance - Requires direct (one-on-one)
patient contact by the provider

Hint: When selecting the most appropriate CPT modality
code, be sure and read the description of the various
modalities.

Supervised Modalities

97010 Application of hot or cold
packs
97012 Traction, mechanical (one or
more areas)
97014 Electrical Muscle Stimulation
(unattended) (one or more areas)

Constant Attendance Modalities

• 97032 Electrical Stimulation (manual),
each 15 minutes (one or more areas)
• 97035 Ultrasound, each 15 minutes (1 or
more areas)
• 97124 Massage Therapy
• 97140 Manual Therapy
• All Active Rehabilitation Codes

97140 Manual Therapy
97140-- Manual therapy techniques
(mobilization, manipulation, manual
lymphatic drainage, manual traction), 1 or
more regions, each 15 minutes

For a more in depth description and history
of this code please visit F80 in the
ChiroCode DeskBook.

Active Release Practitioners (ART Certified),
please pay close attention. The CPT code book
specifically prohibits this code when performed in the
same anatomical areas as a chiropractic manipulation.

If you ART the cervical spine, then you cannot use a
chiropractic manipulation code if you adjusted the cervical
spine.


*Coding/Compliance Pearl: When performing along with
Chiropractic Manipulation Treatment in other areas
append with modifier 59. (97140-59)*


Doctors, even if you have been using this code with CMT
codes and getting paid, you are at a higher risk for a
negative post-payment audit if you are found to be
performing in the same area as a CMT.

Basically, you’ve just been lucky so far; fix it now, before it
comes back to bite you.

97124 Massage Therapy
• This is a time based code and cannot be
used if a vibratory massager or percussion
instrument is being utilized.

• This must be done by hand, and the
technique used must be documented.


If the office employs a massage therapist,
then the doctor must provide a prescription
for the massage which includes the
following instructions:

• Anatomical site to be worked on (specific muscles)
• Treatment frequency and duration (Three times per week
for four weeks)
• Treatment time per session (30 to 60 minutes): I would
advise no longer than 60 minutes.
• Diagnosis code that corresponds to the necessity
 728.85 Muscle Spasms
 729.1 Myofascitis

98940: 1-2 Areas of Spinal Adjustment

The RVU data states work time to be
estimated at 12 minutes: 2 minutes pre-
service, 7 minutes intraservice and 3
minutes post service. (RVU .69)

98941: 3-4 Areas of Spinal Adjustment

minutes post-service. (RVU .96)

98942: 5 Areas of Spinal Adjustment

minutes post-service. (RVU 1.25)

98943: 1 or More Areas of Extraspinal Adjustment

minutes post-service. (RVU .65)

CMT

Includes:
Pre- & Post-manipulation
Patient assessment
Usual (routine) evaluation & management
(E/M) service
A variety of techniques
Use of hand held assistive devices

Spinal Regions

As Determined by CPT are Cervical,
Thoracic, Lumbar, Sacral and Pelvic

Extraspinal Regions
As Determined by CPT are Head, Lower
Extremities, Upper Extremities, Rib Cage
and Abdomen

Full Spine Adjustments
In order to adjust full spine, there must
be documentation of symptoms in the
cervical, thoracic, and lumbar spines.
These symptoms can be anything from
the patient stating there is stiffness or
soreness, to minor aches and pains .

Full Spine Adjustment Rules
 There should be documentation of
symptoms in each area.
 Do not perform full spine adjustments
on every patient.
 There should be a diagnostic impression
to correlate with each area of treatment.
 With improvement, the number of areas
being adjusted should continually
decrease.

Major Red Flag

A major red flag and the main reason for
Medicare claim denials is not having the
diagnosis match the areas of CMT.

Red Flag for Medicare?
Give every patient a 98942 (5- region CMT)

Modifiers

A modifier provides a way to report, or
indicate, that a performed service or
procedure has been altered by some specific
circumstance.
But it does not change the actual definition or
code.

Modifiers: Don’t forget them!

The five modifiers used in chiropractic care are:
GY : Non-covered service
GA : Properly delivered ABN
GZ : “Oops”. Use this on the rare occurrence that
you should have gotten an ABN but, for some
reason, did not.
GP : Therapy
AT : Active care (acute and chronic) spinal CMT.

Commonly Used Chiropractic
Modifiers

1. AT
1. 25 2. GA
2. 26 3. GY
3. 51 4. GZ
4. 52 5. LT
5. 59 6. RT
7. TC

Advanced Beneficiary Notice
ABN

Revised ABN

The revised Advanced Beneficiary Notice of Non coverage
(ABN), form CMS-R-131 goes into effect January 1, 2012

Revised ABN

The revised ABN is issued by providers in
situations where Medicare payment is
expected to be denied.

General Information

The Financial Liability Protection provisions (FLP) of
the Social Security Act, protects beneficiaries and
healthcare providers under certain circumstances
from unexpected liability for charges associated with
claims that Medicare does not pay.

FLP Provisions
• Limitation On Liability (LOL) under §1879(a)-(g) of the Act;

• Refund Requirements (RR) for Non-assigned Claims for
Physicians Services under §1842(l) of the Act; and

• • Refund Requirements (RR) for Assigned and Non-assigned
Claims for Medical Equipment and Supplies under §§1834(a)
(18), 1834(j)(4), and 1879(h) of the Act.

Limitation on Liability

A healthcare provider (herein referred to as a “notifier”) who
fails to comply with the ABN instructions risks financial
liability and/or sanctions.

The Medicare contractor will hold any provider who either
failed to give notice when required or gave defective notice
financially liable.

ABN Scope

The revised ABN is the new CMS-approved written notice
that is issued by providers, practitioners, suppliers, and
laboratories for items and services provided under Medicare
Part A (hospice and regional non-medical healthcare
institutes only) and Part B and given to beneficiaries enrolled
in the Medicare Fee-For-Service (FFS) program.

ABN Scope

The revised ABN will now be used to fulfill both mandatory
and voluntary notice functions.

The revised ABN replaces the following notices:

• ABN-G (CMS-R-131-G)
• ABN-L (CMS-R-131-L)
• NEMB (CMS-20007)

Voluntary ABN Uses
ABNs are not required for care that is either statutorily
excluded from coverage under Medicare (i.e. care that is
never covered) or fails to meet a technical benefit
requirement (i.e. lacks required certification). However, the
ABN can be issued voluntarily in place of the Notice of
Exclusion from Medicare Benefits (NEMB) for care that is
never covered such as:

Care that fails to meet the definition of a Medicare benefit as
defined in §1861 of the Social Security Act;

Notifiers

Entities who issue ABNs are collectively
known as “notifiers”.

ABN Triggering Events

Notifiers are required to issue ABNs whenever
limitation on liability applies. This typically
occurs at three points during a course of
treatment which are initiation, reduction, and
termination, also known as “triggering
events”.

Initiations
An initiation is the beginning of a new patient
encounter, start of a plan of care, or
beginning of treatment.

If a notifier believes that certain otherwise
covered items or services will be non covered
(e.g. not reasonable and necessary) at
initiation, an ABN must be issued prior to the
beneficiary receiving the non-covered care.

Reductions

A reduction occurs when there is a decrease in
a component of care (i.e. frequency, duration,
etc.).

Terminations

Termination is the discontinuation of certain
items or services.

Blank (G) Three Options
❏ OPTION 1.

This option allows the beneficiary to receive
the items and/or services at issue and requires
the notifier to submit a claim to Medicare.
This will result in a payment decision that can
be appealed.

❏ OPTION 2.
the non covered items and/or services and
pay for them out of pocket.

No claim will be filed and Medicare will not be
billed. Thus, there are no appeal rights
associated with this option.

❏ OPTION 3.
the non covered items and/or services and
pay for them out of pocket.

No claim will be filed and Medicare will not be
billed. Thus, there are no appeal rights
associated with this option.

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.

For More Information
ADVANCED
COMPLIANCE
TECHNOLOGIES
Physician Coding and Compliance Services

Please visit the website
www.arkfeldcompliance.com
Email: tarkfeld@arkfeldcompliance.com
Phone: 989-448-8065

Fall 2012: Arkfeld Notes

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