Chiropractic Local Coverage
Determination and
Supplemental Instructions
Article
Today’s Presenters
• Andrea Freibauer - Provider Outreach & Education Consultant
• Donna Pisani - Provider Outreach & Education Consultant
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.
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
Acronyms
• Please access the Acronyms page on the http://www.NGSMedicare.com Web site to view any acronym used within this
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.
Agenda
• LCD
• Medical necessity
• Documentation guidelines
• Utilization guidelines
• Active vs. maintenance therapy
• SIA
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
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
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.
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
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
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
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
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
Documentation of Direct
Relationship
• Mechanism of Injury
• Chief complaint
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
Documentation of Initial Visit
• All components of history
• Evaluation
• Diagnosis
• Treatment plan
– Recommended level of care
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
Documentation of History
• Previous occurrence?
– What worked, what failed?
• Detailed descriptors of symptoms
– Quality – Onset – Duration – Intensity – Character – Location – Radiation – Frequency – Other?
Documentation of Subsequent
Visits
• Link back to treatment plan-review
• Measure
– Progress towards goals – Changes since last visit
• Exam
• Evaluate
Documentation of a Treatment Plan
• Treatment plan
– Date of initiation of treatment – History of prior treatment
Documentation of a Treatment Plan
• Treatment plan – Individualized – Patient-centered – Realistic – Reasonable time-frame – ToleranceChiropractic LCD
L27350
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
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
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
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
Active vs. Maintenance
Treatment
Active/Corrective Treatment
• Goal driven
• Treatment plan
• Individualized
• Usually short term
Active Treatment
• Reasonable expectation of improvement
• Not always recovery
• Not always complete return to prior level of function
Maintenance
• Preventative
• Promote health
• Prolong or enhance the quality of life
Maintenance
• Supportive
• Noncorrective
• No reasonable expectation of further clinical improvement
Maintenance
• May be beneficial
• May be necessary treatment
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
Chiropractic SIA
A47385
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
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
Significant Facts for
Successful Chiropractic
Billing
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)
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
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
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
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
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
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
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:
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
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
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.
NGSCONNEX
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)
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
Comprehensive Error Rate
Testing
Who Performs CERT?
• Livanta – CERT Documentation Contractor (CDC)
– Requests documentation for selected claims
• Advance Med-CERT Review Contractor (CRC) – Reviews
Who Performs Recovery Audits?
• Region A: Performant Recovery, Inc. • Contact Information:
– Web site: https://www.dcsrac.com/providerportal.aspx – E-mail: info@dcsrac.com
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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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
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