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Chiropractic Local Coverage Determination and Supplemental Instructions Article May 1, _0214

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Chiropractic Local Coverage

Determination and

Supplemental Instructions

Article

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Today’s Presenters

• Andrea Freibauer - Provider Outreach & Education Consultant

• Donna Pisani - Provider Outreach & Education Consultant

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Disclaimer

National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly

changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to

change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at http://www.cms.gov.

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No Recording

Attendees/providers are never permitted to record (tape record or any other method) our educational events

– This applies to our Webinars, teleconferences, live events, and any other type of National Government Services educational event

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Acronyms

• Please access the Acronyms page on the http://www.NGSMedicare.com Web site to view any acronym used within this

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Objectives

• Provide a sampling of chiropractic billing

concepts and guidelines to give you a better understanding of the Medicare Program,

while helping to decrease your National Government Services claim submission billing errors.

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Agenda

• LCD

• Medical necessity

• Documentation guidelines

• Utilization guidelines

• Active vs. maintenance therapy

• SIA

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LCD L27350 - Coverage Document

SIA A47385 - Supplemental Instructions

• LCD - Specific information need to bill – Indications of Treatment

– Limitations of Treatment

– Primary/secondary ICD-9 codes supporting medical necessity

– Documentation requirements

– Utilization guidelines / frequency

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Medicare Coverage

• Medical Necessity:

Title XVIII of the Social Security Act, Section 1862 (a)(1)(A). This section allows coverage and payment

for only those services considered medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

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Medicare Coverage

• LCD-Medical Necessity

– The patient must have a significant health problem in the form of a neuro-musculoskeletal 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.

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Medical Necessity

• Medical Necessity

– Assures services to Medicare patients are reasonable and necessary for diagnosis or treatment of illness or injury

• Remittance Remark Code – CO-50 Medical Necessity Denial

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Medical Necessity Denials

• Some services are only covered in some instances

– Example: Chiropractic manipulation

• ONLY covered for a diagnosis listed in LCD

Any other diagnosis will be denied as not medically necessary

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Medical Necessity Documentation

• Written documentation (office records, diagnostic test results, etc.)

– Do not submit with claim

– Send to Medicare when requested

• Statement or diagnosis of just “Pain” not sufficient to support medical necessity

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Medical Necessity Documentation

• Precise level(s) of subluxation(s) must be

specified for each spinal region manipulated – List exact bones (C5,C6)

– Area/Region if it implies only certain bones

• Use terms that are clearly understood to refer to bone/joint space or position

• Document the need for an

extensive/prolonged course of treatment – Must be appropriate to the reported procedure

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Documentation of Subluxation

• X-ray

– 12 months before/three (3) months after

– CT/MRI

• Physical exam

Asymmetry/misalignment

ROM abnormality

Soft tissue/tone changes

Pain/tenderness

• Must have two (2) of the four (4) mentioned above, one of these must be asymmetry or ROM abnormality

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Documentation of Direct

Relationship

• Mechanism of Injury

• Chief complaint

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Documentation

Reasonable Expectation

• Age of the patient

• Comorbidities

• Prior level of function

• Measurable goals

• Keep it realistic

• Terms that relate to the patient’s necessity for treatment

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Documentation of Initial Visit

• All components of history

• Evaluation

• Diagnosis

• Treatment plan

– Recommended level of care

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Documentation of History

• Symptoms: What brought the patient in? – Acute injury/trauma

– Chronic condition…..why now?

• Prior level of function

• Health and relevant family history

• Patients age

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Documentation of History

• Previous occurrence?

– What worked, what failed?

• Detailed descriptors of symptoms

– Quality – Onset – Duration – Intensity – Character – Location – Radiation – Frequency – Other?

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Documentation of Subsequent

Visits

• Link back to treatment plan-review

• Measure

– Progress towards goals – Changes since last visit

• Exam

• Evaluate

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Documentation of a Treatment Plan

• Treatment plan

– Date of initiation of treatment – History of prior treatment

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Documentation of a Treatment Plan

• Treatment plan – Individualized – Patient-centered – Realistic – Reasonable time-frame – Tolerance

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Chiropractic LCD

L27350

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Medicare Coverage

• Break down of key points:

Significant health problem in the form of a

neuro-musculoskeletal condition

Services have a DIRECT therapeutic effect Reasonable expectation of recovery -OR-

improvement of function – Subluxation

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Covered Services

• CPT/HCPCS codes

Chiropractic manipulative treatment

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

• Regions: cervical, thoracic, lumbar, sacral, and pelvic

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Medicare Coverage

• Coverage is specifically limited to treatment by means of manual manipulation i.e., by use of hands

• Manual devices may be used but no

additional payment is available for use of the device

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Utilization Guidelines

• A chiropractic manipulation service for a

beneficiary can only be reimbursed once per day

• The frequency and duration of chiropractic

treatment must be medically necessary and based on the individual patient’s condition

and response to treatment

• Medical necessity determines visits/no set number of visits

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Active vs. Maintenance

Treatment

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Active/Corrective Treatment

• Goal driven

• Treatment plan

• Individualized

• Usually short term

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Active Treatment

• Reasonable expectation of improvement

• Not always recovery

• Not always complete return to prior level of function

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Maintenance

• Preventative

• Promote health

• Prolong or enhance the quality of life

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Maintenance

• Supportive

• Noncorrective

• No reasonable expectation of further clinical improvement

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Maintenance

• May be beneficial

• May be necessary treatment

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Noncovered Services

• The following services are considered noncovered services when ordered,

performed, or interpreted by a chiropractor – Labs

– Physical therapy (CPT 97140) – X-rays

– Massage

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Chiropractic SIA

A47385

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Coding Guidelines

• Two diagnosis required on all claims

– Precise level of the subluxation (region of spine) must be listed as the primary diagnosis

– Resulting disorders (condition) are to be listed as secondary diagnosis

• Date of initial treatment/exacerbation of existing condition

– Must be entered in Item 14 of the CMS-1500 claim form or the electronic equivalent

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Coding Guidelines

• If using an x-ray as documentation of the subluxation

– the date of the x-ray (or existing MRI or CT scan) must be

entered in Item 19 of the CMS-1500 claim form or the electronic equivalent.

• HCPCS modifier AT (acute treatment) must be appended to chiropractic manipulation code to indicate manipulation was medically necessary and reasonable treatment of an acute

subluxation/chronic subluxation as defined in national policy and the LCD

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Significant Facts for

Successful Chiropractic

Billing

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Chiropractic Services

Allowed Places of Service - SIA

– Office (11)

– Home (12)

– Assisted Living Facility (13)

– Group Home (14)

– Temporary Lodging (16)

– Inpatient Hospital (21)

– Outpatient Hospital (22)

– Emergency Room (23)

– Nursing Facility for Patients in Part A Stay (31)

– Nursing Facility for Patients not in Part A Stay (32)

– Custodial Care Facility (33)

– Independent Clinic (49)

– Comprehensive Outpatient Rehabilitation Facility (62)

– State or Local Public Health Clinic (71)

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Contacting the Telephone

Reopening Unit

• TRU Line: 888-812-8905 - follow prompt

• Part B TRU line hours of operation:

Monday - Friday, 8:00 a.m.-3:00 p.m. ET

• Faxes are accepted and representatives are permitted to accept more than 3 claims per call

• When calling TRU, provide the following information:

– Beneficiary’s name

– Medicare Health Insurance Claim Number

– Your full name (first and last name)

– Your phone number

– Provider’s name

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Record Requests/Documentation

Tips

• Respond to an ADR within 30 days • Documentation

– Legible

– Copy both sides

– Signatures

– Do not bind records together

– Do not highlight records

– Do not tab records

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esMD-How to Submit Medical

Records Electronically

• Submit ADR letter requests electronically

• Must either build a gateway or submit via Health Information Handler

• News Article: How to Submit Medical Records Electronically to National Government Services

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Signature Requirements

• Signature requirements for medical documentation

– The use of stamped signatures is not acceptable on any medical record

– Medicare requires a legible identifier for services provided and ordered

– Medicare will accept handwritten, electronic signatures or

facsimiles of original written or electronic signatures for medical review purposes

– The Medical Review department will deny claims not meeting the signature requirements on records requested on ADRs

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Timely Claims Filing Requirement

• Claims not submitted by time limit are provider-liable • Beneficiary cannot be charged for provider-liable

charges

• Claims submitted that include span dates of service, the line item “From” date will be used to determine the date of service and filing timeliness

• If a line item “From” date is not timely, but the “To” date is timely, the line item will be split and deny untimely services as not timely filed

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Submitting Duplicate Claims

• May delay payment

– Resubmitting your claim prior to receiving a determination not only increases administrative costs to the Medicare Program but to you as well

• Could cause you to be identified as an abusive

biller; or may result in an investigation for fraud if a pattern of duplicate billing is identified

– Although National Government Services does not believe

providers are trying to deliberately receive duplicate payment by submitting duplicate claims for one service we must remind

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Jurisdiction K Part B PWK Fax and Mail Cover Sheet Form Is Now Available

PWK Fax and Mail Cover Sheet Form

PWK will allow documentation to be submitted with an electronic claim

• Use of PWK segment will allow providers to submit electronic claims that require additional

documentation for claims adjudication • This process allows voluntary submission of

supporting documentation for a version 5010A1 electronic claim in one of two methods:

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Revalidation of Provider Enrollment

Information SE Article SE1126

Provider Enrollment Revalidation - Wait until you

hear from your MAC

Need to Revalidate - If you enrolled in the

Medicare Program prior to Friday, March 25,

2011

Do NOT submit your revalidation until you are notified to do so by your MAC. You will receive a

notice to revalidate between now and March 2015

(54)

Completing Online PECOS

Enrollment

• Three basic steps

– Active NPPES User ID and Password/NPI Enumerator at 800-465-3203

– https://pecos.cms.hhs.gov

– Print, sign and date the Certification Statement and mail to the Medicare contractor along with all supporting paper

documentation within 7 days of the electronic submission.

• Check status

– https://pecos.cms.hhs.gov

• Processing time frames

– Internet-Based – Process begins within 5 days of receipt - 90% within 45 days

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JK Contact Information

IVR: 877-869-6504

Provider Contact Center: 866-837-0241

Fax on Demand: 866-709-1905

EDI Helpdesk: 888-379-9132

• Correspondence

National Government Services

Part B Provider General Written Inquiries P.O. Box 6189

Indianapolis, IN 46207-6189

Direct telephone number for Provider Enrollment (JK): 888-379-3807

Beginning Monday February 3, 2014, the provider enrollment number will be available 7:00 a.m.-6:00 p.m. ET.

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NGSCONNEX

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What is NGSConnex?

NGSConnex is a free Web application maintained by

National Government Services

• NGSConnex allows for self-service functions including:

– Beneficiary eligibility

– Claim status

– Initiate reopening and/or redetermination request (Appeal)

– Obtain status of all redetermination requests

– View provider/supplier demographics

– Query financial data

– Submit cost reports, letters and supporting paperwork to Audit and Reimbursement (PART A ONLY)

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How to Sign Up for NGSConnex

• Sign up for NGSConnex by following the setup instructions at

https://www.NGSConnex.com

• NGSConnex is FREE and only requires users to have an e-mail address and Internet

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Comprehensive Error Rate

Testing

(64)

Who Performs CERT?

• Livanta – CERT Documentation Contractor (CDC)

– Requests documentation for selected claims

• Advance Med-CERT Review Contractor (CRC) – Reviews

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Who Performs Recovery Audits?

Region A: Performant Recovery, Inc. • Contact Information:

– Web site: https://www.dcsrac.com/providerportal.aspx – E-mail: info@dcsrac.com

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Coverage and Billing Resources

CMS IOM Publication 100-02, Medicare

Benefit Policy Manual, Chapter 15

– Section 30.5, Physician Services-Chiropractic Services

– Section 240, Chiropractic Services-General

• National Government Services - Chiropractic Services

– LCD: L27350 – SIA: A47385

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E-mail Updates

• Subscribe to receive the latest, up-to-date Medicare information.

(74)

Web Site Survey

• This is your chance to have your voice

heard—Say “yes” when you see this pop-up so National Government Services can make your job easier!

(75)

Medicare University

• http://www.MedicareUniversity.com

• Interactive online system available 24/7

• Educational opportunities available – Computer-based training courses

– Teleconferences, Webinars, live seminars/face-to-face training

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Medicare University

Self-Reporting Instructions

• Log on to the National Government Services Medicare University site at

http://www.MedicareUniversity.com

Topic = JK: Chiropractic Local Coverage Determination and Supplemental Instructions Article

Medicare University Credits (MUCs) = 1

– Catalog Number = To be provided

– Course Code = To be provided

– For step-by-step instructions on self-reporting please visit

(77)

Thank You!

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