Any type of payer review can create some headaches for providers and cause problems for a healthcare office. Even for a practice that has taken administrative steps to try and prevent a prepayment review, it can still happen. A prepayment review means that you must include documentation WITH your claim. The payer will review that documentation BEFORE deciding if they will pay your claim. Reviews can take up to 30 days to determine if a claim will be paid. The result can be financially crippling to a practice, especially if one of their biggest payer puts them under prepayment review. So how should you respond when this happens to your practice?
First and foremost - do NOT ignore the problem. It will NOT go away on it’s own. If you continue to have a high claim error rate, it could lead to more than just a prepayment review. It could lead to a postpayment audit or even being added to an exclusion database. You don’t want it to get to that point so you must be proactive.
If the pay...
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Question: What do I do when a Medicare patient refuses to sign an ABN?
Answer: That depends on whether the patient is still demanding to have/receive the service/supply. If they aren’t demanding the service, then there is no need to force the issue. Just make sure that you still have an ABN with a note on it which states the patient refused to sign it. 
However, if they are demanding the service, then even though the Medicare Claims Processing Manual, Chapter 30, Section, states that “The beneficiary cannot properly refuse to sign the ABN at all and still demand the item or service” there are a few exceptions to that statement.
The following additional information from CMS provides some guidance:

If the beneficiary or the beneficiary’s representative refuses to choose an option or sign the notice, you should annotate the original copy indicating the refusal to choose an option or sign the notice. You may list any witnesses to the refusal, although a witness i...
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One constant in our industry is change. Policies change, contracts change, and there are updates. Also, people aren’t perfect and mistakes can be made. So this article will cover a variety of topics.
Published Articles
We appreciate feedback from our valued customers. We have received feedback regarding two of our articles which have been corrected on our website. Corrections are identified by strikeout and green text.

“Q/A: I Submitted a Claim to the VA and it’s Being Denied. Why?” Published March 15, 2019.Correction: While technically you may treat the patient with one visit under the Choice Program, additional visits must be authorized through TriWest. To clarify the policy, the following paragraph needs to be revised:Did you obtain an authorization for these services? An authorization is not necessarily the same thing as a referral. Check with the provider relations department to determine their requirements. Although the first visit does not need to be authorized unde...
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Question: My patient seemed confused about which of the options they should check. Can I just tell them which one they should check?
Answer: No! That could be construed as coercion. The official instructions state “Under no circumstances can the notifier decide for the beneficiary which of the 3 checkboxes to select.”
Now, this doesn’t mean you can’t help them understand the three different options. You can answer their questions, but never tell them that they have to check a specific option.
Another problem that we have seen is that providers will check the option for the patient. The official instructions state that “Pre-selection of an option by the notifier invalidates the notice.” You can NOT check that box for them UNLESS the patient is physically unable to check the box and they ASK you to do it for them. If that is the case, you must make a notation on the ABN about that unique situation. Although it is not required, it might be helpful to have someone witness th...
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Even though we may think we truly understand what it means to be a participating provider, Medicare doesn’t quite work the way that other insurance plans do. Far too many providers do not understand the difference and get into hot water. To further complicate matters, the rules are different for Part A/B versus Part C/D. Also, do not confuse ‘out of network’ with participation status. Perhaps the time has come for us to start using different words to describe a provider’s status with a third-party payer. Using “in network” instead of “participating” to refer to situations where you have gone through a credentialing type process with the payer and using “Out of network” instead of “non-participating”.
Medicare Part A or Part B
Medicare Part A and Part B are known as ‘traditional’ Medicare plans. For Medicare Part A and Part B, participation status has to do with your payment status — not your enrollment status.
It is critical for you to understand th...
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How do we know which codes a payer will allow?
The best way to determine the codes (CPT, ICD-10-CM and HCPCS) allowed by a payer is to review their payer policy. While it is good to know the official guidelines (e.g., ICD-10-CM Official Guidelines for Coding and Reporting, AMA Guidelines, Medicare NCDs/LCDs), knowing the payer’s policy is the only way to know for sure what they want specifically.
You might want to begin by looking on the provider’s website or calling their Provider relations department. If you do call, keep in mind that you can get two different answers from two different people. It’s best to ask for a copy of their written policy for the service in question (e.g., chiropractic manipulative treatment, physical therapy).
When the payer doesn’t have an official policy, it can be helpful to review other payers’ policies, but that isn’t a guarantee of payment. You’ll still have to follow all other rules and policies for the payer in ques...
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Although it has been quite some time since ChiroCode published an article about the revised instructions for non-participating providers  who use the ABN, there are still some outstanding questions about this change. So far, Medicare has not provided additional guidance about this question despite requests by us for clarification.
Medicare now requires non-participating providers to include the following highlighted statement in the (H) Additional Information section (see this article for more information about this requirement):
“This supplier doesn’t accept payment from Medicare for the item(s) listed in the table above. If I checked Option 1 above, I am responsible for paying the supplier’s charge for the item(s) directly to the supplier. If Medicare does pay, Medicare will pay me the Medicare-approved amount for the item(s), and this payment to me may be less than the supplier’s charge.”
It should be noted that Medicare's stated reason for this change was to ...
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I submitted a claim to the VA and it’s being denied. Why?
There are several reasons why your claim might be denied by the Veterans Administration (VA). However, without more information about the claim itself (e.g., services billed), we can only provide the following general information about the VA and chiropractic care.
Although the VA has expanded care options for veterans, like all payers, they do have policies that need to be followed. Unless you are contracted directly with the VA, you are most likely billing through their Patient-Centered Community Care Program (PC3) or the Veterans Choice Program (VCP). The information presented here relates to these programs. 
The following are some key points to evaluate when deciding why the claim has been denied:

Do you have a referral? According to the ACA, a referral from a VA primary care or specialty provider is a requirement prior to rendering care.
Are you contracted with the associated payer? This varies de...
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We've had some patients coming in with new Medicare cards, but not all of them. Does every Medicare patient have a new card? Am I supposed to be using the new number on all the claims and what's with the dashes in the new number, do I use that on claims? Could you provide a little more information for us? Thanks.
As many of you are aware, CMS began issuing new Medicare identification cards last year which required the replacement of social security numbers with a new Medicare Beneficiary Identifier (MBI). All cards have now been mailed out and patient's should have the new cards when they come in. Currently, we are in the transition period until January 2020. This means that even though you should be using the new MBI on claims, you have some time to phase out the old ID numbers in your system.
Every beneficiary should have a new card, but don't be surprised if they come in and don't have one because they might not realize that they were supposed to replace t...
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Providers need to ensure that they are reporting radiology dates of service the way the payer has requested. Unlike many other professional services which only have one date of service (DOS), radiology services can span multiple dates.
There seems to be some disagreement between professional organizations and payers as to which date to use. Back in October 2017, the American College of Radiology stated that they recommended that the DOS for the professional component should be the date when the technical component was performed. However, according to MLN Matters SE17023 which was updated February 1, 2019, Medicare states that the date to report depends on the portion of the service (global, professional, technical) completed by the provider. SE17023 states that:

If only the technical component (TC) is performed, report the date the patient had the imaging performed.
If only the professional component (PC) is performed, report the date the report was completed.
If the provider...
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Is M62.81 Muscle weakness still valid? Is there a better code to use for upper/lower extremity muscle weakness d/t pain?
The code has not been deleted. It is still valid. A payor could take issue with it and ask for more information.  Unfortunately, it is not very specific. There is no better code that specifies the location.  Just be sure to document the details in case a payor wants to know more than the code tells them.  ...
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Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and policy manual, which identify code pairs considered integral to one another or bundled. An NCCI code pair consists of two codes representing procedures that, when performed during the same operative session, on the same patient, and by the same provider, should not be billed separately because they are considered part of the greater procedure. A different way of explaining this would be to consider how upset you might be if you went to a restaurant and paid for a nice meal but were then asked to pay a separate fee for use of the silverware, water glass, and napkins. Those items are integral to your meal, to your ability to eat it, and you shouldn’t be charged separately for them.
NCCI code pair edits are published quarterly and become effective immediately. A companion policy manual, updated and published annually (October 1st), explains the reasoning behind the code pair edits and whether or no...
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The nice thing about MediGap policies is that they pay for some of the healthcare costs that an original Medicare plan (Part B) does not cover. So when a patient has Medicare and a Medicare supplement (MediGap) and their condition is related to an extremity (a noncovered service), Medicare must be billed for the denial in order for the Medicare supplement to consider payment. However, the exact manner of billing this situation has prompted some to ask:

Does the claim for Medicare list an extremity diagnosis and will this yield a denial with the correct PR codes?
When billing Medicare (even when the extremity condition is the primary reason for the encounter) must a spinal subluxation be listed as the diagnosis for the claim to be pushed through Medicare to get a proper denial?

Keep in mind that MediGap policies generally pay for the deductible and coinsurance for covered services. MediGap policies must follow federal and state laws and it must clearly be identified as a “Medic...
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 In the situation of a locum tenens/substitute provider, can you help me understand the difference between the Q5 and Q6 modifier and when it would be appropriate to use each one?
It's important to understand that these modifiers are not interchangeable. These modifiers recently had their descriptions changed to clarify some of the problems previously associated with them. Use Q5 when there is a reciprocal billing arrangement and use Q6 is when there is a fee-for-time compensation arrangement. Medicare has some specific rules about the time involved so be aware of individual payer policies and their time requirements.
 Please read the following article for a more detailed explanation of these two modifiers:

Reciprocal Billing and Locum Tenens Arrangements Changes
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Some providers mistakenly think that they cannot bill a missed appointment fee for Medicare beneficiaries. You can, but Medicare has specific rules that must be followed. These rules are outlined in the Medicare Claims Policy Manual, Chapter 1, Section 30.3.13. You must have an official “Missed Appointment Policy” which is the same for ALL your patients. In other words, they don’t want you penalizing Medicare patients differently than other patients. 
There are no fee amount guidelines other than the fact that you cannot charge a Medicare patient any more than you would charge a non-Medicare patient. This goes back to the one policy for all patients described above.
These charges should not be submitted to Medicare because they are the responsibility of the patient. It would be a good idea to include your “Missed Appointment Policy” as part of your “Informed Financial Consent Policy” so the patient fully understands their financial responsibility. See “Step 2. Establi...
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Are you aware if digital x-ray of the spine requires a different code than plain x-ray?  If so, where can I find the information specific to digital x-ray codes?
There are no separate codes for digital x-rays. However, there may be modifiers that are required to be submitted with the usual imaging codes. The Consolidated Appropriations Act of 2016, titled "Medicare Payment Incentive for the Transition from Traditional X-Ray Imaging to Digital Radiography and Other Medicare Imaging Payment Provision" makes it clear that Medicare wants providers to use digital imaging and like EHR, they will penalize you for not using the newer technology. 
Effective January 1, 2017, Medicare requires modifier FX if the image is done with film. This modifier reduces payment of the technical component (and the technical component of the global fee) by 20 percent. It is important to note that this reduction ONLY applies to the technical component. This fee reduction can not be passed ...
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How do I code it so that PT services in a chiropractic office don’t count against their PT visit max? Is there a way to code claims so that they are considered chiropractic only? But still get compensated enough? We have been running into some issues as of late pertaining to how we code our claims; the chiropractor here also has physical therapy privileges which I believe is where we are running into the problem. She has been coding her claims so that it considered under both chiro and PT, which in turn exhausts her patients benefits faster (ie: A patient has 20 chiro visits and 30 pts visit allowed; the way the claims are coded the first 20 ‘chiro visits’ would also be considered pt, thus giving the patient only 30 visits in total versus 20 chiro visits and then 30 additional pt visits).
This is unfortunately a known problem that has existed for years. Physical therapy practices are often hard hit by this situation. If a physical therapy service is provided A...
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By Wyn Staheli, Director of Research & Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
It is not unusual for a healthcare provider to review x-rays taken and professionally read by another entity. Questions arise regarding how to bill this second review. It is essential to keep in mind that the global (complete) service of taking an x-ray is composed of both a professional and technical component. The professional component includes reading the x-ray and creating the written report and the technical component is reported by the owner of the imaging equipment who also takes the image (x-ray).
In the hospital (facility) setting, usually a radiology group is contracted to read the image and produce a written report, adding modifier 26 to the CPT code for the service while the facility, who owns the larger equipment (eg, MRI, CT) that produces the image will report the code for the service with modifier TC.
Physician groups usually own lower cost imaging equipment (eg, x-ray ultrasound) th...
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Which code should I use for a lab interpretation fee? Specifically, I have ordered a female hormone saliva test, and would like to charge a fee for time spent on the interpretation and consult
This type of service generally does not involve a third party, so it may be acceptable to just bill the patient with an internal code you created for this purpose. However, you might consider the HCPCS codes S3650 or S3652 if they apply to the situation you are describing.  Unfortunately, these codes do not allow you to add the modifier 26 to separate the professional component of the service from the techinical component.  
Perhaps the best option for you is to use 99199 - Unlisted special service, procedure or report.  ...
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These are really two separate questions with two separate answers.
For the first question, code G8730 only needs to be reported when you are participating in MIPS — a CMS Quality Payment Program — and yes they are active. While many chiropractic physicians are not mandated to participate in MIPS due to the low volume threshold, you may choose to participate by either voluntarily reporting (which has no payment offsets) or opting in. Beginning in 2019, providers can opt into the MIPS program and be eligible for MIPS payment adjustments in the 2021 payment year.
For the second question, it is essential to note that there are many other G codes that are still active and required for non-quality reporting (e.g., G0283 for electrical stimulation). In fact, new G codes are added each year to the HCPCS code set. Be sure to use the appropriate procedural G codes as required by payers....
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As many of you may already be keenly aware, there have been ongoing problems with many payers (e.g., BCBS of Ohio) regarding the appropriateness of reporting an E/M visit on the same day as CMT (CLICK HERE to read article). The AMA recently released an FAQ which renders their opinion on what services are included in the pre- and intra-service work involved when performing CMT (98940-98943). While this new FAQ does not necessarily state that you cannot report E/M with CMT, it is less vague than guidance from previous CPT Assistant issues (e.g., December 2007 page 16c, January 1997 pages 7-8) and does offers some additional information/clarification.
To more fully examine the problem, we begin with the official CPT Guidelines as found in the CPT codebook (emphasis added):

The chiropractic manipulative treatment codes include a pre-manipulation patient assessment. Additional evaluation and management services … may be reported separately using modifier 25 if the patient's condit...
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The new year is upon us and so it’s time to double check and make sure we are ready. As always, there were changes to all the official code sets (i.e., ICD-10-CM, CPT, HCPCS) which could affect your practice.
Diagnosis Code Changes 
For the official ICD-10-CM code set fiscal year 2019 which began October 1, 2018, there were 279 new codes, 51 deleted codes, and 143 revised codes. However, there weren’t very many changes which affect chiropractic. As we mentioned back in September, the most significant change is the expansion of code M79.1 “Myalgia” to 4 new codes. M79.12 “Myalgia of auxiliary muscles, head and neck” and M79.18 “Myalgia, other site” will most likely be the ones used in your office. Since M79.12 says ‘auxiliary muscles’, it seems that M79.18 would be the most commonly used code of the two.
Code G71.0 “Muscular dystrophy” has also been expanded to define the type of dystrophy.
In the External Causes, Chapter 20, there were no new codes added tha...
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Recently we posted a Q/A with stated that Cox-flexion distraction was not billable with code 97012. We received a comment from a customer stating that was not entirely correct because there is an add-on to the standard Cox table which satisfied the mechanical requirements to use code 97012. This article further clarifies the previous Q/A.
Please note that the original question did not mention any special ‘optional’ equipment so our answer was based on their question. It is our understanding that the majority of providers do not add the additional or optional components. Also keep in mind that there are other brands of equipment so we will refer to this as flexion-distraction technique.
Our answer was based on the standard of coding guidelines and rules including policies issued by the American Chiropractic Association (ACA). According to the American Chiropractic Association (ACA) Policy (emphasis added):

Flexion distraction is a Chiropractic Manipulative Technique. Per th...
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The correct coding of dry needling, also known as trigger point needling, has been a subject of confusion for quite some time. The American Chiropractic Association (ACA) and the American Physical Therapy Association (APTA) have been working together for several years to obtain appropriate codes to describe this service. In September of 2018, they made a presentation to the American Medical Association (AMA) CPT Panel which subsequently approved new non-time-based codes which will be in the Surgery section of the CPT code book in the “Procedures on the Musculoskeletal System” section. These new codes describe needle insertion(s) without injection(s) and will likely be effective in January 1, 2020.
So that leaves us with another year to muddle through. Basically, it really boils down to what payers want. The problem is that even though various professional organizations have stated their policies, payer policies are varied. Let’s review these differences.
AMA: The AMA’s positi...
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On December 14, 2018, the Office for Civil Rights (OCR) issued a Request for Information (RFI). They are considering making changes to some of the HIPAA regulations. Earlier this year at the HIMSS (Healthcare Information and Management Systems Society) meeting, Roger Severino, the head of the Office for Civil Rights (OCR) gave a presentation in which he outlined some possible changes to the HIPAA regulations. This RFI is the first step.
According to the release,“OCR seeks information on the provisions of the HIPAA Rules that may present obstacles to, or place unnecessary burdens on, the ability of covered entities and business associates to conduct care coordination and/or case management, or that may inhibit the transformation of the health care system to a value-based health care system.”
They are seeking input on:

"Promoting information sharing for treatment and care coordination and/or case management by amending the Privacy Rule to encourage, incentivize, or require...
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There was a ruling that was requiring providers to be enrolled in Medicare in order to provide services for Part C (Medicare Advantage (MA)) and/or Part D. However, on April 2, 2018, CMS released the 2019 Final Rules for MA and Part D which changed this previous ruling. According to a CMS press release (see References below), as part of the  “Patients Over Paperwork” Initiative, effective January 1, 2019, they are “eliminating enrollment requirements for healthcare providers and prescribers that bring value to Medicare Advantage and Part D beneficiaries.” This is only for Part C and Part D plans. For Part A and Part B, it is still necessary to be enrolled as a Medicare provider. Healthcare providers who have opted out of Medicare may now provide services to beneficiaries under Medicare Part C or prescribe Part D covered drugs.
This doesn’t mean that ANY provider can now start providing services for Part C beneficiaries. Medicare Advantage plans will utilize a “Preclusio...
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by Wyn Staheli, Director of Research & Editing
While equipment for home strengthening is arguably good for the patient and the prognosis of their condition(s), payers have very strict guidelines as to what is considered medically necessary when it comes to Durable Medical Equipment (DME). While I have seen some workers compensation policies which do pay for DME like therabands, exercise balls, and theracanes, many health insurance payers will not cover them. It comes down to their definition of durable medical equipment and what constitutes medical necessity. Take, for example, Humana’s definition of DME in policy HCS-0429-021 (emphasis added):

Can withstand repeated use (ie, could normally be rented and used by successive individuals); AND
Generally is not useful to a person in the absence of illness or injury; AND
Is appropriate for use in an individual’s home or may be necessary for use at other locations or in the community to allow basic activities of daily living (ADLs)...
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By Dr. Ray Foxworth, MCS-P, President of ChiroHealthUSA
Over the past decade, we have seen health care costs rising faster than the average annual income in the U.S. Many of our patients are feeling the pain from higher premiums, deductibles, and copays. As a patient, I understand the pain. As a provider, I feel the increased burden of rising costs in my practice and diminishing reimbursements. When facing similar challenges, some doctors try to justify not charging for some services in their practices. I hear it all the time, “Well, I do XYZ for free. But, it’s okay because I don’t charge my patients or the insurance company.” That sounds good in theory, but the reality is that giving away any service for free can be risky.
Although, as business owners, we all feel that we should be able to operate our businesses as we see fit, the truth is that we can't always do what we want, especially in health care. The business of health care is the second most regulated industry in th...
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Question: Do the Croft Guidelines apply to a patient's condition immediately following the collision or are they applicable to a patient's state when they first come to see you? Whether that has been weeks or months since the collision without treatment?
Answer by Tom Grant Jr., DCMed-Legal ConsultantDirector of Education, 
Great question, one that finds a growing number of DC's are confused and misapplying the Croft Guidelines. ICD-10 coding provides no help in identifying the type of collision and its impact forces nor do they provide an injury severity identifier. The apparent effort of the Croft Guidelines (CG's, which can be further explored at is to provide a set of general guidelines that prove a measure of injury severity (since ICD-10 codes don't have severity indicators) using a classification of collision type (Type I-III, Other) and a grade of severity classified by the presenting injuries of the patient (CAD Grade I-V) and the presenting sta...
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There were some very minor reductions to the RVUs for CMT codes 90840-90843. The practice expense (PE) RVUs for codes 98940, 98942, and 98943 were reduced by .01. So using the final 2019 PFS conversion factor of $36.04, which is slightly higher than the 2018 PFS conversion factor of $35.99, the national, unadjusted Medicare allowed fees for 2019 will be:


2019 Fee

2018 Fee





- 0.33




+ 0.05









Other payers who use the same RVUs could also have minor fee reductions for 2019. Now is the time to prepare for the upcoming year. Be sure you:

Contact your contracted payers to find out what their allowed amounts will be. Evaluate your contracts.
Review Chapter 1.5 - Establishing Fees in the 2019 ChiroCode DeskBook.

ChiroCode also offers a comprehensive fee analysis service. CLICK...
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Question: In Pennsylvania for Personal Injury cases we do not need to go through specific care paths or get precertification in order to treat patients, however, in New Jersey (NJ), doctors that practice there are required to get that precertification. Our question is that when we bill a New Jersey auto insurance company they are stating that we need to get precertification when we do not because we are based in Pennsylvania. What would be the best way to get the insurance companies to understand and not argue with us about the fact that we do not have to get precertification? Is there a specific way to communicate that to an insurance company from a different state?
Answer: This sounds like you are dealing with a situation called diversity jurisdiction. The prevailing law is based on where the accident occurred as well as the physical location of the insured that was at fault. The insurance company must abide by the prevailing law. Therefore, if either the accident or the insured is ...
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The waiting is over, the Final Rule for CMS' 2019 Medicare Physician Fee Schedule (MPFS) is available - all 2,379 pages for those looking for a little light reading. As anticipated, there are some pretty significant changes. Most of us were carefully watching the proposed changes to the Evaluation and Management codes for office visits, but that's not all that was included in this 2,300+ page document. The following is a summary of some of the major provisions.
Evaluation & Management
CMS' stated goal was to reduce administrative burden when reporting these services. Some changes are happening right away and some will happen later. The following take effect January 2019:

Home visit: Eliminate the requirement to document the medical necessity of a home visit in lieu of an office visit
Office visit - established patient: When relevant information is already included in the medical record, instead of repeating it all again, documentation should focus on what changed since the last...
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I am setting up an LMT to work as employee under Dr. Clifton, DC. i need to know several things - hoping they are related and can be grouped into this one question.... does she need her own NPI? where does that NPI # go? what box #? if not, how do i indicated that she is the "provider of service" for the massage"

You have a choice to bill either of the following ways:

Bill directly under the LMT’s own NPI as a professional performing a service within his/her scope of practice and who independently reports that professional service, or

As a clinical staff member, under the Doctor of Chiropractic’s NPI

Several organizations recommend that the LMT obtain their own NPI and bill the service directly. However, they would then need to be on the panel for the insurance company being billed, which may be difficult to do. Additionally, some payers, like original Medicare, do not cover massage (therapeutic or otherwise) as a benefit (see ABN for non...
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The Coding Clinic for ICD-10-CM and ICD-10-PCS is a quarterly newsletter published by the American Hospital Association's Central Office (AHA). The information they publish is a joint effort of several organizations including the Centers for Disease Control and Prevention (CDC), the National Center for Health Statistics (NCHS), the Centers for Medicare and Medicaid Services (CMS), and professional organizations such as the American Medical Association (AMA). Because the information included in the Coding Clinic is considered an official resource is it important to pay attention to their publications. 
Usually there isn't much related specifically to chiropractic care, but the Quarter 3, 2018 Coding Clinic addressed the coding of lumbar spondylolisthesis with radiculopathy. There is no available combination code which identifies both conditions so it is necessary to code both the spondylolisthesis (M43.1-) AND the radiculopathy (M54.1-) according to the anatomic site. The AHA article ...
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I am a certified DOT medical examiner and have applied to get my CLIA lab (waiver) for urinalysis, finger prick blood tests for A1c, cholesterol and glucose. I realize I cannot diagnose patients with these tests, but I am using them to make decisions in the DOT process and with nutritional counseling. What codes do I use for these tests?
You may want to double check with the manufacturer of the device(s) you are using since they likely have done the research already and know which codes are applicable. CLICK HERE for an example of a fact sheet by one manufacturer.
Some other possibilities are:

Blood glucose:  82962 - Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for home use
A1C: 83037 - Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use

There are some payers that will also pay for the collection of the blood (code 36416) in addition to the laboratory testing service, but others consider i...
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We have been receiving several DDS referrals to our massage therapists who do intra-oral work. The only problem is that the referral from the DDS lists code R51 for headaches as the only DX code. Since most plans don't cover massage therapy for headaches alone, are there any codes that can distinguish the headaches as TMJ related so they can be more widely covered?
TMJ has a history of being denied for treatment - any type of treatment and that includes massage. Documentation must always be correct and clear. If the patient is getting massage FOR the TMJ then the notes must reflect this. Documenting a headache that is associated or caused by TMJ is fine, but the notes need to reflect that as well.
You really need to be careful about how you bill insurance based on what was treated. Having a different diagnosis than what is on the referral could potentially be a red flag for an auditor unless your findings are properly documented.
It can also depend...
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Is cox-flexion distraction billable as 97012? Also, with using the 97140 code in conjunction with a manipulation code, I am aware that they cannot be performed in the same regions. Would this example work: manipulation of the cervical, thoracic and SI regions, billed as 98941, plus lumbar manual traction billed as 97140?
Unfortunately, Cox Flexion Distraction is not billable as 97012 as it doesn't meet that code criterion.  This would typically be part of the CMT (9894-).  
Regarding the 97140...yes, your example would work, depending on payer policy.  Some state that it can't be done in an adjacent region (i.e. lumbar can't be billed if thoracic or SI is manipulated too). You would need to append the 59 modifier to the 97140.  Make sure documentation is clear and there are adequate diagnoses supporting each service and that these diagnoses are pointed properly on the claim form to the appropriate service....
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The OIG recently concluded an audit on a chiropractic office located in Florida and had some significant findings. They recommended the following:

Refund to the Federal Government the portion of the estimated $169,737 overpayment for claims for chiropractic services that did not comply with Medicare requirements and are within the 4-year claims reopening period
Exercise reasonable diligence to identify and return the overpayments in accordance with the 60-day rule, for the remaining portion of the estimated $169,737 overpayment for claims that are outside of the reopening period, and identify any returned overpayments as having been made in accordance with this recommendation;
Exercise reasonable diligence to identify and return any additional similar overpayments outside of our audit period, in accordance with the 60-day rule, and identify any returned overpayments as having been made in accordance with this recommendation; and
Establish adequate policies and ...
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Question: Is it legal for us to not allow a patient to be seen in our office if their parents have bad debt with us? We have a family who has a history of taking a VERY long time to pay their balance. The parent wants to schedule another child for an appointment. Can we not accept him because of his parents bad payment history?
According to a legal website, by law, physicians cannot refuse to accept a person for ethnic, racial, or religious reasons. Nor can they discriminate based on the person's sex, unless the sex of the patient is relevant to the physician's specialty.
This situation does not meet those limitations, so it is entirely up to you. If the individual is of legal age though and is financially responsible for the bill, then you might want to have him complete the financial policy paperwork so he understands what his personal responsibility will be. However, that is entirely up to you. See “Step 2. Establishing Patient Financial Responsibility” on page 21 of ...
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The leaves are beginning to change and it’s time once again for the annual code changes for 2019. ICD-10-CM codes are out and will be effective October 1, 2018. CPT code changes also just came out and will be effective January 1, 2019. The ChiroCode DeskBook and ICD-10-CM Coding for Chiropractic books have been updated and are now shipping! HCPCS code changes are not yet available, but will be by December, at which time, we will let you know about revisions that may affect your practice.
As for ICD-10-CM codes, the one that is most significant for chiropractic care is the expansion of the code we typically use for myofascial pain syndrome, M79.1 “Myalgia”. It has been expanded to the following:
     M79.10 Myalgia, unspecified site     M79.11 Myalgia of mastication muscle     M79.12 Myalgia of auxiliary muscles, head and neck     M79.18 Myalgia, other site
Be sure to implement policies to ensure documentation clearly identifies the site to ensure proper code select...
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Are there any alternative procedure codes for billing mechanical massage (e.g., muscle master vibromassage, genie rub, etc)? I know that 'by the book' mechanical devices are not covered under 97124, but wondered if you have suggested a go-around code. Personally, I haven't unless they can show/document some type of myofascial, trigger point, or joint tissue work/benefit.
ChiroCode has never recommended billing separately for mechanical massage. If it gets coded at all, the most applicable code that could be used would be an unlisted code - 97039. However, the code really doesn't matter because payers simply won't pay for it. If the provider is doing myofascial release or trigger point work, it must be "manual" to satisfy the requirements for 97140, so I don't think that the use of a vibracussor would count since the machine is doing everything. It is just a nice adjunct service....
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Why would a chiropractor be concerned about depression screenings when you aren’t trained to be a mental health provider? The answer lies in patient outcomes. Many quality care organizations recommend depression screenings for patients with a chronic condition. According to The National Institute of Mental Health, “People with other chronic medical conditions have a higher risk of depression.” This is because depression can not only make a chronic condition worse, but it also can be triggered by illness-related anxiety and stress. Because depression affects how a person manages their health condition, not addressing depression when dealing with a chronic condition can have a negative effect on patient outcomes.
ACA’s “Choosing Wisely” program addresses this topic. They state (emphasis added):
4. Do not provide long-term pain management without a psychosocial screening or assessment.
There is a high probability that any person with a chronic pain syndrome has a concomi...
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Once a PI patient is released with symptoms, or without symptoms, and a prognosis of likely exacerbations with a future medical estimation of $1500 over then next 2 years, how am I supposed to release them from care when they still have ongoing needs?
We have discussed this with several different experts. The consensus is that the patient should not be released from the PI case until BOTH of the following have occurred:

the ortho/neuro exam is normal or has stabilized AND
outcome assessments show no significant measurable and functional change after 3 exams over varying times. This one, known as a trial withdrawal of care, is commonly overlooked by chiropractors

If the patient shows no measurable and functional change and they don't worsen without treatment, they should either be released from care or referred out. During the trial withdrawal of care, the patient should be instructed to gradually and carefully increase their activity level to what is was befor...
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Yes it is legal to shred patient records only after a certain period of time has passed. The question is, what amount of time? The typical time frame is 6-10 years. According to HIPAA rules, medical records must be retained for six years from the date of its creation or last use—whichever comes later. To meet HIPAA standards, it is best to use a cross-cut shredder and be sure to document which records were destroyed, how they were destroyed, and by whom in your Record Retention and Purge Log. If you use a destruction company, you also need to have a Business Associate Agreement in place.
Be sure that you have an official Destruction Policy in your practice's Policies and Procedures Manual.
Please note that "CMS requires Medicare managed care program providers to retain records for 10 years," we recommend that you keep them at least 10 years unless your state has a mandate that is more stringent. Check with an attorney in your state to ensure that you are meeting your state ...
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It is no secret that providers have long argued that E/M coding is burdensome and does not truly reflect the services provided. This fact is acknowledged by CMS with the following statement "Prior attempts to revise the E/M guidelines were unsuccessful or resulted in additional complexity due to lack of stakeholder consensus (with widely varying views among specialties), and differing perspectives on whether code revaluation would be necessary under the PFS as a result of revising the guidelines, which contributed another layer of complexity to the considerations."
The problem has been, and will continue to be, a "lack of consensus" by both providers and payers who "interpret and apply the guidelines as part of their audit processes".
Last year, CMS began the process of making changes and it became clear from the comments that (emphasis added) "any changes would have substantial specialty-specific impacts, both clinical and financial. Based on this feedback, it also seems that the...
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Question: Are visits when a Chiropractor just uses a spinal decompression table billable to insurance? If so, what code is recommended?
Answer: There is a code to describe this service, it is S9090 - Vertebral axial decompression, per session. Some payers will cover this service and some do not. It should also be noted that some payers also allow 97012 to be used to report decompression. The best way to handle this is to review the payers policy before using 97012 because there have been reported cases where the provider had to return money for biling 97012 because the payer did not allow it for that service.
Coverage varies widely so there is no substitute for reviewing the individual payer policy to ensure that you are reporting the service properly....
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It is important to keep in mind that Medicaid is run at a state level so there can be some differences when it comes to coverage. However, the rules regarding balance billing of covered services is set at the federal level. The law states (emphasis added):
A state plan must provide that the Medicaid agency must limit participation in the Medicaid program to providers who accept, as payment in full, the amounts paid by the agency plus any deductible, coinsurance or copayment required by the plan to be paid by the individual. - 42 CFR § 447.15 Acceptance of State payment as payment in full
According to this law (above), the only amounts you could collect from the patient for covered services, are the Medicare allowed deductible, coinsurance, and/or copayment. However, according to Medi-Cal’s Provider guidelines, you cannot do that. It states “Providers must not bill the recipient for private insurance cost-sharing amounts such as deductibles, coinsurance or copayments...
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Answer: These two codes are not interchangeable. Code 97140 is for manual therapy techniques which do not require active participation of the patient (e.g., soft tissue mobilization, manual lymphatic drainage, manual traction). Code 97530 describes dynamic activities which require patient participation (e.g., throwing, lifting). Please see Chapter 6.3 - Common Procedure Codes & Tips in the 2018 ChiroCode DeskBook for more comprehensive information on using these codes....
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We recently heard about a small practice that had been faithfully submitting all the required “G” codes for the Quality Payment Program (QPP) only to discover that for 2018 they are excluded from MIPS because the low volume threshold increased from $30,000 in Part B allowed charges or 100 Part B beneficiaries to $90,000 in Part B allowed charges or 200 Part B beneficiaries. They were unsure about what they needed to do at this point and how it would impact their practice.
An increase from $30,000 to $90,000 is a significant increase for a small or solo practice. This step was taken by CMS due, in part, to feedback they received about small practices having a hard time meeting all the participation requirements. In fact, chiropractic is one of several specialties which have very few applicable quality measures to report.
Along with this low-volume threshold increase, they also added the following to help small practices:

5 bonus points
3 points for measures in the quality p...
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Do we have to have patients with Medicare replacements that our office is not in network with sign an ABN with Option 2 marked?
Medicare Advantage (Part C), sometimes referred to as Medicare replacements, are not subject to the same rules as regular Medicare (Part B). Do NOT use the ABN for any Part C plans, regardless of whether or not you are in-network. Part C plans can have their own unique requirements regarding billing so it is necessary to find out that information from the payer. 
Be careful about balance billing rules. They can vary by state and by plan so be sure that you do NOT charge more than is allowed. CLICK HERE to read more about rules for non-contracted providers....
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Q: The code , 97124, Is specifically for massage but I have read that Insurance will more likely pay for 97140. Could we bill for whichever one pays? I believe that we have to indicate which area is used for CMT and which area for massage. Is it enough to document that or should we indicate it on the claim form with diagnosis pointers? What do you recommend?
A: Codes are intended to only represent a specific service and not be interchangeable. A different code can really only be used if a different service is being performed. Massage is “efflurage, petrissage, and tapotement.” Manual therapy includes “mobilization/ manipulation, manual lymphatic drainage, manual traction.” The code should be assigned based on which of these services was performed. From a compliance perspective, this decision has to be made regardless of which code is more likely to be paid. Unless the contract says otherwise the patient can pay for the non-covered service out of pocket. 
Massage (97124) docu...
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Most providers are aware of Medicare’s “Mandatory Claim Submission Rule” (Social Security Act (Section 1848(g)(4))) which requires the submission of claims for all Medicare beneficiaries and applies to all physicians and suppliers. If you see a Medicare patient, you must file a claim for covered services. If you don’t, you “may be subject to a civil monetary penalty of up to $2,000 for each violation, a 10 percent reduction of a physician’s/supplier’s payment once the physician/supplier is eventually brought back into compliance, and/or Medicare program exclusion” (see MLN Matters® Number: SE0908)
What some providers may not be fully aware of is that there are several exceptions to this rule. Here are a few:

Noncovered services: Noncovered services do not need to be billed UNLESS the beneficiary specifically requests that a claim be submitted to Medicare so that a supplemental policy will have the necessary Medicare denial to process the claim. Be sure that you obt...
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Whether or not a physical therapy assistant (PTA) may perform physical therapy modalities depends on two factors: state law and payer policies. 
First, verify with your state to see which modalities are allowed under state scope of practice laws.
Second, check the individual payer policy because even if it is allowed under state law, it might not be allowed by the payer. For example, Medicare only allows licensed therapist assistants (this does NOT include physical therapy technicians) to provide therapy services in an outpatient private practice setting ONLY if those services are performed under the direct supervision of a licensed therapist. See 42 C.F.R. §410.26(b)(1)-(7) and CMS Medicare Benefit Policy Manual, Pub. 100-4, Ch. 15, §60.1 - §60.5. However, there are a list of conditions which must be met such as the supervised therapist performs the evaluations and establishes a plan of care and the supervising therapist must be on-site and sign the documentation....
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By Gregg Friedman, DC, CCSP
As both a chiropractor for 31 years and one who reviews a lot of medical records for themedicolegal arena and has been teaching documentation for many years, the range of motionquestion comes up frequently. Although we used to get reimbursed very well for a specificrange of motion code back in the 90’s, it’s pretty much disappeared from insurancereimbursement, other than for personal injury cases. Even other record reviewers get this onewrong, so I’ll keep this as simple as possible.
There is a specific CPT code for Range of Motion Measurements – 95851 (Range of motionmeasurements and report (separate procedure); each extremity (excluding hand) or each trunksection (spine)). The long-standing problem with this code has been, if it’s performed and billedon the same visit as your ortho/neuro exam, which was billed as an E/M code, insurers andreviewers will usually deny the 95851 code, accusing you of the dreaded “unbundling” error.The problem i...
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Q:  I have a payor who is denying modalities, claiming that they are “excessive”.  At a single encounter I billed for:

98940- Chiropractic manipulative treatment (CMT); spinal, 1-2 regions
97110- Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
G0283- Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
97010- Application of a modality to 1 or more areas; hot or cold packs

Is this excessive?  How do I know how much is too much?
A:  First it is important to point out that modalities can be considered passive or active.  Some folks consider therapeutic procedures, like 97110, to be active modalities.  Others might say that modalities do not include therapeutic procedures, but that they are in their own category.  Regardless, many payors get worked up over too many of the same type of passi...
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Question: I have a question about a wellness ABN. Do you have to specify for repetitive or continuous noncovered care the frequency and/or duration of the item or service in the Blank D area (box in the middle of form). I have heard from other sources that Blank D (Services) box should look like (example) 24 CMT visits/1year. I was not doing them this way but another consultant group pointed out that it is in the instructions. Is this right?
Answer: To answer that question, let's look at the official instructions with emphasis added. It's like the non-participating provider instructions to strikeout certain text. There is some abiguity which leaves the door open for some interpretation.

"The notifier must list the specific items or services believed to be noncovered under the header of Blank (D).

In the case of partial denials, notifiers must list in Blank (D) the excess component(s) of the item or service for which denial is expected.
For repetitive or continuo...
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Recently, Medicare's Innovation Center released an informal Request for Information (RFI) seeking input on several different system reformation proposals. As the market moves towards value based payment systems, new models are being sought to both reduce costs and increase quality. This article outlines some of the ideas presented in the RFI which we find of particular interest to doctors of chiropractic.
Expanded Opportunities for Participation in Advanced APMs
Alternative Payment Models have been picking up some steam since MACRA began in 2015. CMS must be seeing positive results because they are trying to figure out ways to further encourage provider participation. This could be an excellent opportunity for chiropractic care to expand by participation in these models.
Consumer-Directed Care & Market-Based Innovation Models 
Empowering consumers to make choices on how their healthcare dollars are spent can yield more bang for the buck. There were several ideas presented in ...
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Question: A number of patients now have high deductible plans. Sometimes, deductibles can be $5000 or $10,000. My payer contract states that I must submit all claims to insurance for covered services. However, sometimes patients with these high deductibles come to my office and state that they would prefer to receive a modest discount for paying cash and in turn, not have their services submitted to insurance. As a doctor, this places me in a tough situation. Do I follow the patient's wishes or the payer contract?
AnswerHIPAA's "Out of Pocket” provision allows a way for you to honor your patient's wishes. However, ALL of the following criteria must be met:

The patient completes a "Request to Restrict" disclosure form
The disclosure is to a health plan for payment or health care operations
The disclosure is not required by law (e.g., court ordered)
The protected health information pertains solely to healthcare for which the patient (or someone on behalf of the patient) has pai...
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I am looking for a supraspinatus and infraspinatus tendonitis code but I only see a rotator cuff tear. I am not sure if there is a better one.
Unfortunately, ICD-10 really doesn't have many options when it comes to tendonitis. According to one doctor, tendonitis is the default radiologist term for inflammation of the tendons which could be either bursitis or tendonitis even though they are not entirely the same thing. It sounds like you were referring to "M75.1- Rotator cuff tear or rupture, not specified as traumatic." However, unless the radiological report specifies a tear, the more appropriate options (based on the ICD-10 index which refers to nontraumatic lesions, the ICD-10 crosswalks, and the recommendations of others) would be one of the following, depending on the clinical record:

M75.5- Bursitis of shoulder
M75.8- Other shoulder lesions
M75.9- Shoulder lesion, unspecified (note this is unspecific and the other two are typically better choi...
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Attention Premium Members: Don’t miss out on your PACE CEU’s!
 CEU’s are now available for the following Webinars:
       Practice Risk Areas, Presented by Brandy Brimhall   (1 CEU)
       Secrets of Chiropractic Documentation, Presented by Compliant Coding Systems.  (4 CEU’s)
 CEUs are available in the following states:                                                                                                                                                                                                                                                                              ...
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As chiropractors we feel the new modifier 97 is more appropriate than 96 for our PT codes such as stim and traction. Yet Carefirst is asking for 96 only. Should we use this code on all the PT codes and for all the other insurance companies?
We also agree that modifier 97 would be the correct modifier for most physical therapy services provided in a chiropractic setting. Do not begin using modifier 96 for any payer UNLESS it truly is to help a person DEVELOP skills or functions they didn't have before. If not, then the documentation would not meet the requirements of that modifier and we have concerns about future claim reviews with the possibility of fraud allegations.
Before you bill CareFirst with modifier 96, get an official statement from them that they want you to use modifier 96 for both habilitative and rehabilitative services. 
After reviewing CareFirst policies, it would appear that using modifier 96 would be inappropriate in your setting.
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The Affordable Care Act (ACA) requires coverage of certain essential health benefits (EHBs), two of which are rehabilitative and habilitative services and devices. Since the ACA did not define these terms or specify coverage requirements, it is left up to individual states to create benchmark plans to determine coverage requirements. As of January 1, 2018, there are two informational modifiers which should be used when reporting these two different types of services. Since physical therapy services may be either habilitative or rehabilitative, the appropriate modifier needs to be used when reporting these services.
What's the Difference?

Habilitative (modifier 96): services that help a person DEVELOP skills or functions they didn't have before.
Rehabilitative (modifier 97) services that help a person RESTORE functions which have become either impaired or lost.

Requirements may vary from payer to payer. Let's examine some key concepts excerpted from one payer's policy (empha...
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By Wyn Staheli, Director of Research
Noridian, the Jurisdiction F Medicare Administrative Contractor (MAC), recently announced that they will be extending their pilot program: Provider Self-Audit with Validation and Extrapolation (PSAVE). Whenever a program is extended, that means that it has been successful for the payer, which likely means that they are saving money. It doesn’t state HOW they are saving money. Historically, when a pilot program is proven to be successful, it isn’t too long before other MACs follow. Before signing up to participate, providers need to carefully evaluate the program.
What is PSAVE?
According to Noridian, “The PSAVE program allows the provider to perform a self-audit after agreeing to waive appeal rights on the universe of claims.” In exchange for waiving their appeal rights, the provider receives immunity from MAC and Recovery Auditor (RA) reviews.
Providers who voluntarily participate in PSAVE receive education on how to perform a self-audi...
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by Wyn Staheli, Director of Research
Section 1848(r)(4) of MACRA requires that claims submitted for items and services furnished by a physician or applicable practitioner on or after January 1, 2018, include codes for the following:

care episode groups
patient condition groups
patient relationship categories

Previously, CMS decided to use procedure code modifiers to report patient relationship codes on Medicare claims. In December 2016, they asked for public comment regarding this proposal. The 2018 Physician Fee Schedule Final Rule included the following table of modifiers to be used to report patient relationships. The “Notes” column is not part of the official Table 27 in the Physician Fee Schedule Final Rule (see References). That information was added from information found in another CMS press release (see References).
Table 27: Patient Relationship HCPCS Modifiers and Categories (with Notes added)

HCPCS Modifier

Patient Relationship Categories

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by Wyn Staheli, ChiroCode Director of Research & Dr. Evan Gwilliam, Clinical Director PayDC Software
In August of 2017, a Brooklyn chiropractor was ordered to repay $672,805 to Medicare because the reviewer found that 100% of the claims reviewed (from 2011-2012) did not meet medical necessity requirements. The chiropractor enlisted help from two reputable experts who disputed the findings of Medicare’s Professional Reviewer (MPR). However, the OIG maintained that the findings of the original auditor were valid.
Even though we do not have access to the original documents, there are some very important things that all chiropractors can learn from the unfortunate outcome if this particular audit. Since none of us have ½ million in cash just laying around, it is essential to learn, understand, and make changes where appropriate to help audit-proof patient documentation.
Policy Manual
Problem: OIG stated that “allowable payments occurred because the Brooklyn Chiropractor did no...
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Question My office was broken into last night. I use electronic health records, but we do store some protected health information for my patients in paper files. These files are not secured, so the burglars did have access to them. It did not appear that the files were touched as the burglars were looking for cash. What responsibilities to I have to my patients in a situation like this? Do I need to contact them and advise them that their PHI could have been compromised?
AnswerRegardless of whether or not you think that there was a breach, HIPAA mandates that you do a Breach Risk Assessment and document the results including police reports of the incident.
Depending on the results of that risk assessment, you would then take whatever is considered the appropriate steps. To be perfectly honest, even if it looks like they did not open the file cabinets, you do NOT have definitive proof (unless you have fingerprinting done on the cabinets or a video tape showing that they did not enter ...
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Billing nutrition counseling services may not be as straight-forward as you might think. Some providers mistakenly choose Medical Nutrition Therapy (MNT) codes (97802-97804, G0270, G0271) because it states nutrition therapy in the title. However, according to CPT guidelines, when MNT assessment and/or intervention is performed by a physician or qualified healthcare professional who may report evaluation and management services, they are supposed to report an Evaluation and Management or Preventive Medicine service code instead of the MNT codes.
Preventive Medicine
Preventive Medicine codes 99381-99387, 99391-99397, and G0402 are more comprehensive than MNT and include:

an age and gender appropriate history and examination
counseling/anticipatory guidance/risk factor reduction interventions
ordering of laboratory/diagnostic procedures

Documentation needs to clearly identify that this service is not for treatment of a disease-related diagnosis and some payers ...
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I have a patient that was involved in a PI case. His lawyers are asking that we bill his insurance company first. This particular patient has xxxx insurance and the clearing house is rejecting the claim based on "ERROR 3430-Invalid principal diagnosis code." We lead with diagnosis code V43.52XA, could we change the position of the V43.52XA code? Or should we submit a paper claim for the case instead?
The medical insurance company is rejecting the claim because they want a medical diagnosis. The advice would be the same as for all other cases, PI or not, you bill the appropriate injury and symptom codes for the encounter first (which is not an external cause - V code), and then follow it with applicable codes, like this one, which describe the encounter. In fact, since most payers do not require the use V codes, it is likely not required, but still helpful information to include.
According to Dr. Tom Grant, a personal injury claim expert, using V codes for PI cases...
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Diagnosing, Documenting, and Coding for Radiculopathy
Radiculopathy can be an unpleasant condition, but diagnosing, documenting, and coding for it does not have to be. It just takes a little research. The brain communicates with the body via the spinal cord which is protected by the bones of the spinal column, called vertebrae. Nerve roots exit in between each bone through openings called foramen. The nerves from the neck carry signals back and forth to and from the arms, hands, and fingers. Cervical radiculopathy is the name for pain and other symptoms caused by problems with these nerves. Problems with the nerves from the low back can cause leg and feet symptoms, called lumbar radiculopathy or sometimes sciatica. 
Diagnosing radiculopathy can be done with a variety of orthopedic, neurological, and imaging procedures.  Orthopedic tests reproduce the symptoms by increasing pressure or stress on the affected nerves. You might see documentation with names like “Straight Leg Raiser...
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A number of patients now have high deductible plans. Sometimes, deductibles can be $5000 or $10,000. My payer contracts state that I must submit all claims to insurance for covered services. However, sometimes patients with these high deductibles come to my office and state that they would prefer to receive a modest discount for paying cash and in turn, not have their services submitted to insurance. As a doctor, this places me in a tough situation. Do I follow the patient's wishes or the payer contract? Please advise.
HIPAA's "Out of Pocket” provision (45 CFR §164.522) allows a way for you to honor your patient's wishes. However, in order to do this, ALL of the following criteria must be met:

The patient completes a "Request to Restrict" disclosure form
The disclosure is to a health plan for payment or health care operations
The disclosure is not required by law (e.g., court-ordered)
The protected health information pertains solely to health care for w...
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To properly answer the question, it is important to first review the requirements of selecting the appropriate level of Evaluation and Management (E/M) service and how that relates to reporting a 99080 special report service.
Every CPT code has both performance and reporting (documentation) requirements. The level of an Evaluation and Management (E/M) service is determined based on the amount of key components performed or time spent counseling and coordinating care AND also includes the documentation that describes what was done. For an established E/M service, performance of 2 of the 3 key components (History, Exam, Medical Decision Making) is required or, if based on time, the performance portion is determined based on the length of the face-to-face time the provider spent with the patient and what was counseled and/or coordinated (separate from the time spent performing the key components).
Reporting or documentation is the second requirement. It is retained in the medical record...
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Q: I just received a note from an attorney regarding a patient who was rear ended about 40 mph and ended up with neuropathy in her upper and lower extremities. We  treated her for about 3 months after previous care failed to give much relief. I used flexion distraction and deep muscle stimulation to break up adhesions from the injury and used the 97112 code of neuromuscular re-education. The insurance company said that code was not warranted for her spinal sprain diagnosis and denied all of the services. Do you know how I could justify it? It greatly improved her condition with each visit and the patient said we provided the greatest relief she received.                                               
A: To justify 97112 you need to show that the patient has neurological damage. The code description includes the following:
Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or sta...
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Question: I have a provider that provides Department of Transportation (DOT) exams. I have found ICD-10 code Z02.4 (encounter for examination for drivers license) but I am unsure which CPT Code to use. Would I still use 99203 or 99204?
It would be inappropriate to use E/M office visit codes as these require all the components of a 'sick' visit (e.g., chief complaint, PFSH, Exam, and Medical Decision Making) which do NOT fit the DOT exam. We have heard that some people use the preventive medicine codes (99381-99387, 99391-99397), but those too have specific E/M requirements. The Unlisted E/M Visit (99499) is the safest code to use.
However, if you do happen to perform a regular E/M visit at the same time, use the unlisted code and bill the E/M service with modifier 25.
One thing to note is that DOT exams should not be billed to the medical insurance. Some employers may pay for them, but in most cases, it is paid for by the patient....
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Recently, many healthcare providers have begun to experience a downpour of denials when billing therapy services. The states which seem to be experiencing the most difficulty are Illinois, Oklahoma and Texas, particularly for claims submitted to BCBS plans owned by Health Care Service Corporation (HCSC). Since HCSC also owns Blues plans in Montana and New Mexico, the problems may be extending there as well.
In August of 2017, there was an innocuous-looking announcement which stated that BCBS would be implementing a new "code-auditing enhancement" which would be "clinically validating modifiers". Unfortunately, last fall HCSC began using their new claim editing software which focuses on the use of particular modifiers (i.e., 25, 59, and X{ESPU}) which resulted in claim rejections for many services using these modifiers. Please note that these claim rejections include both E/M services and CMT, whether or not physical therapy services are included. It is modifier based and it...
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Question: With a maintenance patient of Medicare age that has a Medicare replacement plan (Part C), do they need to fill out an ABN?
Answer: According to the ABN Booklet by CMS, "You should not use an advance written notice of noncoverage for items and services you furnish under the Medicare Advantage Program (Part C) or the Prescription Drug Benefit (Part D)." Be aware that these plans could have their own type of form that they require so be sure you verify their requirements for non-covered services....
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The OIG recently released a "Portfolio" regarding chiropractic service which stated (emphasis added):
This portfolio presents an overview of program vulnerabilities identified in prior Office of Inspector General (OIG) audits, evaluations, investigations, and legal actions related to chiropractic services in the Medicare program. It consolidates the findings and issues identified in that work and discusses recommendations from prior reports that have not been implemented or have been implemented ineffectively.
In other words, the OIG is not pleased with the way that CMS has handled their previous recommendations and so they released this portfolio summarizing their findings and recommendations. In the portfolio, they go as far as to say, "chiropractic services that are not reasonable or necessary can potentially harm Medicare beneficiaries." So just what is in this portfolio that doctors of chiropractic need to be aware of? Mostly it reiterates the ongoing documentation and maint...
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Are there consultation codes that can be used for new and existing patients when a review of systems and detailed history is performed but no examination due to the patient's reluctance to make a decision to continue with the visit but has taken up 30-45 minutes of the doctors time?
You would actually use your typical E/M codes (9920- or 9921-) and instead meeting the required criteria for documentation of these services, you would be using the time override rule for these codes.  Time override does have some specific criteria for each code which you will want to review.  This is detailed on page 322 of your 2017 ChiroCode DeskBook....
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Question: Can two untimed codes be performed at the same time? For instance can I perform lumbar traction (97012) at the same time as e-stim (97014)?
Answer: According to a publication from Medicare which came from the FAQ page for physical therapy services, the following information (in italics below with emphasis added) indicates that it is appropriate to perform them at the same time and that they are not requiring a modifier. However, this information is from Medicare, different payers may have different policies so be sure to verify coverage with individual payers.
2. Billing - CPT Codes: Permitted
In the same 15-minute time period, one therapist may bill for more than one therapy service occurring in the same 15-minute time period where "supervised modalities" are defined by CPT as untimed and unattended -- not requiring the presence of the therapist (CPT codes 97010-97028). One or more supervised modalities may be billed in the same 15-minute time period with any...
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There has been some controversy over the use of the ICD-10-CM subluxation codes commonly referred to as traumatic (S13.1-, S23.1-, and S33.1-). Are they appropriate for chiropractors to use? The answer to that question is complicated. The problem basically lies in the lack of official guidance and differing opinions on what the word “subluxation” means. The official description for those categories states “Subluxation and dislocation of” along with the associated location. According to the ICD-10-CM Official Guidelines for Coding and Reporting, Section I.A.14, when the word ‘and’ appears in the title, it is to be interpreted as meaning either “and” or “or”. Therefore, based upon these guidelines, it would be appropriate to read the description as “subluxation of.” However, there are those who assert that subluxation in this context refers to an allopathic subluxation which is not the same thing as a vertebral subluxation (also known as the chiropractic or no...
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There are differences between the purposes of strapping and taping and using the correct codes depends on the application - literally.
Strapping: This application is for the purpose of immobilizing an area. It is clinically indicated for the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures, or other deformities involving soft tissue.
Coding: See codes 29200-29280 (body/upper extremity) and 29520-29584 (lower extremity). Note that code 29220 (strapping of low back) was deleted in 2010 and the CPT book now states to use 29799to report low back strapping.
Kinesio Taping: Typically, but not always, this application is for the purpose of providing assistance in movement. According to one payer's policy, "Kinesio Taping is designed to facilitate the body’s natural healing process while allowing support and stability to muscles and joints without restricting the body’s range of motion. It is used to treat a variety of ort...
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How do I find out how much I can charge for a 98941 for a Medicare beneficiary?
There are many factors involved. First, fees vary by geographic location. Then, if you are non-participating, you can bill the Limiting Charge. If you are participating, you will be reimbursed the Allowed Amount. Depending on your penalties from PQRS and/or Meaningful Use, that amount can be adjusted down further.  
The official rules can be found here, and a CMS calculator is here. Those with Premium Membership can view the Allowed Amount on the code information page inside the ChiroCode Online Coding Library. For a more comprehensive discussion on Medicare fees, see Chapter 2.3 of the 2018 ChiroCode DeskBook. If you still have questions, call your Medicare Contractor and talk to their provider relations department.
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Can you please help me with the definition of Office Visit? We have used code 99213 E&M code for office visits. However, we have some insurance companies that will cover office visits but not chiropractic treatments. Can we bill for office visits even though we are giving chiropractic care? And, is code 99213 a good code to use for an established patient visit? Providence Health here in Oregon did not like us billing 99213 and using M99 codes along with this CPT code. They still consider it chiropractic treatment. Which it is but we did not use a CMT code. We charge a flat fee for office visits/treatments.
If you bill for an office visit on the same date as chiropractic treatment, you must append the 25 modifier to the office visit/exam code.  On this note, you must be sure that you are indeed performing a "distinctly separate" office visit, in order to bill and collect payment from this as a separate procedure.
Bear in mind also that there are different levels of ...
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The following are some commonly asked questions about ChiroCode's Qualified Chiropractic Coder (QCC) certification.
Q: What's on the test?
A: There are 100 randomized questions covering the following topics:

Billing requirements
Types of Insurance including Medicare
Reimbursement and collections
Coding - Procedures and Diagnoses

Q: What score do I need to pass?
A: 70%
Q: Can I stop in the middle of the test and start it up again later?
A: No, it must be completed in one sitting.
Q: How long is the test?
A: There are 100 questions so it depends on how many answers you know immediately off the top of your head and how many you need to refer to the books or the ChiroCode Online Library for answers.
Q: How many times can I take the test?
A: Purchasing the exam once grants you 3 attempts. If you fail those 3 attempts, you may purchase another 3 attempts by contacting customer support. There are no limits or time constraints on any attempts. This me...
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By:  Aimee Wilcox, CPMA, CCS-P, CST, MA, MT
We recently received an email from a reader asking whether or not range of motion (ROM) testing (95851-95852) using a dual computerized inclinometer with a separate report, when done at the same time as an Evaluation and Management (E/M) service, could be billed if reported with modifier 59 to override the NCCI edit. The reader referred to the patient's condition indicating the need for “more definitive and quantifiable data” and referred to the specific ROM Assessment guides set by the AMA.
Although it may seem justifiable and even medically necessary to perform these services simultaneously, CMS has determined they are incidental to each other. According to the National Correct Coding Initiative (NCCI) edits, when range of motion (ROM) testing is performed (95851-95852) at the same time as an Evaluation and Management (E/M) service it will be denied as incidental (or an expected part of) the physical examination portion of the E/M ...
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Q: When patients have a true Medicare secondary insurance we've always billed other Medicare non-covered codes such as G0283 for electric stimulation with modifier GY because we are aware Medicare will not pay for that service but the secondary insurance does. We just were notified by our MAC that GY is not a valid modifier and I have to enter a GP or other therapy modifier. What is the new proper modifier to enter?
A: Medicare recently released an article stating that in order to track physical therapy caps, one of three therapy modifiers (i.e., GN, GO, or GP) needs to be added to the code on the claim. There are some MACs which have required modifier GP in this situation. All of the following codes are on that list:

97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761, 97762 (this code was deleted and replaced by 9...
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There's still time to report quality measures for the 2017 reporting period and CMS just made it a little easier. On January 2, 2018 they announced a new data submission system for eligible clinicians to report quality measures for the Quality Payment Program. Data may be submitted through the new platform on the website. The announcement stated:
     "Data can be submitted and updated any time from January 2, 2018 to March 31, 2018, with the exception of CMS Web Interface users who will have a different timeframe to report quality data from January 22, 2018 to March 16, 2018. Clinicians are encouraged to log-in early to familiarize themselves with the system.
     Real-Time Scoring
     As data is entered, clinicians will see real-time initial scoring within the MIPS performance categories. Data is automatically saved and clinician records are updated in real time. This means a clinician can begin a submission, leave without completing it, and then finish it at...
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By Wyn Staheli, Director of Research

Medicare's MLN Matters Number: MM10176 was recently revised to identify services subject to their therapy cap. The revision became effective on January 1, 2018 and some providers have begun to receive claim rejections because they are not using the appropriate modifier. The article states the following:

     "Services furnished under the Outpatient Therapy (OPT) services benefit – including Speech Language Pathology (SLP), Occupational Therapy (OT), and Physical Therapy (PT) – are subject to the financial limitations, known as therapy caps, originally required under Section 4541 of the Balanced Budget Act (1997)."
There are two such caps. One cap is for PT and SLP services combined and another cap is for OT services. In order to accrue incurred expenses to the correct therapy cap; the use of one of the three therapy modifiers (GN, GO, or GP) is required on a certain set of Healthcare Common Procedure Coding System (HCPCS) codes i...
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Q: I checked the government website to see if I am an eligible clinician and it says that I am not. I just don't want to get blindsided with a letter saying I will be penalized. Is there anything you would suggest or recommend that I do now to protect myself from future penalties. Thank you
A: For the 2018 reporting year, there are a significantly higher number of providers who are excluded because they raised the low-volume threshold significantly. However, it is imperative to keep in mind that Medicare payment programs can change frequently (they have done so in the past) so the advice I'm going to give right now could change in the future due to legislative action. Also, keep in mind the 2 year 'lag' in which your current payments are affected by what you did 2 years ago. Hang on to your documentation that you CURRENTLY do not qualify for 2018 MIPS participation due to the low volume threshold.
Even though you are not required to report measures for 2018, you need to pay a...
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By:  Wyn Staheli

Medicare’s Merit-based Incentive Payment System (MIPS) Final Rule increased the threshold for participation. With this increase, a significant number of providers fall into the exempt category and they are now breathing a sigh of relief. However, there’s one hidden tidbit which you may have missed - the potential damage to your reputation and practice if you DO NOT participate. As incredulous as this may sound, it’s a possibility to consider as your scores will be published on the Physician Compare website for all the world to see. Those scores may also be used for other third-party physician rating websites. One study found that 65% of people are aware of these rating sites and many use them regularly. Providers with high scores have an advantage over their competitors. Damage to online reputations could take years to undo.
These online ratings play a role in the hiring process as well. If two providers were seeking employment at an organization and one...
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Can EMR records be deleted? If so, when?
 We suggest that you just expand the memory on your computer and keep electronic records forever.  However, you should follow the strictest guidelines that pertain to your practice when destroying patient records.  
While individual states generally govern how long medical records are to be retained — HIPAA rules require a Medicare Fee-For-Service provider to retain required documentation for six years from the date of its creation or the date when it last was in effect, whichever is later.  For minors, the clock doesn't start until after they reach the age of majority. 
 Note also that any retention and disposal guidelines and processes for your practice absolutely must be documented according to compliance regulations....
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By:  Brandy BrimhallPublished:  September 29th, 2017

Healthcare providers need to be aware of several different fraud and abuse laws. Most are aware of the False Claims Act and the Health Care Fraud statute. Another important one to pay attention to is the Physician Self-Referral Law, also known as the Stark Law. In some industries it is legal to reward those who refer business to you; however, in federal healthcare programs, paying for referrals is illegal.
The Stark Law is a federal law governing referrals for services or supplies which are payable by government entitlement programs such as Medicare, Medicaid, and CHAMPUS. This law prohibits providers from referring patients for "designated health services" (DHS) to any “entity” with which the physician (or an immediate family member) has a “financial relationship", unless an exception applies (42 U.S.C. § 1395nn(a)(1)(A)). As such, if you don’t participate in ANY Medicare, Medicaid, or related government healthcare se...
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We have a question regarding using modifiers when billing CMT and non-covered codes to Medicare. For several years we have used ATGA to bill for active care for CMT codes 98940-98942  (Ex: 98941-ATGA). AT for "Active" and "GA" to show they'd signed an ABN. We've never had any rejections from our electronic clearing house, nor from Medicare. Our concern is we were told today, by our state association, that we should never bill GA with AT. But don't we need to show they've signed an ABN so we can collect from the patient "just in case" Medicare doesn't pay? If the CMT is for a maintenance visit, should we use the GA (98941-GA), so we can collect from the patient?
 AT GA are not permitted to be used together by Medicare.  Medicare prohibits the use of the ABN form if the patient is in active/corrective care (AT).  
Medicare will penalize for inappropriate use of the ABN.  They do not allow the ABN to be used for:
1).  Covered services that are expected to be p...
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As we at ChiroCode worked to find an example of the perfect daily treatment visit note, we came across many authoritative sources. For your convenience, we have included them here. The four sources here include Medicare, a chiropractic network, one state board's rules, and one insurance company's requirements. At first glance they may appear to be very different, but, there are many similarities. For the 2018 ChiroCode DeskBook, we considered all these sources and created a SOAP note format that we believe captures all of these requirements so that you can use the same layout for all payers and circumstances. You can read about it in Chapter 4.3 in the 2018 ChiroCode DeskBook.
1. Medicare (proposed as of 9/2017):
Documentation Requirements: Subsequent Visits
The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:
1. History (an interval histor...
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Effective June 21, 2017, providers need to be using the new ABN form. Be sure that new ABNs are properly delivered for any Medicare patients seen since June 21st.
Non-participating providers need to note some specific instructional additions to the ABN which states the following (highlight emphasis added):
Special guidance ONLY for non-participating suppliers and providers (those who don’t accept Medicare assignment):
Strike the last sentence in the Option 1 paragraph with a single line so that it appears like this: If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.
This single line strike can be included on ABNs printed specifically for issuance when unassigned items and services are furnished. Alternatively, the line can be hand-penned on an already printed ABN.
The sentence must be stricken and can’t be entirely concealed or deleted.
There is no CMS requirement for suppliers or the beneficiary to place initials next to ...
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Q: I went to the CMS site to check my NPI and was informed that I did not meet the requirements for quality reporting and was therefore exempt from participation. Now I have received a letter from CMS saying there will be a 2% payment reduction. What is going on?
A: One VERY important thing to consider is the year that you checked your status. This is because the reporting threshold and requirements have changed over the years and there is a 2 year lag between reporting and payment adjustments. If you checked recently, then the reporting threshold is actually higher so you could very likely be exempt for 2017 which would affect payments for 2019 (because of the 2 year lag). HOWEVER, if the year in question you DID meet the requirements for reporting and you did not, then the adjustment would rightly apply.

At this point, to be sure that this is NOT an administrative error, the best thing to do would be to contact your MAC, the QualityNet HelpDesk (1-866-288-8912  or Qnets...
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Q: In order to code carpal tunnel syndrome G56.01 or G56.02, does there need to be documentation that nerve conduction (EMG testing) has been performed to confirm the diagnosis?
Really it depends on the normal medical diagnostic practices as well as the requirements of the payer. For CTS, there are physical exam findings (non EMG testing) which support the diagnosis and typically providers say "these symptoms with this patient history = carpal tunnel syndrome" so it would be appropriate as long as the physical exam findings support it.
However, if there is a need for more extensive procedures such as surgery, it is necessary to find out what the patient's insurance payer requires, which may be further testing to confirm the physical exam findings....
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Author: Dr. Ron Feise is a practice consultant and coach with RJF Consulting
We received this email from a chiropractic colleague: “I recently attended acontinuing education seminar accredited by a chiropractic college. The presenterwas talking about outcome measures and highly recommended cervical andlumbar range of motion (ROM) as a good outcome measure for patients withspinal conditions. But I am hesitant to use ROM, because it seems to beinconsistent with a patient’s status.”
What does the current research demonstrate? Today we investigate therelationship between spinal manipulation and ROM. In 2012, a systematic reviewassessed whether spinal manipulation improves range of motion findings (Millan2012). This study was published in Chiropractic & Manual Therapies. Theresearch team consisted of 5 PhDs. Overall, this study had good methodologicalrigor. The research team performed a thorough search of the literature withmultiple reviewers selecting and ap...
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Can an unlicensed person perform say 97110 service as long as they're under doctor supervision? I use only PT, ATC, or DC's to perform these codes and I've been told that I don't need such highly qualified therapists to perform therapy. 
Depends on the state regulatory boards who set the administrative practice standards, laws, and rules. They determine whether or not the provider can delegate certain services that require clinical skill and licensing to non-licensed individuals. Check with your state board to verify if this is possible and then check with the individual payers with whom you are contracted to verify if they have any set policies on that as well. If the payer states it is inappropriate to delegate these services to unlicensed individuals (even under the provider's supervision) even when the state regulatory board states it's allowed, then do not engage in that activity to avoid any potential allegations of fraud. ...
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Fall has always been the season for CMS fee changes and on November 2, 2017, CMS announced the finalization of four rules which directly impact the following payment systems:

Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018
Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes for 2018
HHAs: Payment Changes for 2018
Quality Payment Program Rule for Year 2

Of these four rulings, the physician fee schedule rule and the Quality Payment Program Rule are the most applicable to doctors of chiropractic. Please note that these rulings do change some of the information that was included in Chapter 2 and Chapter 6 of the 2018 ChiroCode DeskBook.
This article only contains a brief overview of some of the key points. To read a more comprehensive analysis of all four rulings, see “Four Final Rules Affecting CMS Payments for 2018”.
Physician Fee Schedule
This final rule includes a new Patients over Paperwork initiative, RVU chang...
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Is it necessary to use the modifier NU for all supplies? or is NU part of the code itself? Where should the NU be noted on the 1500 form?
No.  NU is typically required if you are billing for new DME supplies which can often be rented, purchased new or purchased use.  NU will distinguish the DME as new.  As a standard rule for general supplies, no modifier is needed....
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By: David Klein CPC, CPMA, CHC
Recent events regarding delegation of services to ancillary personnel have given rise to concerns regarding the delivery of outpatient physical medicine by Chiropractors, specifically regarding the appropriate use of one-on-one codes as opposed to group therapy code CPT 97150 - Therapeutic procedure(s), group (2 or more individuals). This advisory provides guidance on how to properly use one-on-one and group therapy codes, both independently and together.
Certain codes, CPT 97110-97139, require direct one-on-one patient contact by the Physician. When direct one-on-one patient contact is provided, the Physician bills for individual therapy and counts the total minutes of service to each patient in order to determine how many units of service to bill each patient for the timed codes (e.g. each 15 minutes). These direct one-on-one minutes may occur continuously (15 minutes straight), or in different episodes (for example, 8 minutes now, 7 minutes later). A...
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What is the best code to use for PNF stretching of the hamstrings and gluts? The doctor is currently using 97112.
97112 is an active therapy whereas the patient is physically actively doing something.  That would be the obstacle with PNF stretching, depending upon the provider's approach to the procedure.  
If this stretching is something that's not requiring the patient be actively participating but rather they're laying still while the doctor does the stretching for them, perhaps 97140 may be a better code.  I have included descriptions for both codes here for you.  The doctor will need to consider his/her approach to the procedure, documentation, etc., to determine the appropriate code.
97112 - Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
Therapeutic procedures for neuromuscular reeducation are u...
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Here at ChiroCode we are often asked for examples of perfect forms to use in the office. As such we have developed some, but we recognize that most offices now use computerized notes of one form or another. Regardless, we have added some examples to the Documentation chapter of the 2018 DeskBook. Make sure you order your copy so that you can learn how we have designed patient records that are relatively easy to use, but also compliant with all of the requirements to substantiate the service.
A SOAP note template has been added to this year's book, with the elements listed for each section that should satisfy Medicare, private payers, state boards, and anyone else who wants to look at your records. Some say that Medicare patients need different notes, but we think there is a way to set a standard for your office that is easy to use for everyone.
After reading Chapter 4.3 Subsequent/Treatment Visits you will get a good idea of how that works and be directed to a resource online where y...
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Chiropractors cannot opt-opt of Medicare. Does that only refer to chiropractors that see Medicare patients? Do all Florida chiropractors have to complete Medicare enrollment/credentialing? Bottom line- do ALL chiropractors, no matter where or who, have to complete Medicare enrollment since they cannot Opt-out?
No, all chiropractors do not have to enroll with Medicare.  You only have to enroll with Medicare if you will be treating patients with Medicare Part B.  In this case, your options would be to enroll as a Medicare Participating Provider or a Medicare Non-Participating Provider.  Either way, you must enroll with Medicare IF you will be treating Medicare patients with chiropractic (spinal) adjustments.
If you will not be treating Medicare patients at all, you are not required to enroll with Medicare.  But in this case, there really is no way around it.  Even if a Medicare patient wants to see you, you must refer them to another facility that accepts Medicar...
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Do we need to charge for non-covered services performed under a maintenance visit if we use the S8990 code when billing Medicare?
Medicare prohibits the use of the S8990 code for maintenance visits.  You must use the standard 98940-98942  codes, collect the appropriate ABN form for maintenance care and append the GA modifier to the 9894- service.  ...
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Just kidding. After wading through all of the updates and changes, all we could find that seemed to matter to chiropractors is the following:
For ICD-10:
Deleted September 30, 2017:M48.06 Spinal stenosis, lumbar region
Added October 1, 2017M48.061 Spinal stenosis, lumbar region without neurogenic claudicationM48.062 Spinal stenosis, lumbar region with neurogenic claudicationDeleted December 31, 2017:97762 Checkout for orthotic/prosthetic use, established patient, each 15 minutes
For CPT:
New as of January 1, 2018:97763 Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes
So, don't fret about code changes this year. Make sure you pick up a copy of the current DeskBook to learn how to get more proficient with the codes that are staying the same....
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Does every single visit need to document quality and quantity of pain and an update to the treatment plan?
Any relevant subjective changes should be documented at each encounter. Completing the Verbal Numeric Rating Scale and documenting it at every visit is quick, easy, and satisfies MIPS Quality Measure #131 for Medicare. While this might not change from one visit to the next, it could easily change before a re-exam scheduled two weeks out. For typical daily visits we recommend that you note any variation from the plan and the response of the patient. In other words, it is not necessary to repeat the plan at every visit. Instead, you reference it, which allows you to submit the plan should you receive a records request. This keeps the daily notes concise, but still provides the detail necessary for a fair chart review....
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Doing the MIPS Minimum - Penny Wise but Pound Foolish?
Are you planning to “do the MIPS minimum” -  the “Test” reporting option - in 2017 and submit the minimum amount of data possible to avoid the penalty?  Perhaps every silver lining does not have a cloud, but “Pick Your Pace” sure does.  Just as we cheered when the SGR was buried, only to see MIPS emerge from the grave, perhaps the “Pick Your Pace” regulations should undergo more scrutiny before we throw our hats into the air at this regulatory “reprieve.”  
Practices can't survive a fee-schedule freeze, let alone a cut
Practices that do the MIPS minimum settle for a 0.5% positive fee adjustment for the first year that the MIPS payment adjustments are in effect. Going forward, performing at the threshold will doom these practices to a fee schedule FREEZE for the following 6 YEARS. 

This is simply a path to destruction for most practices.  Your only REAL option, outside of engaging in an AAPM, is to wor...
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October 2nd is 90 days from the end of the year, which means that if you want credit for partially reporting MIPS data, you need to start with data from patient visits on that date. If you still don't understand MIPS, check out this free webinar here, or more advanced training available for purchase here. 
MIPS is a program that allows Medicare to collect data from providers about high quality low cost care that uses technology effectively. There are four categories and providers need to learn about the available measures so that they can pick the ones that make them look the best. 
This is really just another step towards a whole new way to reimburse providers based upon the outcomes and quality of care rather than number of services billed. If you want to stay relevant in the world of healthcare reimbursement you need to know how to convey that you are worth paying and that you're getting patients better....
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What is the proper usage of CPT 97150 and what are the documentation requirements for that?
See page 299 in the Common Procedure Code chapter of the 2017 DeskBook (5.2).  
Here is some general information for you (below).  As far as documentation must document to support medical necessity, type(s) of therapy, and all other specific therapy related details for each participating individual.
97150 - Therapeutic procedure(s), group (2 or more individuals) 
AMA Guidelines:

(Report 97150 for each member of group)
(Group therapy procedures involve constant attendance of the physician or other qualified health care professional [ie, therapist], but by definition do not require one-on-one patient contact by the same physician or other qualified health care professional)
Therapeutic procedures performed in a group of 2 or more individuals can include aquatic therapy, conditioning therapies, or exercise therapy with a physician or licensed th...
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Watch the latest Quick Tip from the ChiroCode Helpdesk here and learn solutions for your documentation with Dr. Gwilliam. 
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In our office when the doctor initially sees a new patient, we bill a new patient code. (99201, 99202, 99203, or 99204) At that time, the doctor gives the patient an X-ray script and informs them to return to the office with their disk for an ROF (review of findings) to go over their results and also to determine their treatment plan, etc. When this happens, can a separate E/M code be billed, like 99211, 99212, 99213, 99214 or is there another code that can be used?
E/M codes can be billed based on meeting the criteria for the three key components, or for a time override. If you document 50% of the total time was spent face to face, counseling the patient, then the time override may apply. Review the details on page 322 of your 2017 ChiroCode Deskbook, and/or watch the Video DeskBook training for that chapter. ...
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Arlington, Va. - The American Chiropractic Association (ACA) recently submitted comments to the Centers for Medicare and Medicaid Services (CMS) in response to the federal agency's proposed rule changes to the Quality Payment Program (QPP) for 2018. 
QPP is a new payment model for physicians, including chiropractors, created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  
"ACA strongly supports the agency’s efforts to further develop the methodology that ties annual Physician Fee Schedule (PFS) payment adjustments to value-driven, quality care," said ACA President David Herd, DC. "The QPP will encourage participation in Alternative Payment Models (APMs) by creating an incentive program. The provision to supply technical assistance to small practices and practices in health professional shortage areas will also be helpful for chiropractic participation. ACA hopes the low-volume threshold will remain the same." 
ACA's c...
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ODG Series
Part II: Proper Use of Guidelines
By Dr. Ronald J. Farabaugh
General Rules/Facts Related to the Proper Use versus Misuse of Guidelines

Please consider the following issues when using guidelines:All guidelines serve merely as background information to assist doctors in the clinical decision-making process.
A guideline serves as a compass for care, not a cookbook for care.
Guidelines should never be used punitively, or as prescriptions for care.
Each patient is unique and treatment recommendations must be based on the specific factorspertaining to the individual case.
Guidelines are only one piece of evidence to consider when considering the medical necessity ofcare. Other pieces of evidence include research, clinical experience/decision-making, patientvalues, risk stratification, process of care, response to care, documentation, etc. Again, guidelinesare not cookbooks with rigid dosages for treatment.
Nearly all guidelines, including the OSCA Guidelines (which is n...
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We have one doctor in our practice who qualifies under the MIPS guidelines so he is continuing to use the PQRS and G-codes. We are having the rest of our doctors do the same, just in case, and because it is good practice, but is that completely unnecessary and can it possibly do us more harm than good? All of our doctors are diligent about using outcome assessment tools. Here is what we currently do: -Quadruple Analog Scale- at the initial visit, every 30 days, re-exaccerbations, final exams. -Oswestrys- at the initial visit, re-exaccerbations, final exams. Is this what you would recommend continuing with, or is it overkill and unnecessary for our doctors who do not qualify for MIPS to be doing an outcome assessment (quadruple analog scale) every 30 days?
It will not do any harm to report G codes even if the practice/provider doesn't need to.  It could be somewhat overkill for those doctors that do not qualify for MIPS.  However, note that Medicare is extre...
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Respectfully submitted by Dr. Ronald J. Farabaugh
Topic: Electrical Stimulation (EMS)
Question: An orthopedic surgeon/IME recommended a denial for all electrical stimulation(EMS) by stating that “according ODG electrical stimulation is experimental therefore notmedically necessary or eligible for reimbursement”. Is that true?
Answer: NO. ODG DOES NOT prevent reimbursement for electrical stimulation. As sooften happens, the IME who stated that EMS is experimental misquoted ODG content andcherry picked a specific sentence, out of context, in order to support his intent to deny care.ODG does state the following: “Not recommended as an isolated intervention.”
But who used EMS as an “isolated” treatment option? Most physicians or therapists whoutilize EMS do so as just one component of an overall treatment plan that also may includea combination of other passive and active therapies.
ODG further states, “There is no quality evidence of effectiv...
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A locum tenens provider is one that works in the place of the regular physician for a short duration of time. Guideline typically allows this time period to be a 60 day maximum, when a substitute doctor would be brought in to your office to cover your original doctor's actual schedule during the time he/she is absent. Services by the Locum Tenens provider would be performed at the facility that your doctor's NPI and group are registered. When submitting claims for a locum tenens provider, your office or billing service would submit claims just as you do for your original provider, including using the original provider's NPI. The modifier Q6 must be appended to each service code rendered by the locum tenens provider. Locum tenens providers must be licensed in that state and able to fulfill the schedule and duties of the regular provider. Note also that individual carriers may have their own rules in addition to what is standard for locum tenens providers. As a result, before mak...
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While scanning my news feed this morning, a few alarming words caught my eye: "Opioids could kill nearly as many Americans in a decade as HIV/AIDS has killed since the epidemic began in the early 1980s." Across America, people are talking about chiropractic as a safer alternative to opioid medication for pain relief, and yet, I don’t think the magnitude of this opportunity has been realized by most doctors of chiropractic in this country. This crisis has weighed heavily on my mind for weeks. Not only because of the potential to save lives in my community but because I know first-hand the effects of opioids on our bodies.
Someone I know and love suffered an injury from prescription opioids that forever changed her life. And it is not just my family that has been affected. While discussing the opioid epidemic during a team meeting, I quickly learned that everyone in my office knew someone whose life had been touched by opioid abuse. As a doctor of chiropractic and a board member ...
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Q:  My state does not allow me to delegate the supervision of therapeutic exercises (97110).  I am the licensed chiropractor.  If I provide the constant attendance myself, can I do it for a group of patients?  If so, how do I document and bill for this?A:  Consider the following when billing 97150 Therapeutic procedure(s), group (2 or more individuals)The therapeutic exercises should be documented just as thoroughly as 97110, including clear goals, details of the skilled services, functional loss and gains, etc.The group can be up to four patients (per CMS), but check with individual payors.Constant attendance (visual, verbal, and or manual contact) must be maintained throughout the service, but one-on-one contact is not required.  Patients may or may not be doing the same activity.97150 is not time-based, therefore it is reported once per session per individual.  TIme should still be recorded, but the minimum 8-minute rule should not apply.  97150 would be reported for each individual...
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Watch this short video to learn all that you need to know about the proper support for 97140....
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How should I bill for face-to-face Counseling time spent with the patient?

A provider may only use time in choosing the procedure code when spending more than 50% of the total face-to-face time of the visit in counseling / coordination of care. Documentation of the total time of the visit, the time spent in counseling/coordination of care, and the nature of the counseling/coordination of care must be in the medical record. Counseling is a discussion with a patient and/or family concerning one or more of the following areas: Diagnostic results, impressions, and/or recommended diagnostic studies, Prognosis, Risks, benefits of management (treatment) options, Instructions for management (treatment) and/or follow-up Importance of compliance with chosen management (treatment) options, Risk factor reduction, and Patient and family education. ChiroCode has a sample form to use for E/M Counseling. See the DeskBook Resources page. Remember when billing for counseling on t...
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Our claims are being rejected. We think it is related to our diagnosis codes. What is the reason for this?

There are dozens of possibilities. First, check each of your diagnosis used to ensure that you have not inappropriately added any digits or characters to a code that is not required by ICD-10 guideline and coding instructions. Secondly, check to make sure that your software isn't including the diagnosis decimal point onto the claim forms as this is not required on claims and will result in rejection. Third, for those codes that do require the 7th character (such as the 'S' codes), make sure this character is being properly added. Finally, if all of the items above are in proper order, it would be best to check directly with the payer to determine if there is perhaps a processing glitch being addressed or if there is policy available that identifies codes that may not be acceptable on claims for that payer....
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Identity theft has become a major problem in the United States. As a prevention measure, the Centers for Medicare& Medicaid Services (CMS) is readying a fraud prevention initiative that removes Social Security numbers from Medicare cards to help combat identity theft, and safeguard taxpayer dollars.


Personal identity theft affects a large and growing number of seniors. People age 65 or older are increasingly the victims of this type of crime. Incidents among seniors increased to 2.6 million from 2.1 million between 2012 and 2014, according to the most current statistics from the Department of Justice. Two-thirds of all identity theft victims reported a direct financial loss.


Providers are reminded to always protect their patient's information. Information such as social security numbers, driver's license numbers and credit card information, if breached, can lead to financial ruin for the patient and the doctor. If a breach occurs, the physician must notify CMS and the O...
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Q.  We currently are using an outside radiologist to read all of our x-rays, therefore we have an official report on each x-ray.  If we go back to reading our own x-rays, do we need to have a separate official report made?  Or is it sufficient to just put the x-ray findings as part of the SOAP?  Also, we are questioning the way we are billing our x-rays.  Some of us feel like you should be able to bill for taking the x-rays and then reading them as well.

A. Technically the x-ray findings do not have to be in a separate report, but, as an auditor, I much prefer a separate and distinct page with all of the essential elements included.  Thre is a nice summary of what that might look like on page 233 of the 2017 DeskBook.  Too often I see a SOAP note with a brief mention of the x-rays and it is deficient in terms of explaining the rationale and results of the procedure.

Radiology codes actually include a technical component (TC) and a professional component (26).  So, if you bill 721...
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Q. Can you tell me what modifier I can use when billing massage code 97124 with 97140?
I was using -59, but I am not sure that is correct.

A. In the Online Library within ChiroCode Premium membership, you have access to a tool called the NCCI Edit Validator.  This is a Medicare database that most private payers follow to determine which codes can be billed together and when modifiers are necessary.  You can list all the codes you plan to bill together and the tool will identify which codes do and don't need a modifier and which ones can't be billed together no matter what.    It turns out that no modifier will allow 97124 to get billed along with 97140.  If a private payer allows you to do it in, say different body areas, you could try modifier XS for "separate structure" if that applies, but they may still reject it. ...
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Q. Is there a modifier that can be added on to CPT codes to show we performed the service even though they are bundled charges or Medicare doesn't pay for them?  For example 97140 billed to BCBS or 99202 billed to Medicare.  Is the GY modifier for all insurance companies or just Medicare?

A. I suggest you check out chapter 5.6 of the 2017 DeskBook which is all about modifiers.  Also, if you have a Membership, the Online Coding Library includes a tool called the "NCCI Edit Validator" which allows you to dump in codes and find out which ones need a modifier and which ones can't be billed together at all.

For any service you submit on a claim to Medicare that is not 98940, 98941, or 98942, you should add modifier GY, which tells CMS to deny the service.  GY means "statutorily excluded".  It can be helpful if you need a denial to submit the charges to a secondary for beneficiaries who have another insurance plan.  For example, an E/M might be billed as 99202-25-GY.  The GY is only ...
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The Centers for Medicare and Medicaid Services (CMS) has revised the Advanced Beneficiary Notice of Non-coverage (ABN) Form.  The revised Advanced Beneficiary Notice of Non-coverage (ABN), Form CMS-R-131, is issued to the patient or client by providers, physicians, practitioners, and suppliers in situations where Medicare payment is expected to be denied. The revised ABN replaces the ABN Form that was last released in November 2011.

When a physician or supplier has a “genuine doubt” that a service will be covered, they are required to notify the patient of this fact.  The ABN form is required to be used for a service that is covered.  In the Medicare program, chiropractic coverage is limited to coverage for spinal manipulation by means of the hands or hand-held device.  For all non-covered services, a standard letter informing the patient of the non-coverage or the ABN may be used.  

The newly revised ABN form may be used at this time; however its use becomes mandatory on Jun...
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This code is not reserved for stroke recovery, but it could certainly apply when treating some symptoms of a stroke.  It is often used for many other conditions so long as medical necessity is present and clearly supported.  Consider using this on patients with documented loss of coordination or balance.  These might not be everyday cases in a chiropractic clinic, but they certainly would occur from time to time.  The service should focus on restoring the specific functional loss.  If the purpose is to improve strength, range of motion, or flexibility, then consider 97110 therapeutic exercises instead.

 Here is some additional info:

97112 - Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities

Therapeutic procedures for neuromuscular reeducation are used to develop conscious control of a single muscle or muscle group and heig...
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Yes, you will have to bill 97039 (unlisted modality).  This code should be accompanied by a report to explain the service. Unfortunately, there is not a more specific code for the class IV laser, and unlisted codes are rarely payable....
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We are using the ABN for non-covered services (such as therapy codes) when the patient is under active care. We are also using the ABN for CMT codes when the patient is under maintenance care.
We are now confused about when to use the modifiers GA & GY when billing CMT & therapy codes.  Would you please explain when & why each should be used for Active and Maintenance Care?                                                                                                              
                  GA is only permitted to be used on "covered but not payable procedures" which is only 98940-98942.  This is the modifier you would append...
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The Infinite Banking concept is an educational tool and financial process that enables individuals and businesses to better control and reap the benefits of their own money cycles.  

Infinite Banking is a process that has been in place for over 200 years and is used by the wealthy to build, preserve and protect their money.  This process is one that can be easily learned and implemented by everyone, regardless of debt, income, or cash flow!  

Did You Know...
We finance everything we buy!  If we use credit, we pay interest.  Yet, if we use cash for purchases, we give up interest that we could recapture ourselves.  By learning and implementing the Infinite Banking process, you can recapture some or all of your money that is currently being spent and will be spent in the future.
Infinite Banking will teach you:
 - A tax efficient system for wealth creation.  Learn how to better use and maximize the $ you make!
 - Improve returns of investment you're going to be making anyway
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The codes that begin with S73.1- are for sprains of the hip.  If the two ligaments offered in that subcategory do not pertain to your patient (iliofemoral and ishiocapsular), then the most appropriate code would be S73.19- for other sprain of the hip.  Your documentation would then need to specify why the other codes did not work by identifying the ligament that was sprained....
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ChiroCode Q&A "Maintenance Visit Documentation" With Dr. Evan Gwilliam.
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When using code 99050 (after hours), do I just add a amount, example $25.00, to our normal total charges for that patients visit?

99050 is a stand alone code that reports for after hours. You would establish a fee for this service itself. Any other services performed on the after hours visit would be billed accordingly at their typical fees. For example, if you saw a patient on a weekend, adjusted them 3-4 regions of the spine and performed e-stim, your coding may look like this: 99050 98941 G0283...
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The Medicare contractor, NGS, made changes to its E/M coding guidelines for level 3 exams.  Even if you don't bill NGS, this change could be a sign of things to come for other payers. Watch here....
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Watch Another quick tip from the ChiroCode HelpDesk - I've heard about MIPS, now what? ...
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Patient-reported outcome measures are increasingly necessary elements of good clinical practice.  By using a clinically meaningful outcome measure at the initial assessment and measuring change over time, you can track shifts in patient progress and thereby improve clinical decisions. Documenting treatment necessity (which can improve and facilitate reimbursement and decrease insurance denials) can fine-tune your treatment regime and provide a rationale for ongoing treatment. Outcome measures are useful in establishing maximum therapeutic recovery, and they can identify patients at risk for poor outcomes.

Barriers To The Implementation of Outcome Measures

Despite the benefits of using outcome measures, some practitioners resist using them in everyday practice. In a cross-sectional study of both users and non-users, more than 70% of respondents felt it takes too much time for patients to complete. Most self-reporting instruments measuring spinal pain and dysfunction are underutili...
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Watch Another quick tip from the ChiroCode HelpDesk -  Plain Film Xray Penalty 2017. 
Even though this news comes from Medicare, who does not reimburse chiropractic physicians for x-rays, private payers nearly always follow their example.  This represents the trend of X-ray reimbursement for all of healthcare....
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Q: An insurer told me that chiropractors cannot bill 99204 or 99214 because those exams  "require a level of decision making that would typically only occur in an emergency room."   Is this true?  Do I have any recourse?

A: This assumption can be challenged, but the provider would need the help of a certified coder if they want to start a fight.  The level of decision making for level four exams is "Moderate Complexity".  This requires that the documentation support 2 of the 3 criteria for Medical Decision Making.  The Emergency Room is not mentioned as in any of those three in order to qualify as "Moderate Complexity".  And if it did in one of them, it would not matter because only 2 of the 3 criteria must meet or exceed the requirements.  

Furthermore, a 99214 is much easier to reach than a 99204 because the Medical Decision Making can be thrown out entirely since only the History and Exam must meet or exceed the criteria for established patients.  

Additionally, in some c...
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One major part of running a business is properly managing the financial aspect.  This means using our revenues and cash flow in a way that they can be optimized for the business, the family, and the future.  Business owners of all industries as well as their workforce members, often find themselves in uncomfortable financial cycles where a solution may be difficult to identify.  We all have at least some of the following expenses to address on a regular basis: business overhead, household expenses, family related expenses, unexpected expenses, needs, wants, and the list goes on.  Financial planning, availability of funds, and management of funds in general are among the greatest stress factors for many people.   
Unfortunately, understanding how to maximize our dollars and best manage the aforementioned costs, get out of debt, and/or build for the future is an area that most people invest very little time into.  The tendency is to  learn on our own, often by trial and error, or follow...
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"Medicare has changed the ABN.  Effective June 21, 2017, you must be using this new form.  Watch this short video to learn more, and click here to download a copy of the form. ...
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Q:  Our office would like to send a survey to our patients.  Are there compliance rules for this?

A:  Under the HIPAA privacy regulations, health care facilities may conduct "quality assessment and improvement activities" as part of the facility's health care operations. A survey or questionnaire that determines whether patients were satisfied with the quality of care they received would be a quality assessment and improvement activity and, therefore, considered health care operations. 
Before conducting these activities, however, the facility must state (if applicable) in its notice of information practices that it may use identifiable health information for the facility's health care operations (most chiro facilities don't do this).  If a health care facility agrees to a restriction on its use of a patient's health information, any use of information for health care operations, including patient surveys, would be limited by that restriction. In addition, if a patient makes a re...
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On February 3, 2017, the Department of Justice (DOJ) issued a Final Rule to increase the civil monetary penalties assessed under the False Claims Act (FCA), due to inflation for the year 2017, to an all-time high of $10,957 (minimum) to $21,916 (maximum). Thirty years ago, in 1986, Congress amended the False Claims Act to provide the government with a more effective way of protecting against false claims and fraud in waste and abuse of federal monies used to fund healthcare programs like Medicare, Medicaid, and TRICARE. At that time, they set the fines at $5,000 (minimum) to $10,000 (maximum) per false claim submitted to these federally funded programs. Since that time, we have seen those penalties first raised to $5,500-$11,000 and just last August (2016) they almost doubled the previous penalty rate, raising them to a minimum of $10,781.40 and maximum of $21,562.80 per claim. 

This new announcement has some people asking "Are these fines and penalties too steep?" Such significant ...
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Q:  Are there any alternatives for code 97112 Neuromuscular Re-education? This code is counted toward both Chiropractic and Physical Therapy visits with BCBS, and we want to preserve the insurance benefits.

A:  In a sense, no CPT codes have an alternative.  Each code describes a specific service and you would only use a different code if you were performing a different service.  You cannot continue to do the same procedure and just change the code.  Make sure you know when each code should be used and how they are defined.  See chapter 5.2 of your current DeskBook for tips and tricks on the most common CPT codes used in chiropractic.  Review the codes from 971-- to 975-- for other services related to 97112.
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When it comes to managing expenses in your practice, there are dozens of categories to evaluate: equipment, technology, loan costs and interest rates, sundries, marketing, and on and on they go.
Many practice owners are quick to shop-out what they believe are the most obvious expenses, but few understand the impact of one of the largest expenses and how it can be dramatically reduced to increase profitability. The highest expense for most practices is payroll, followed by real estate. Real estate encompasses your monthly rent or mortgage payments, along with the property’s operating expenses, maintenance fees, utilities, and janitorial costs. 
If you consider these top two expenses, payroll and real estate, only one of them is really negotiable. With payroll, you can either pay people their value or they usually find another job that will. You may decide that you can cut staff, but if you need people you need to pay them what they deserve or they will eventually leave. 

Real est...
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Q:  If a patient is treated with chiropractic manipulation and it is clinically appropriate but doesn't qualify as medically necessary care, what is the proper way to communicate this when billing the insurance company for the service?  I would like to append the GA modifier, as we do with Medicare but private payers can't answer how to handle this.  Can we use GA for all payers for this situation?

A:  The GA modifier is exclusive to Medicare.  There is not a maintenance care modifier for other payors.  To code and bill for maintenance care treatment, you would use code S8990.
S8990 - Physical or manipulative therapy performed for maintenance rather than restoration...
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As a chiropractor, we use E/M codes frequently, but not at every encounter, as do our medical counterparts.  These are the CPT codes used to describe the work involved in figuring out what is wrong with a patient and creating a plan to manage them.  One of my good friends, Dr. Mario Fucinari, told me that he explains that chiropractic care is like a loaf of bread.  The heels are the initial evaluation and the discharge evaluation.  All of the slices in between are the treatment visits.  Depending upon the duration of the care plan, you might insert a few update evaluations in amongst the slices as well.  If those occasions are significant and separately identifiable from the chiropractic manipulative treatment, an E/M code would be billed then. 

E/M codes have all kinds of rules and components.  They can be difficult to understand, especially if you want to spend your time working on your patients rather than coding and documentation.  Fortunately Dr. Gwilliam has waded through all ...
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Question: Is it true that I can opt out of MIPS & MACRA if my part B charges are less than or equal to $30,000?  If so, are the charges based on covered Medicare charges (98940, 98941, 98942) or all charges sent to Medicare? Some patients want non-covered charges sent to Medicare too. 

Answer: In order to be eligible for MIPS incentives or penalties, you need $30,000 in covered services only AND you also need to see 100 unique beneficiaries.  However, voluntary participation may be wise just to get used to the program and earn a Composite Score for assessment on CMS's Physician Compare web site.   The administrative burden may not be too high if you already participated in PQRS and Meaningful Use in the past.  

Melissa Hall...
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Thanks to our friend, Dr. Marty Kotlar, of for the following information about the dramatic increase of Medicare audits that have been happening in several states.

Why is Medicare doing this audit?
This audit relates to a 2015 Office of Inspector General (OIG) report that stated $76 million for chiropractic services were questionable and another $21 million was improperly paid due to a lack of documenting the proper primary diagnosis. There have been other OIG reports that reveal high rates of improper payments for chiropractic services.     
Who is StrategicHealthSolutions, LLC (Strategic)?
Strategic is a Supplemental Medical Review Contractor (SMRC) chosen by CMS to identify possible improperly paid claims.   
Why was I chosen for this audit?
This audit appears to be based on random selection, rather than a targeted review based on aberrant billing.
Update:  According to Dr. Mario Fucinari, he believes they have focused on the top 10-15% o...
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Did you know that inconsistent and un-reviewed fee schedules can lead to some of the following occurrences:

•Prompt an audit or some level of claims review
•Cause claims delays
•Increase provider liability in case of an audit or investigation
•Potentially lead to being paid less than the actual value of a service rendered
•Losing patients or losing referrals due to overpriced fees and higher patient out-of-pocket
•Lead to patient complaints and/or complaints from peer providers in your area
•Liability and penalties for use of dual fees
•Liability and penalties due to excessive and/or improper discounting

Many providers are unsure of where their fee schedule actually came from or when it was last reviewed.  As a component of compliance and for other preventive purposes, fee schedules should be evaluated once per year.  Just as CMS routinely (usually once per year) updates fees for all regions and we adjust accordingly, all other fees for services should be e...
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 Q: What is the proper code for "Lumbar Decompression?  

 A:  We have it under 97012 which includes mechanical cervical traction and lumbar traction.                                                                                                                                                                                     97012 is the mechanical traction code and is often appropriate to use when reporting spinal decompression.  However, individual payors may require that S8990 is used.  The S8990 may not be reimbursable, but the 97012 has a relatively low RVU.  To know which code to use, you would need to review the individual payor policy.
Diagnoses that would likely be associated with this service should indicate adhesions, inflexibility, or compression, such as radiculopathy or disc problems. ...
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A:  Yes, this could be the reason that you are being denied for Medicare claims.  Of course, a complete review of your claims would be necessary in order to determine this for sure, although I can tell you that box 14 is required to be completed by Medicare.  Do note that the Medicare rule for box 14 requires that the date input is the date of initiation of the course of treatment (the date the patient presented for care).  
Please see page 9 of the Medicare Claims Processing Manual, Chapter 26 for further confirmation of rules for completing box 14 for chiropractic claims.  Of course, practices are encouraged to review this manual in detail for specific instructions to properly complete the CMS 1500 for Medicare claims.
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The following chart identifies each of the 7 zones for ZPIC and the states/regions within each zone.   Links are provided for each zone which contains information about each zone as well as activity and updates in those regions. 

Safeguard Services (SGS)
Zone 1	- States in Zone; California, Hawaii, Nevada, American Samoa, Guam, Mariana Islands

Health Integrity (subcontractor to AdvanceMed)	
Zone 2	- States in Zone; Alaska, Arizona, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming

Cahaba Safeguard Administrators
Zone 3	 -States in Zone; Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, Wisconsin

Health Integrity
Zone 4	- States in Zone; Colorado, New Mexico, Oklahoma, Texas

NCI AdvanceMed
Zone 5	- States in Zone; Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, West Virginia

Under Protest (being handled by Safeguard Services until resolution...
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A:  Neglecting or overlooking a sound HIPAA Compliance policy can be crippling to a 
practice. Compliance should be addressed at all levels. See the link below to learn 
more about those penalties that are specific to HIPAA violation.

Click here for information on HIPAA violations and enforcement....
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Generating a differential diagnosis — that is, developing a list of the possible conditions that might produce a patient's symptoms and signs — is an important part of clinical reasoning. It allows a provider to perform appropriate testing to rule out possibilities and confirm a final diagnosis.

Courts view the formulation and documentation of a differential diagnosis as evidence of a physician's competence, prudence, and thoughtfulness.  In 1966, Abraham Maslow, a renowned psychologist,  said, "I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail."  Do your records make it look like you treat every patient like a nail?  Do they all have the same diagnoses and the same care plans?  Payers sometimes accuse chiropractors of providing cookie cutter care where every patient receives the same treatment regardless of the cause of their problem.  Documenting a differential diagnosis lets third party reviewers know that you have consi...
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Q:  Is my software vendor a business associate to my practice?

A:  Here's what the Department of Health & Human Services has to say about that:
The mere selling or providing of software to a covered entity does not give rise to a business associate relationship IF the vendor does not have access to the protected health information of the covered entity (your practice).  If the vendor does need access to the protected health information of the covered entity in order to provide its service, the vendor would then be a business associate to the covered entity, and thus, a business associate agreement would be warranted. ...
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Whiplash Damages in Rear-end Collisions 						
The Patient’s Dilemma

The rear-end collision is a major cause of cervical spine injuries which often require treatment by chiropractors and other health care practitioners. Claims adjusters trivialize soft tissue injuries [it’s “only” a sprain or strain] but whiplash is real and so are the damages that come with it. 

While many auto claims scenarios raise troublesome liability issues [who’s at fault?], such is not the case with the patient who’s been rear-ended. Almost without exception, the driver who caused the accident is responsible for the damages suffered by the victim of his negligence.  

The insurance carrier for the at-fault driver will readily concede liability. From a claims perspective, the battle is half won when the parties agree that the driver who rear-ended the patient should pay for the damages he’s caused.

The patient seldom has to fight to get medical bills paid. Claims adjusters routinely ext...
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A health and wellness extravaganza is being held in sunny Arizona on January 26-29, 2017 and you're invited to attend!  

Speakers from across the country are gathering under one roof to share their experience and expertise in in chiropractic hot topics!

Topics covered include:
-Functional Medicine
-Peripheral Neuropathy
-Body Contouring
-Bio Craniopathy
-Organic Non-GMO Whole Food Nutrients in a pre-digested format
-Ketogenic Diet
-Mitochondrial function and dysfunction
-Rules, regulations, coding, and audits - Risk Management for your practice!

19.5 CEU hours available for the following states:
AL, CA, CO, FL, GA, ID, IL, IA, KS, MO, MT, NE, NM, NJ, NC, TX, UT, VT, WA, WY, CT, DC, DE, IN, MD, MS, OH, OR, RI, SC and VA.

Learn more about this one-of-a-kind event, including viewing presenter information, seminar itinerary, and registration details by clicking here.
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The average American spends 25% to 35% of their income on interest through things like mortgages, car loans, student loans, and credit cards and tries to save 10% of what they make. Conventional financial planning focuses on what to do with the 10% savings portion of your income. Learn a financial process that focuses on how you can redirect the 25% to 35% you’ll spend paying off debts like your mortgage, car loans, student loans and credit cards. This process enables you to be the one receiving the benefits of your own expenses, instead of bank shareholders.
Join a ChiroCode Special presentation on Thursday, January 12, 2017 to learn how this financial process that has been in place for almost 200 years and is followed by families and businesses that have built and maintained immense wealth from one generation to the next can easily be implemented and followed by YOU.
All registrants will receive a free e-book with steps, guidance, and real life testimonial of How to Build a Legac...
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The government has become increasingly concerned with how they spend money in the healthcare sector.  As part of the latest proposal to fix this, the Medicare Access and CHIP Reauthorization Act (MACRA) was passed in 2015.  This law changes reimbursement to remunerate providers more when they provide high quality care rather than just more care.  It rewards value over volume.  It also ends the flawed Sustainable Growth Rate (SGR) formula that had been in use to determine Medicare payment for many years.  And, it combines three other quality-based programs into one.  It’s biggest and lasting impact may be how it influences the way that patients select the provider they choose to see.  

Regardless, many providers do not have to participate in this new program in 2017.  If you are in your first year of practice, or you don’t see over 100 Medicare (CMS) beneficiaries in 2017 OR you bill Medicare less than $30,000 in allowed charges, participation is optional.  However, this model is...
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Q:  How do we obtain the Security Risk Assessment to conduct this for our practice?

A: You can obtain the Security Risk Assessment Tool (SRA Tool) by visiting and clicking on the 'SRA Tool' in the Products/Services dropdown menu.  While this Tool will allow you to perform your required Security Risk Assessment efficiently, it is a comprehensive analysis so as to meet HIPAA requirements.  It is not recommended to wait till the end of the year to begin as this must be completed once per year per HIPAA Security guideline as well as if you attest for Meaningful Use.  ...
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Question: We are continually getting denials when we bill office visit E/M code 99213-25 along with a CMT on dates that we do re-exams. When we appeal they always uphold their original decision even though we provide clear evidence that all of the bullets for the 99213 have been satisfied and that this is a re-exam after a months of care. Any advice?
Answer: Page 323 of your 2017 ChiroCode DeskBook covers examples of situations where the 25 modifier might be applied to evaluation and management codes because the service is significant and separately identifiable from the CMT. Here are some examples:

Periodic re-evaluation (see the CCGPP algorithms in Chapter 4.5 — Treatment Plans and Outcomes Assessments for more guidance)
A new condition or injury
Exacerbation, aggravation, or re-injury
Return after lapse in care
Counseling (using the Time override)
Release/discharge from active care

The official guidance is: "Additional Evaluation and Management services... may be repor...
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Q:  How do I determine who is a Business Associate to our practice?

A:  A Business Associate is formally defined as:  "a person or entity that performs certain functions or activities that involve the use or disclosure of PHI (protected health information) on behalf of, or provides services to, a covered entity (Reminder:  Your practice is a covered entity).  A member of the covered entity's workforce is not a business associate.
Common examples of business associates (but not a complete list) includes:
-Billing service  
-Cloud storage provider               
-A consultant that performs file reviews or audit consulting where PHI identifiers have not been removed
-An independent medical transcriptionist that provides transcription services to a health care provider...
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Better Financial Planning and Management

Business owners of all types as well as workforce members often find themselves in uncomfortable financial cycles.  We all have one or more of the following to address on a regular basis, and that may cause stress or struggle to cover; Business overhead, household expenses, family related expenses, unexpected expenses, needs, wants, and the list goes on. 
Managing our finances is one of the things we all tend to have to learn on our own or take the advice that's been passed down from family members.  However, financial management for our future, our businesses, our homes, and our families is among the most important responsibilities we have. 
Year after year, one of the top New Year's resolutions of individuals is to take better control of their money.  It's no secret that knowledge is our greatest tool and the more we can learn about anything, the more we can help others and help ourselves.  

After all, who doesn't want to learn ...
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Effective March 14, 2016, the CMS Final Rule regarding the reporting of over payments took effect. This ruling clarifies the standards that have been unclear for years since the the PPACA created what is called the "60-day rule." The problem has been the unclear standards on what it means to "identify" an over payment and when the 60 day clock begins running.

Now, the 60-day rule requires anyone who has received an over payment from either Medicare or Medicaid to report and return the overpayment within the latter of:

60 days after the date on which the over payment was identified and
the due date of a corresponding cost report (if any). 
Failure to both report and return an identified over payment within the time-frames specified may be subject to substantial liability under the False Claims Act. 

The following are some key points of this rule:


Under the rule, providers have an obligation to exercise “reasonable diligence” through “timely, good faith in...
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I am having an extremely difficult time getting reimbursed by [insurance carrier]. They keep denying everything as maintenance. Why?

There are several reasons why a carrier denies a claim as maintenance. It is up to the provider to prove medical necessity by appropriately documenting the patient encounter in accordance with established guidelines. The important thing is to include the complaint, objective findings, and then create a plan with goals. It is important to demonstrate that there is progress or improvement. Some other possibilities are:

The initial date in Box 14 is too old
The frequency of visits are too regular (i.e. monthly visits)
The documentation does not show a plan, end point, or progress.
Diagnoses are the same that have been used for the same patient(s) for an excessive amount of time....
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A common topic of interest in chiropractic practices includes the billing department and whether or not the primary duties of insurance claims submission would be best kept in-house or outsourced to a professional billing service.  Multiple factors weigh-in on this topic, and rightfully so.  Things that providers are, and should be considering, include the following:

Employee Role:   Do you have the right person/people for this job?  While data entry, coding, billing, collection and follow-up systems can be taught, the duties and responsibilities of this role must never be taken lightly.  The person or people in charge of this department are second in line to the doctor in keeping the practice doors open.  Additionally, the understanding and correct application of guidelines, attention to detail, efficiency, integrity, and communication skills necessary to manage this role will serve as significant protection for your practice.

Training:  What tools do you have and utilize to ens...
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Q. We get lots of physician referrals. When we do, we bill a consult code. AND someone told one of our doctors that when there is a referral but it’s not on our referral pad, we can’t bill the consult code. Do you know anything about this?

A. Unfortunately true referrals must be coded as an ordinary office visit E/M.  Consultation codes are different from other primary E/M services in that there must be: 

1. a written request from an appropriate source.  According to CPT guidelines, an appropriate consultation source includes a physician assistant, nurse practitioner, doctor of chiropractic, physical therapist, occupational therapist, speech language pathologist, psychologist, social worker, lawyer, or insurance company.

2. a written report that is sent back to the requester.  This extra work is the reason that consultation codes have a higher value than office/outpatient E/M codes.

The written request must be only asking for your expert opinion, not a referral to you t...
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Electrical stimulation (97014) will affect the body in many ways including: stimulating muscles to contract; stimulating nerves to decrease pain; increasing blood flow to speed healing and reduce inflammation.  Some of the following might be diagnoses that justify this service:

·        Spinal pain** (M54.2, M54.5, M54.6)

·        Myalgia (M79.1)

·        Muscle spasms (M62.83-)

·        Inability to contract muscles, weakness or denervation (M62.81)

·        Poor muscle coordination 

·        Peripheral edema** (R60.0)

·        Inflammation (M60.88)

Some payers consider the use of e-stim for pain or edema investigational, so check with guidelines before billing for this service....
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Did you know that inconsistent and un-reviewed fee schedules can lead to some of the following occurrences:

•Prompt an audit or some level of claims review
•Cause claims delays
•Increase provider liability in case of an audit or investigation
•Potentially lead to being paid less than the actual value of a service rendered
•Losing patients or losing referrals due to overpriced fees and higher patient out-of-pocket
•Lead to patient complaints and/or complaints from peer providers in your area
•Liability and penalties for use of dual fees
•Liability and penalties due to excessive and/or improper discounting

Many providers are unsure of where their fee schedule actually came from or when it was last reviewed.  As a component of compliance and for other preventive purposes, fee schedules should be evaluated once per year.  Just as CMS routinely (usually once per year) updates fees for all regions and we adjust accordingly, all other fees for services should be e...
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From the ChiroCode HelpDesk:

Q: The Doctor says he was told by a billing company a few years ago to avoid the 97112.  So he has been doing 97110 instead.  They do the items listed in 97110, but often some of the ones in 97112 as well.  His question was, should he actually be avoiding 97112?  Or is there simply something he needs to be mindful of when using it?

A: It isn't that he shouldn't ever use 97112.  It is that he needs to understand when it is appropriate.  Some chiros have used it inappropriately in the past, thus leading to higher scrutiny by payers.
If a patient has loss of strength, flexibility, or ROM, then 97110 would likely be the right code.  There would be a documentation and/or a diagnosis code that lists these kinds of problems, such as muscle weakness or inflexibility.  The care plan would need to outline how, for example, the 97110 will restore the lost strength.  Then the update evaluations should document if that goal has been achieved.
If a patient ...
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On October 19 the Office of Inspector General for Health and Human Services (OIG) released another report on chiropractic.  Oddly enough the Wall Street Journal had an article on that report published the day it was released (I wonder how that happened).  This report stated that 82% of chiropractic services in 2013 were paid in error.  This means that chiropractors as a group were overpaid by hundreds of millions of dollars.

There are a few problems with this report.  The first being that, based on the other information available from 2013, it is totally wrong.  According to the Comprehensive Error Rate Testing program (CERT), the improper payment rate for chiropractors for 2013 was 51.7%.  Not good, but certainly not 82%.

The second problem is the methodology used in the development of this report.  The authors of the OIG report arrived at 82% by dividing chiropractic services into three groups.  The first group included services up to 12 visits, the second group included servic...
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(from page 210 in chapter 3.5 of the 2017 DeskBook)

One of the biggest problems providers face when audited is that many services are deemed not medically necessary and are routinely denied. Much of the proof falls back on the medical record. Here are some specific situations as they may relate to audits.

• Irrelevant physical examinations   The exam must pertain to the patient’s presenting problems or complaints and their history. It may be appropriate to manipulate/adjust a segment(s) that may not be symptomatic and/or located in the same spinal region as the area of chief complaint, but is contributing to the patient’s overall condition. The need for treatment to these segments should be established through clinical measures and have a direct therapeutic effect and be well documented.
Objective findings could necessitate a more comprehensive exam. It is essential that such findings are clearly indicated in the documentation to support the clinical need for this extended...
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On October 14, HHS finalized its policy implementing the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM) incentive payment provisions in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), collectively referred to as the Quality Payment Program. The new Quality Payment Program will gradually transform Medicare payments for more than 600,000 clinicians across the country, and is a major step in improving care across the entire health care system. 

The final rule with comment period offers a fresh start for Medicare by centering payments around the care that is best for the patients, providing more options to clinicians for innovative care and payment approaches, and reducing administrative burden to give clinicians more time to spend with their patients, instead of on paperwork. 

Accompanying the announcement is a new   Quality Payment Program website, which will explain the new program and help clinicians easily identify ...
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Q:  We have a Business Associate who has recently had a data breach.  We think they are handling it but are we liable?

A:  When a Business Associate has a data breach, one of their first immediate responsibilities is to contact the Covered Entity(ies) (your office) impacted.  Upon doing so, the Covered Entity (you) and the Business Associate have the responsibility to determine how the breach is best and most efficiently mitigated.  This may include contacting patients whose information has been compromised, technical IT related corrections, procedural/training corrections/improvements, etc.  In many cases, it may be necessary that both the Covered Entity and the Business Associate work together to mitigate the issue and handle necessary details together.  

Additionally, your practice would have documented full detail of the breach incident upon being contacted by the Business Associate.  This includes the date of the incident, details of what happened, when, how, who was involve...
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If the patient’s spouse or parents have an additional insurance plan, there could be multiple insurance plans which could cover the patient. It is very important to correctly determine which is the primary insurance and which is secondary.

The “birthday rule” can be helpful in establishing the proper coverage. Generally, when both spouses have insurance coverage, the husband’s insurance plan is the primary for him, and the wife’s insurance plan is the primary for her. For dependents, the primary insurance company is determined by the insured’s birthdate, which is referred to as the “birthday rule.” The primary insured is the person whose birthdate (month and day) comes earliest in the year.

For example, if the father’s birthday is September 20 and the mother’s birthday is February 5, the mother’s insurance would be the primary plan for their dependents since her birthday is earlier. The year of birth is not applicable.

Chirocode addresses how to handle mu...
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Q:  Our office has not yet completed the annual Security Risk Assessment for Meaningful Use and I know we'll need to be doing that soon since the end of the year is very close!  Do you have information for our staff to help us do this more efficiently and also have better understanding of what the Security Risk Assessment is?

A:  Yes, the end of the year is quickly approaching and the Security Risk Assessment is not only necessary for Meaningful Use attestation but is also a required element to HIPAA Security.  It is very important for practices to complete this assessment and also essential to understand what, why, and how to perform this annual Security Risk Assessment.  
To give you more information, office training, and also an efficient and manageable way to complete your annual Security Risk Assessment, visit this link to see a previously recorded lesson on the topic!  ...
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A:  Updating the date in box 14 is typically warranted when:

1.  Patient presents with a new injury/condition
-Which means you have an updated complaint as well as a new priority of treatment for care, update treatment plan, etc.

2.  If the patient presents with a significant aggravation or exacerbation that causes a change in treatment plan and an appropriate level of re-evaluation.

3.  If the patient has had a lapse in care and hasn't been in for treatment for an extended period of time.
-Your office policy should define this as well as the chief complaint and subjective detail that is collected from the patient upon presenting again for treatment.
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There are thousands of code changes going into effect on October 1.  Here is a list of the the 70 or so that are most relevant to chiropractors.  Don't miss this week's webinar where Dr. Gwilliam will help you know what you should do about these changes, and teach you how to prepare for the end of the CMS grace period on ICD-10 documentation.  All of this information, and a whole lot more can be found in our brand new 2017 ICD-10 Coding for Chiropractic book.  Order yours today and get a free cheat sheet!

G56.03    	Add	   Carpal tunnel syndrome, bilateral upper limbs
G56.13   	Add	   Other lesions of median nerve, bilateral upper limbs
G56.23 	Add	   Lesion of ulnar nerve, bilateral upper limbs
G56.33 	Add	   Lesion of radial nerve, bilateral upper limbs
G56.43  	Add	   Causalgia of bilateral upper limbs
G56.83  	Add	   Other specified mononeuropathies of bilateral upper limbs
G56.93   	Add	   Unspecified m...
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We're flying through the last quarter of 2016!  Before we know it, we'll be ringing in the new year, so we'd better be ready!  As always, there are end of the year things that we must be sure to complete so as to best prepare for the future and protect our practices.  Taking a proactive approach is of utmost importance and significant risk management to help you minimize risk and avoid penalties.  

Though a comprehensive 'to-do' list will be provided to you soon, one thing that you can do now is register for the ChiroCode webinar on Tuesday, October 18, 2016.  The Security Risk Assessment is a REQUIRED element for Meaningful Use Attestation and has proven to be very costly to practices that have not performed their annual Security Risk Assessment according to this guideline.  Additionally, the Security Risk Assessment is a REQUIRED element to HIPAA Security whereas penalties may be assessed for non-compliance with this guideline as well.  

Importantly, this is an essential step f...
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Consumer Directed Healthcare Plans (CDHP) were developed as a way to shift the control of healthcare dollars from the insurance companies to the patient (consumer). The goal of these types of plans is to allow the patient to take a more active role in their own health and healthcare decisions in an effort to control costs. Typically these are health insurance plans that allow members to use health savings accounts (HSAs), Health Reimbursement Accounts (HRAs), or similar medical payment products to pay routine health care expenses directly, while a high-deductible health plan (HDHP) protects them from catastrophic medical expenses. The numbers of employees covered by CDHPs has grown significantly over the years and is projected to continue to increase due to Obamacare (PPACA).

CDHPs are generally associated with:

Health Savings Accounts (HSA)
Medicare Medical Savings Accounts (MSA)
Health Reimbursement Arrangement (HRA)
Voluntary Employee Benefit Associations (VEBA)
Multiple E...
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The Department of Health and Human Services (HHS) oversees all government health care programs. They are administered by various agencies such as the Centers for Medicare & Medicaid Services (CMS), the Veterans Administration (VA) and even at the state level. Here are the basic government programs:

Federal Workers’ Compensation
Military and Veterans
Federal Employee Health Benefits Plans


 Enroll as a provider for Federal Employee Health Benefits Plans
Find your local Veterans Center
VA Patient-Centered Community Care (VAPCCC or VAPC3)
Triwest VAPC3 fact sheet
Medicare Resources Home Page (resource 210)
Centers for Medicare & Medicaid Services
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The most recent Blog Post from CMS has given a new update on The bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS states they will allow providers four options of reporting for the first year of the program stating they can pick their pace of participation for the first performance period that begins January 1, 2017.

Chose one of these options to ensure you do not receive a negative payment adjustment in 2019. These options and other supporting details will be described fully in the final rule expected to be released in November.

First Option: Test the Quality Payment Program.
With this option, as long as you submit some data to the Quality Payment Program, including data from after January 1, 2017, you will avoid a negative payment adjustment. This first option is designed to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019 as you learn more.

Second Option: Participate for part of the calendar...
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Q: What is the ABN form used for?
A: The Advanced Beneficiary Notice of Non-Coverage (ABN) is the Notice of Liability that is required to be provided to Medicare patients in the event that the service(s) rendered to them are expected to not be covered. For chiropractic, reason for non-coverage is generally due to services not being deemed medically reasonable and necessary per Medicare guideline.
Q: When are ABNs mandatory for use?
A: According to Medicare rules, the ABN is the required method for communicating to Medicare patients their personal responsibility for payment of services received. To be clear, the ABN is mandatory for use only for services generally covered and governed by Medicare that may likely be or will be deemed "not reasonable and necessary". For chiropractic, this is only the 98940-98942 service codes. This allows the patient the opportunity to make an informed decision regarding receiving and paying for these services.
Q: Can ABNs be used to communicate Medic...
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The Problem

Sometimes it seems that the gains made by treatment can be offset, at least in part, by the cost of care, the patient’s time away from gainful employment and the inconvenience of the treatment process. This is especially true for patients who are living on-the-edge financially.

What, if anything, can the physician do about it? Should health care providers assist patients by guiding them to insurance benefits and financial remuneration that may be available as a result of an injury?  How proactive should a physician be in directing patients to benefits of which they may be unaware?

A Solution

Let me suggest a paradigm shift that could be a win-win for both patients and health care providers:

The intake process could include gathering specific and targeted information that directs the patient to sources of reimbursement for not only the doctor’s fees but other compensation as well. Often, there are substantial benefits available to patients that are overloo...
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ICD-10-CM changes for 2017 include 1,974 new codes, 311 deleted codes, and 425 revised codes.  Chiropractors, fortunately, are only affected by about 70 of these changes.  And none of them are ground breaking.  However, if you report deleted codes, your claims could be denied.  If you are unaware of a new code that is more descriptive you might miss out on an opportunity to better establish medical necessity for your care.  A sampling of these changes follow.  For a complete guide to ICD-10 coding for chiropractic, order your 2017 book from the ChiroCode store.

There are a few new codes for bilateral nerve conditions, such as:

G56.03 Carpal tunnel syndrome, bilateral upper limbs

There are new codes for bunions and bunionettes as follows:

M21.611 Bunion of right foot

M21.612 Bunion of left foot

M21.619 Bunion of unspecified foot

M21.621 Bunionette of right foot

M21.622 Bunionette of left foot

M21.629 Bunionette of unspecified foot

There are several codes...
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Come hear me speak at the biggest convention in chiropractic!

I wanted to make sure you are aware that I will be speaking in Orlando at The National, August 25-28th.  This is the largest event for chiropractic worldwide and I don't want you to miss it!  I will be teaching about proper documentation on Thursday afternoon and Saturday morning.  
Yet, I am only 1 of 79 speakers that will unite that weekend in order to educate and excite our profession.  If you can't make the whole weekend, no worries, just come for a few days.  They have CE approved in over 45 states. Want to stay the finest hotel in Orlando for a ridiculously low price?  Consider bringing the family for an overnight, attend an alumni function, and just sample what they have in store for you.  Is your staff interested or do you need to train a new CA?  This event also includes the largest exposition in chiropractic, so bringing your staff and family to shop and get convention goodies!
You know I'm committed to helpin...
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The Chirocode Deskbook offers advice on waivers!

It is improper and illegal to waive co-payments and/or deductibles. For this reason, if you wish to offer some sort of assistance to a patient, the proper way to do so is through an official “Financial Hardship Policy”.

Caution is advised when implementing hardship waivers. For example, waivers and reductions for co-pays, coinsurance, and deductibles should not be routine and should not be advertised in any way. Hardship waivers should be used only in cases where hardship is clearly indicated and documented. Clinics should have a written policy regarding determinations of financial hardship and a clear guideline on what qualifies as a hardship (e.g. by using federal poverty guidelines). ChiroCode created a Financial Hardship Policy and Application which provides both the official policy, and the application which is completed by the patient.

Alert! Hardship waivers are a temporary courtesy arrangement which must be periodica...
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Did you know that the key to a successful and beneficial practice lies within the satisfaction of your patients? This makes sense as no one likes to wait a long time during their appointment nor do they appreciate rude chiropractic staff. Learn how keeping your patients happy will benefit every element of your practice....
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Chiropractic Compliance Solutions ( is a ChiroCode partner, brought to ChiroCode customers due to popular request for very specific training tools.  ChiroCode has been an industry leader for coding resources and education for over 20 years.  It's important to us to continue to meet the needs of the chiropractic practices and work with other industry leaders to support all aspects of your practice.  Chiropractic Compliance Solutions does just that!  

What Chiropractic Compliance Solutions Offers

Chiropractic Compliance Solutions offers comprehensive, online training, complete with the need-to-know elements of compliance for your practice.  

The services available are custom designed to practices like yours and as such, are easy to understand, can be efficiently implemented, and help you to have confidence in your practice systems.  

Services available include:
-Online Compliance Training
-Security Risk Assessment Tool
-Consulting (no contract!)
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Lots of Chiropractic practices want to know why compliance is necessary and how implementing compliance can help the practice. See a few bullet points here on this video for your better understanding!View the video here....
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A chiropractor recently contacted ChiroCode and told us that a payer claims that 97140 manual therapy and 97112 neuromuscular re-education are not separately billable from a chiropractic manipulative therapy (CMT), such as 98940.  While Medicare's Correct Coding Initiative does require the 59 modifier to be added to these codes when billed with a CMT, nothing there prohibits them from being billed together.  To clearly document that the CMT is separate from the 97140 and 97112, the record could indicate a distinct diagnosis that relates to the type of service provided.  For example:

98940 might be justified by M99.01 segmental and somatic dysfunction, cervical region. 
97140 might be justified by M79.1 Myalgia, myofascial pain syndrome. 
97112 might be justified by M62.81 Muscle weakness (generalized), R42 vertigo NOS, or R26.0 ataxic gait.

Always use the diagnosis that most accurately describes your patient.  These are just examples, however, the diagnosis pointers should clea...
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Why do we keep getting denials when using modifier 51? Is there any update or new info on modifier 51? ...Yes! Learn on this short Help Desk response the details that will help your coding, billing, and collections for the 98943 service when using (or not using) the 51 modifier.View the video here....
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Chiropractors should understand the difference between strapping and kinesio taping before selecting billing codes. It is important to be sure that you are using correct coding when submitting claims. This helpdesk video addresses the need-to-know details of strapping vs kinesio taping.  View the video here....
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A formal Financial Report of Findings (FROF) is an essential key to success for any chiropractic office. I am surprised that many of my colleagues skip this step. Today’s patients are healthcare consumers and want us to help them to feel better physically without hurting them financially. In fact, many insured patients walk into our offices under the assumption that their insurance is going to cover all of the care they need with minimal out-of- pocket expense. Raving fan patients can turn angry when they receive a bill several months later for hundreds, if not thousands, of dollars for care that was not covered by their insurance.

The best way to keep patients happy, improve clinical outcomes, and enhance collections in your practice is to clearly and openly discuss your fees and payment policy up front. By conducting a formal Financial Report of Findings in your office, you can clearly outline your treatment plan and the patient's estimated out-of- pocket expense. If you provide...
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This question was asked through the ChiroCode and Chiropractic Compliance Solution helpdesk. View these short videos for answers to some common questions. View the video here....
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Lots of Chiropractic practices want to know why compliance is necessary and how implementing compliance can help the practice. See a few bullet points here on this video for your better understanding!  Click here to view.  Compliance Video...
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Most chiropractic tenants don’t realize that landlords fall into different categories and have different motivations for owning their commercial real estate development. To business owners, being a landlord looks easy - landlords take care of the property and collect the rent. However, landlords can become casualties of the economy and even victims themselves when their tenants can’t pay their rent or completely go out of business.

We have defined the most common types of landlords below … how would you categorize your own commercial landlord?

A professional landlord isn’t a person but a company that exists for the sole purpose of owning; developing; leasing; buying; and selling commercial, residential, and industrial property for a profit. A professional landlord may not only own various real estate assets but also internally manage those properties. Furthermore, a professional landlord uses various commercial real estate formulas to calculate and measure the rate of ret...
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A:  The Security Risk Assessment is a complete and comprehensive evaluation of your practice's HIPAA Security Policies and Procedures.  This helps to ensure that practices do have appropriate systems in place to best ensure the integrity and security of electronic Protected Health Information (ePHI).  

Without appropriate policies and procedures in place, practices have a much greater risk of inappropriate incident, exposure, access, use, and destruction of ePHI.  Not only is this potentially a very costly and damaging hazard to a practice but to patients as well.  Because we operate in an electronic age where information is created, stored, maintained, and transmitted electronically, practices are responsible for implementing appropriate safeguards to minimize risk of this information being inappropriately accessed.

The Security Risk Assessment addresses the administrative, physical, and technical security of your practice and helps you to ensure that adequate policies and proce...
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Staying profitable, productive, and compliant in business today requires a proactive approach.  

Proactive systems to manage and monitor patient visits, billing, collects, etc, are just a mere few components of what must be in place to be profitable.  

Time management, organization, along with clearly defined roles and responsibilities are just some of those characteristics necessary to be productive.  

EACH of the aforementioned items is essential to the health of your practice.  These, along with other critical elements such as staying up-to-date with various guidelines, properly documenting and maintaining your own office policies and procedures for risk management, adherence to compliance, and more, all serve as the foundation to a practice.  

Taking a proactive approach to meet standards, define your systems and expectations has many benefits.  Here is just a few for you to consider:
-Find and fix errors before payors do
-Protect your patients' identifying data in ef...
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In some places, the ICD-10-CM code set uses words we think we are familiar with.  However, a review of the guidelines shows that some of these words have very specific definitions.  Here are a few important ones to remember.

The word “and” should be interpreted to mean either “and” or “or” when it appears in a title. Take a look at the category S33- Dislocation and sprain of joints and ligaments of lumbar spine and pelvis. This category title might be more correctly read as “dislocation and/or sprain of joints and/or ligaments of lumbar spine and/or pelvis.” So, this category works just as well for sprains of the lumbar spine as it does for dislocations of the pelvis.

The word “with” should be interpreted to mean “associated with” or “due to” when it appears anywhere in ICD-10-CM. The fourth character of the code is often designated with the number “1,” when the code description includes the word "with", while the “0” or ...
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A:  97010 is a service that is commonly not covered by payors or if it is covered, reimbursement is very minimal.  This is due to a few reasons:
1.  Hot/cold packs (97010) is not a high "qualified" code.  Meaning in general that the actual benefit of this service and need for this service is relatively low.  From the payors' perspective, the same treatment objectives during a particular visit could be achieved without having to perform this service at all.
2.  Medical Necessity.  Remember that services submitted for third party processing and reimbursement must meet medical necessity requirements.  This means that we must adhere to the standard definition of medical necessity when expecting third party coverage and reimbursement.  It can be quite difficult to support medical necessity for hot/cold packs.
3.  Over utilization.  Hot/cold packs historically has been performed on patients as part of a routine procedure in many offices.  Meaning also that medical necessity was not proper...
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A:  No.  There is no such thing as "under the radar".  Documentation and coding must tell the same story so it is essential that your selected codes be clearly demonstrated and fully supported within the patient documentation.  Under-coding can pose an obstacle to practices as well and result in further investigation of billing and documentation.  
Remember too, that payors evaluate trends and statistics.  Your use of codes is compared to your peers.  If your practice appears to be using particular codes at a significantly greater or lesser frequency of other practices that offer the same services, this could potentially be a "flag" that would prompt a payor to more closely monitor your claims or conduct an investigation.  

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As healthcare reimbursement continues to place more financial responsibility on the patient, it is important that your office billing systems also evolve to make sure that you have processes in place to follow-up on patient accounts receivable. CLICK HERE to watch a video by Dr. Alan Bergquist discussing how this piece of the revenue cycle puzzle can affect your practice in more ways than you might think.
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When it comes to Medicare, providers and patients alike feel like beating their heads against the wall. Signing up to be a provider or a patient is confusing, understanding what is covered is confusing and just about the time you think you have it figured out, you receive a notice that suggests you don’t. I travel across the nation most weekends attending chiropractic conventions and the topic of Medicare comes up frequently. The struggles of treating Medicare patients varies from low reimbursement rates to when should a patient sign the ABN form. It doesn’t help that, as a provider, you can often receive conflicting answers to even the simplest questions. That is if you have the patience to sit on hold for hours to speak with a live person at CMS. All of the chaos associated with Medicare has even the most seasoned chiropractors asking themselves if they really want to continue treating Medicare patients.

Currently, 44 million beneficiaries, some 15 percent of the U.S. populati...
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A:  That has certainly been the trend over the past several years.  It is likely that this same trend will continue.  Other insurance related trends include reduced coverage, more limitations in coverage such as services rendered, limited visits per year, and things of that nature.  While this poses concern for providers, one lesson in this is that practices must be sure to focus more on those things that they can control.  In other words, evaluate your billing procedures, follow-up procedures, make sure that your billing team knows how to review EOB's for correct processing and is proactive in doing so, and make sure you have good procedures in place to maintain a healthy and manageable accounts receivable.  Certainly, if help is needed, reach out for guidance.  ChiroCode ( offers weekly webinars that periodically cover these topics and Chiropractic Compliance Solutions ( provides online training, consulting, File Reviews and more. ...
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ACOM Health - Total Practice Performance Webinar Series

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A: Yes. The best prevention for audits is to be proactive.  It is much easier on a practice to find and fix their own errors and oversights versus wait until an audit or records review when the 3rd party payor will surely find these and notify you - usually in the form of a request for refund.

As a measure of risk management, and also to adhere to compliance guidelines, practices should at least once per year perform a File Review.  The File Review evaluates your documentation, coding and billing and enables your practice to prevent errors, find and fix errors before they become long-term and costly challenges, and provides necessary training and education of current guidelines.  

If practices have confidence in their own abilities to conduct the file review, it is okay to do so and is recommended to review multiple random charts of different case types.  Otherwise, you may outsource your File Review to a professional organization that is certified and experienced with this proce...
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Chiropractors can’t just open a practice and expect patients to beat a path to their door. Those patients need to be able to find them. One of the easiest methods to ensure that your chiropractic practice is conspicuous is by means of signage.

While you may envision a large sign prominently identifying your place of business, don’t assume that your landlord will agree. As we explain in our new book, Negotiating Commercial Leases & Renewals FOR DUMMIES, commercial landlords may, in fact, prefer to decrease your amount of signage and will often reject tenant requests for more or larger signage.

This may seem counter-productive to you; however, landlords often find that tenant requests granted become similar demands from other tenants. Therefore, it is easier for the landlord to draw the line on all signage requests. If each tenant leasing in the property is given a larger sign, the site will become cluttered and people may dislike visiting there. This doesn’t mean you shouldn...
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Some time ago I worked with a client who needed help with an appeal.  The provider had seen a patient over the course of four weeks for severe low back pain with radiculopathy to the left calf and foot.  The provider put together a care plan and outlined goals based upon functional deficiencies.  At each encounter the following codes, among others, were billed: 97110 Therapeutic exercises, 97140 Manual therapy.  The therapy services were denied for most of the visits.  The claims reviewer provided the following partial explanation for the denial:

“The information provided does not establish medical necessity for the services provided.  Therapy is goal-oriented and is evaluated on the basis of goal achievement, including quantifiable rates of improvement in functional abilities and documented treatment outcomes...”

The key words I gathered from this statement include “goal-oriented”, “improvement”, “function”, and “outcomes”.  It seems that these are the focus ...
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The most recent issue of the Journal of Manipulative and Physiological Therapeutics has a series of 3 papers that will help to fill the evidence gap and answer the question "Does inclusion of chiropractic care result in cost savings?" Each of these papers focuses on one area of musculoskeletal health that has been identified as a public health burden: low back pain, neck pain, and headache.  Check out each one at the following links:
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Medicare Fee Calculator

Enter your zip code and view a list of Medicare fees for your area! To access the Fee Calculator, hover over the Members tab at the top of the page. You should see a drop down menu with the Basic Medicare Fee Calculator option. NOTE: You may need to click on the Members tab first, then hover over it.  This is just one piece to get you info about your fee schedule.  See our post at for more help.  

You can also access the fee calculator here:
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Our team is frequently asked if it is legal for chiropractic offices to offer coupons or Groupons. We’re not allowed, as a profession, to dramatically discount our services, offer free treatments, or provide gifts or free meals for potential patients. Any one of these things can be considered an “inducement.” Practices that improperly induce patients to seek care or services, for example, by providing coupons for care or supplies, may find that they are in violation of the law if they aren’t careful.

So what will that mean to you and your practice? It isn’t pretty. If your discounts trigger inducement violations, you can expect to pay fines up to $10,000 per occurrence. That’s a pretty expensive slap on the wrist. This means that a small practice could be just one audit away from serious financial hardship, maybe even bankruptcy.

As it stands right now, chiropractors offering Groupons stand a good chance of running afoul of third-party payer regulations. Apart from le...
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Over the last few years chiropractors have had a battle on their hands, and I’m not talking about the one with payers or with non-compliant patients. I’m talking about the struggle between knowing they need to be compliant with HIPAA rules and regulations versus what I like to call “The Alphabet Dilemma.” 

In an interview a few years ago, then Director of the Office of Civil Rights (OCR), Mr. Leon Rodriguez, explained Culture of Compliance as “everybody has to see themselves as being responsible for the privacy and security of health information.” He also said “employers need to make it clear to their employees that this is something they need to take seriously, and it really needs to flow down to all the employees who handle health information.”

In the same interview, Ms. Joy Pritts, then Chief Privacy Officer at the Office of the National Coordinator for Health Information Technology (ONC) stated “you can treat privacy and security as being another thing we ha...
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ChiroCode has proudly served chiropractic for more than 30 years and continues to work to bring the most necessary, affordable, and user friendly products and services to practices.  Increased regulation has hindered practices by creating uncertainty around the nature of guidelines and the expensive penalties that arise from non-compliance with these guidelines(including audits, HIPAA, and others).  While practice owners and providers would love nothing more than to focus on their patients and practice growth, there are other responsibilities to the practice that must not be overlooked.

Advancements in technology, enforcement of billing and documentation guidelines, and increasing risks to protected information must all be appropriately managed in the daily operations of health care facilities.  While most practices understand the necessity of appropriately implementing policies and procedures to minimize risk and adhere to guidelines, practices have struggled to properly implement ...
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Did you know that inconsistent and un-reviewed fee schedules can lead to some of the following occurrences:

Prompt an audit or some level of claims review
Cause claims delays
Increase provider liability in case of an audit or investigation
Potentially lead to being paid less than the actual value of a service rendered
Losing patients or losing referrals due to overpriced fees and higher patient out-of- pocket
Lead to patient complaints and/or complaints from peer providers in your area
Liability and penalties for use of dual fees
Liability and penalties due to excessive and/or improper discounting

Many providers are unsure of where their fee schedule actually came from or when it was last reviewed. As a component of compliance and for other preventive purposes, fee schedules should be evaluated once per year. Just as CMS routinely (usually once per year) updates fees for all regions and we adjust accordingly, all other fees for services should be evaluated as well to mai...
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As someone in the chiropractic industry, you’re aware that the information recorded when a patient is initially registered at your practice is very important. It is necessary to have the most accurate and up- to-date details on your patient to get your claim for payment approved by the insurance companies. Submitting a claim with incorrect or old information will most likely result in a delayed or denied payment. That’s no good.

To ensure that you don’t miss out on a payment, make sure that your patient verifies all of their information when they come into the office. If a patient hasn’t been in your practice in a while, send them an email or a letter than requests that they review and confirm that the information on file is current. 

Next time your patients come into the practice, allow them to grab this checklist to ensure that they always keep you updated with their latest demographic, insurance, and personal information.

Download the PDF version of the patient-to...
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The Chiropractic business model was much simpler 40 years ago.  Perform a service, bill for it, and get paid.  Unfortunately this allowed for a few bad eggs to abuse the system and collect payment when they shouldn’t have.  In addition insurance companies are keen to spend as little money as they can in order to stay profitable.  After all, they have a duty to their shareholders to improve their own bottom line.  With the current trend by payers to perform post-payment audits and refund demands, it’s no longer about if an audit is coming, but when.  Audits are a very effective way for payers to reduce their expenses, especially if they can find doctors who are careless and sloppy.  The best defense is a good offense.  Odds are good that every office will be audited sooner or later, so why not beat them to the punch?  Perform a self-audit.  Per the Affordable Care Act of 2010 it is technically required as part of a mandatory Compliance Plan anyway.  An office that is vigilant about ...
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So often, chiropractic tenants come to The Lease Coach stating that they are not making any money because their rent is too high. Sometimes, this is a true statement but, more often than not, the chiropractic tenant has simply leased too many square feet.

We remember consulting to a client leasing 5,000 square feet of space who couldn’t afford to pay the rent. When we checked with neighboring tenants it turned out our client was actually paying less per square foot than anyone else. It wasn’t the rent per square foot that was killing his business but the amount of area he had been talked into leasing by the landlord’s leasing representative. We regularly see this scenario … leasing representatives and real estate agents, typically, receive a commission from the landlord for signed lease deals (the incentive increases with a tenant signing for a longer term, agreeing to pay a higher rent or leasing more space); however, the unknowing tenant often signs the lease agreement and...
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The Medical History and Health History forms are very important documents for the initial patient visit. Most patients dislike filling out forms when they arrive and sometimes they may not bring all the necessary information with them.
By completing this form before arrival, the patient saves their time as well as yours., In addition, the healthcare provider will have the necessary information to meet documentation requirements for “Review of Systems” and “Health History”.
See Resource 144 with your 2016 book to for a free sample form.
This and much more is in your 2016 ChiroCode Deskbook!...
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Q:  What is a comprehensive program for a systematic approach to becoming a compliant office?

A:  You must have a program that:

      1.  Provides the appropriate training and training topics for your practice

      2.  Provides the necessary materials so you aren't having to look for or create something of your own

      3.  Provides specific action steps that your practice can manage

Compliance is a very broad topic and there is so much to know and to do.  It is important to understand that compliance is a process and not a task.  Visit Chiropractic Compliance Solutions for information on their online training programs.  These were also designed with your valuable time in mind too.  You won't find long modules of discussion but rather shorter modules with the need-to-know information, along with the necessary materials and action steps so that your practice can execute one step at a time in a manageable fashion.  ...
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Some diagnosis codes do not actually describe a condition, rather they simply explain the reason for an encounter with a health care provider.  Classic medical examples include encounters for vaccines, or health screenings.  In other words, these patients have no complaints, therefore there is no condition to report.  In this type of case, ICD-10 codes can still explain the reason for the encounter.  These codes are found in Chapter 21 of the Tabular List. They are easy to identify because they all start with the letter “Z.”

If a patient presents for an annual wellness exam (which would most appropriately be reported with Evaluation and Management codes from the range 99381-99397 Preventive Medicine Service), a few possible ICD-10 codes a healthcare provider might use are:

ZØØ.ØØ Encounter for general adult medical examination without abnormal findings

 ZØØ.8 Other encounter for general examination without complaint, suspected, or reported diagnosis

The first code...
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The HIPAA Security Rule requires that covered entities (your practice) conduct a Security Risk Assessment (SRA) for your organization, at a minimum of once per year. It is critical that practices perform the Security Risk Assessment for multiple of reasons. Not only is it important to comply with rules and regulations, but also, for what you may consider to be a more motivational reason, to protect your practice (and bank account) from what could become disabling fines and penalties.

Let me further explain...The Office of Civil Rights (OCR) in recent months has acknowledged that providers are not making compliance implementation a priority to their practices. Thus, the increased risk of unauthorized access, use, and disclosure of protected (and quite vulnerable) patient health information is still a factor. Not to mention the risk of practices not appropriately implementing other critical areas of compliance, which also pose significant vulnerability to practices as well as the heig...
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It turns out that there is a whole batch of new external cause codes for "Exposure to supernatural forces." They are in a new block from X40-X49.  You might want to pass this on to your contacts.  You can review the new codes here: Proposed new ICD-10 codes for 2017!
Noteworthy examples include:
X42.221_ Struck by invisible jet
X42.41 Injury due to contact with kryptonite
X41.042 Injury due to force push or tractor beam 
The 7th character options are interesting too:
A- encounter with non-humanoid
B- encounter with humanoid
C- encounter with other or unspecified being
D- encounter with device – of non-terrestrial origin or manufacture
E- encounter with device – of terrestrial origin or manufacture
F- encounter with device if other or unknown origin or manufacture
S- encounter involving substance (organic, inorganic or unknown) of non-terrestrial origin
T- encounter involving substance (organic, inorganic or unknown) of terrestrial origin
U- encounter involving substan...
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Q:  Are there more specific codes for supplies rather than using 99070?

A: Yes. The HCPCS supply code series includes multiple specific supply codes.  The HCPCS supply codes are still too often overlooked and unused by providers.  You will find that the HCPCS supply codes are more specific and as a result, often have more applicable codes for accurate reporting than the standard 99070 which is a non-specific,  general supply code. 

Of course, coverage and benefits for these HCPCS codes, like all other codes, does depend upon policy benefits and limitations.  Though you will likely find that when coverage does exist, it is generally much easier and more efficient to get reimbursed using a specific code for the supply versus using the general and ill defined supply code. 

Note too that there are specific modifiers that can be used to even further define the supply and indicate whether the purchase was of New Equipment, a Rental, etc. 

The HCPCS supply section is the last chap...
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As we explain in our new book, Negotiating Commercial Leases & Renewals FOR DUMMIES, parking is often a contentious issue for chiropractic tenants. You will want sufficient space for you, your staff and your patients to leave vehicles while they are inside your practice.

Don’t take parking for granted. Depending on the time of day you visit a property, there may or may not be sufficient parking. The location of the parking and whether the parking stalls are designated are all part of the negotiating process. For many tenants, parking is free. But for some, monthly parking charges for their staff vehicles can range from $85.00/month to several hundred dollars per month and patients may face hourly charges. Even if you’re prepared to pay for parking, don’t assume that it will be available. When The Lease Coach negotiates on parking, there are three considerations: negotiating the number of parking stalls; the location of the stalls and the rental rate, if any.

Chiropractic te...
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Q:  What is the best way to handle denials?

A:  There are a few steps to take when addressing denials.  Here they are:

1.  Review the EOB/EOR in detail to determine the reason for denial.  Payors include denial codes next to line items that are denied.  This provides information to you as to the reason for denial.  Most of the time it is well explained.  The next step you take to handle the denial will be determined by the reason the service(s) were denied.

2.  If after reviewing the EOB/EOR, you are still unclear on the reason for denial, you must call the payor directly to inquire.  Be sure that you have all of the claim information at your fingertips when making the call.

If after reviewing the EOB/EOR, you believe that the service(s) should have been covered, you will do the following:
   -  Review the Verification of Benefits to confirm that you have a record of coverage for the service(s) in question.  If not, you follow the EOB/EOR instructions.  The ...
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JMPT recently published an article entitled Characteristics of US Adults Who Have Positive and Negative Perceptions of Doctors of Chiropractic and Chiropractic Care by William B. Weeks, MD, PhD, MBA Christine M. Goertz, DC, PhD,  William C. Meeker, DC, MPH, Dennis M. Marchiori, DC, PhD.

There are valuable lessons here for DCs. The abstract is below, but the full article can be accessed at


The purpose of this study was to compare characteristics, likelihood to use, and actual use of chiropractic care for US survey respondents with positive and negative perceptions of doctors of chiropractic (DCs) and chiropractic care.


From a 2015 nationally representative survey of 5422 adults (response rate, 29%), we used respondents' answers to identify those with positive and negative perceptions of DCs or chiropractic care. We used the χ2test to compare other survey responses for these groups.

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Who is in charge of these updates?

March 9-10, 2016 the ICD-9-CM Coordination and Maintenance Committee met to discuss changes to ICD-10-CM, which begin October 1, 2016 at the earliest.  A representative from the National Center for Health Statistics (NCHS - part of the CDC) and one from the Centers for Medicare and Medicaid Services (CMS) co-chair the meetings. NCHS is responsible for classification of diagnoses while CMS is responsible for ICD-10-PCS (which is only used in an inpatient/facility setting at this time).
The ICD-9-CM Coordination and Maintenance Committee’s role is advisory. All final decisions are made by the Director of NCHS and the Administrator of CMS. Final decisions are made at the end of the year and become effective April 1 or October 1 of the following year.

Where can I find the official changes?

Official code revision packages, which are referred to as addenda, are available from the CDC.  The agenda for the March 2016 meeting included 1928 proposed...
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The cervical spine usually has a nice forward, or lordotic, curve.  However, many patients can present with a reduced or even reversed (kyphotic) cervical curve that is acquired due to poor posture.  The old ICD-9 code, 737.10 Kyphosis (acquired) (postural), was probably the best choice.  But it was rather general.  ICD-10-CM offers the following choices in the M40 category, which all specify the cervical or cervicothoracic region:

M40.00 Postural kyphosis, site unspecified
M40.03 Postural kyphosis, cervicothoracic region
M40.12 Other secondary kyphosis, cervical region
M40.13 Other secondary kyphosis, cervicothoracic region
M40.202 Unspecified kyphosis, cervical region
M40.203 Unspecified kyphosis, cervicothoracic region
M40.292 Other kyphosis, cervical region
M40.293 Other kyphosis, cervicothoracic region

The M40.0- codes seem like the best option since they include the word "postural", however, for some reason, there is no code designated for the cervical region.  If ...
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It's difficult to know where to start when selecting the best software for your practice.  With dozens of selections to choose from, making the right choice can be a daunting task.  For new or established practices looking to implement or upgrade software into their practices, there are some general need-to-know details that will help better prepare you for evaluating and choosing the software program best suited for your needs.

Software companies have sales representatives that you may have communicated with to learn some of the features of a particular program.  One key thing to keep in mind is that sales representatives, while necessary and usually very informative, generally have one primary goal in make a sale.  While there is absolutely nothing wrong with this, keep in mind that YOU are ultimately responsible for the decision of which software to purchase.  No sales rep will know your practice's needs as well as you.  One  obstacle that practices sometimes encounter,...
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Palmetto GBA (Railroad Medicare) recently released the results of their "Widespread Review of Chiropractic Services for the first quarter of FY 2016” and while the overall charge denial rate of 45.4% was lower than the denial rate of the 4th Quarter FY 2015 review which was 60%, there is still reason for the chiropractic profession to be concerned. 

In the most recent review more than 53.5% of all denials were related to “non-response to requests for documentation” (doctors not sending in their documentation) and in the previous review more than 60.2% of all denials were related to non-response to requests for documentation. The next biggest reason for denials in both reviews was insufficient documentation. 

While it is encouraging to see that the overall denial rates are decreasing it is still alarming to see that, for whatever reason, many chiropractors are not sending in their documentation when it is being requested.  We can only speculate, but the biggest assumption th...
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Q:  We have Meaningful Use questions and wonder if you have a resource that we can access for more information?

A:  Yes!  If you are a ChiroCode Premium Member, you have access to webinar archives. ChiroCode regularly hosts a guest presenter with Meaningful Use expertise. In recent months we have recorded 2 brand new Meaningful Use webinars with need-to-know information and answers to your commonly asked questions. If you aren't yet a ChiroCode Premium Member, please visit here for more ChiroCode Premium Membership information. If you are an existing Premium Member, simply login to your account to access the abundance of tips, information, and training materials that you have access to. Also, please be sure to mark your calendar for Tuesday, March 22 at 11:15 Mountain Time. Meaningful Use experts will be hosting a Q/A session to address your Meaningful Use hot topics. Click here to register....
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The following is a letter from CCGPP's Chairman, Dr. Greg Baker.  Dr. Gwilliam, ChiroCode's Vice President, is a board member and whole-heartedly supports this cause, which is, in part, to get the evidence together to defend our profession from those who deny care.  In Dr. Gwilliam's webinar from 2/22/2016 (note, you need Premium Membership to view archived webinars), he referred to how you can use this article, published by JMPT, to build care plans based on the evidence, so that reviewers have no ammunition to deny care. 

February 22, 2016

Dear Colleagues:
I want to make you aware of some exciting news! CCGPP’s Clinical Compass has just released its new guideline:  CLINICAL PRACTICE GUIDELINE: CHIROPRACTIC CARE FOR LOW BACK PAIN. The publication can be viewed here.
Here’s what Claire Johnson, Editor-in-Chief of JMPT, had to say about this important updated guideline: 

“What could possibly inspire a small group of people, to work with fervor and dedication, ...
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The Office of Inspector General's (OIG) mission is to protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries.  They are dedicated to combating fraud, waste and abuse and to improving the efficiency of HHS programs, such as Medicare.  The OIG releases a Work Plan that sets forth various projects to be addressed each year.  Here are the excerpts from 2016 that pertain to chiropractic.

Chiropractic services—Part B payments for noncovered services

"We will review Medicare Part B payments for chiropractic services to determine whether such payments were claimed in accordance with Medicare requirements. Prior OIG work identified inappropriate payments for chiropractic services furnished during CY 2006. Subsequent OIG work (CY 2013) also identified unallowable Medicare payments for chiropractic services." 

Chiropractic services—Portfolio report on Medicare Part B payments

"We will compile the res...
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The ChiroCode DeskBook is updated annually to reflect the most current information available and necessary for chiropractic practices.  The DeskBook is most commonly used for the procedure codes and related information that it provides.  This allows practices greater confidence in code selection and serves as a great time saver for practices that have this resource at their fingertips and can quickly find or verify codes, definitions and guidelines.  

There are many other benefits to having the ChiroCode DeskBook that are also worthy of attention, as these too save practices time and money.  Here are just a few of those features:

Coding updates

Yes, codes are updated each year!  There are updates that pertain to chiropractic and without this information you could encounter increased denials or even inadvertently trigger an audit.  

Coding tips

Even with current code descriptions, it can sometimes be difficult to determine the best code. ChiroCode goes one step further an...
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Documentation provides clear evidence of continuity of care to communicate with other providers.  It can act as a legal record of the care given.  And it should support the billing for the services rendered.  Have third parties tried to claim that your documentation is insufficient?  Is it a weakness they seek to exploit so that they can avoid payment?  Or, do you see your records as a protection and shield from liability and audits?

The ChiroCode DeskBook contains all you need to create heavily fortified documentation that won't take excessive time to complete.  Here are some targets and the solutions:

There are too many visits
Use Evidence-based Guidelines as you outline your care plan.  See Chapter 4.5 in the 2016 ChiroCode DeskBook

There were too many services at a single visit
Understand the codes and when to use them.  See Chapter 5.2 in the 2016 ChiroCode DeskBook

Billing does not match the documentation
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Q: How do you code for a bilateral condition, such as sciatica?

A: There are not many codes for use in chiropractic that define a bilateral condition. In the instance where there is a bilateral condition, you would need to use two codes, one for the right side and the other for the left side. Using the sciatica example, the codes would be: M54.31 and M54.32....
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The American Chiropractic Association (ACA) has launched a national petition to generate support for expanded access to and reimbursement for chiropractic services for Medicare beneficiaries. The National Medicare Equality Petition is raising awareness of how the current Medicare system shortchanges seniors who want and need the essential services provided by doctors of chiropractic (DCs) to stay healthy, pain free and mobile.

ACA’s campaign focuses on generating a robust level of patient grassroots support aimed at Congress and seeks to eliminate a blatantly anti-competitive provision of Medicare law that arbitrarily limits reimbursement for medically necessary services delivered by DCs. The statutory change ACA seeks would define DCs as “physicians” under Section 1861 of the Social Security Act, enabling an individual DC to provide any existing Medicare-covered service that falls within his or her state scope of practice. ACA believes this new nationwide campaign will result...
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Secure medical records is a broad topic that should be addressed in detail by all practices.  There are multiple items to consider when meeting standards to best safeguard protected health information (PHI).  The primary requirements for safeguarding PHI include:

-Reasonable safeguards must be implemented to protect patients' health information.  This includes primarily, Administrative Safeguards, Technical Safeguards and Physical Safeguards.  

-Providers must have policies and procedures in place that reasonably limit use and access to PHI, based upon minimum necessary standards.  This means that access to protected information must only be allowed to the level that is necessary to complete required duties.

-Appropriate Business Associate Agreements must be in place, identifying access authorization details.

-Appropriate workforce agreements must be in place clarifying access and use authorizations for PHI.

-Policies and Procedures must be well defined and in place to p...
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Many doctors struggle with timed codes and the rules about billing for multiple units.  These rules basically apply to most of the codes from 97032 to 97530.  Each one requires 15 minutes of one-on-one contact.  But, Medicare allows providers to count the 15 minute unit if a substantial portion of the service is complete.  In the case of one unit, this would be a minimum of 8 minutes, which is slightly more than half of 15.  Two units would be a complete first unit (15 minutes) followed by a substantial portion of a second unit (another 8 minutes), therefore two units must be a minimum of 23 minutes (15+8).  Three units would be the full 15 minutes of the first two units (30 minutes) plus a substantial portion of the third unit (8 minutes), therefore three units must be a minimum of 38 minutes (15+15+8).

There is one trick with this rule that many providers miss.  You must complete the time component to bill two or three units, no matter how many different services are provided.  Fo...
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Q: How do we know which codes a payer will allow?

A: Many of the ICD-10 codes translate very closely or even identically in some cases from ICD-9 to ICD-10. It is likely that these direct or very similar crossovers in ICD-10 will process in the same manner as they had previously with ICD-9. That said, there are of course many new codes, combination codes and much more specific codes than what was available in ICD-9. Providers should continue to use those diagnosis that are within their scope to diagnose and that most closely support patient documentation. More specific information as to which codes are best to use in certain circumstances will likely be defined by individual payers in the weeks and months to come. CMS, the ACA and other governing entities will also help to clarify certain ICD-10 issues that arise. As always, billing personnel must carefully watch claims, review EOBs and be proactive in following up with any uncertainties to best familiarize with payer expectations f...
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Measure twice so you only pay once.

As The Lease Coach, representing commercial tenants with leasing matters since 1993, we have found that some landlords are over-charging chiropractic tenants for more square footage than the tenant actually has. Are you paying too much?

This is a common oversight in the commercial leasing game. Tenants frequently trust the reported square footage of their leased premises. However, whether this figure was accidently reported by the landlord or reported by a distant property owner who has never even seen the site, the amount of reported square footage can easily be wrong. Chiropractic tenants, therefore, needlessly pay an increased rent, based on their incorrect square footage … isn’t it better to keep this money for yourself than pay it to your landlord?

Even the smallest amount of phantom space can negatively affect tenants as rental rates and Common Area Maintenance (CAM) charges increase over time. We once found a previous client had a...
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Here at the ChiroCode Institute, we are often asked for an template for a perfect SOAP note.  We often defer back to practice management software (see our MarketPlace for some we like) which should be developed with an ideal SOAP note in mind.  And read Chapter 4.2 Record Keeping in the 2016 ChiroCode DeskBook for a more thorough explanation.  

The note needs to convey medical necessity, but it also needs to accurately describe a unique encounter.  It should tell the story of the patient encounter to a third party who was not there to see it for themselves.  SOAP is an old standard in medical records and it stands for Subjective, Objective, Assessment, and Plan.  The following example is just an example.  Individual reviewers may have preferences and specific guidelines.  Nonetheless, here is a note, made up by Dr. Gwilliam.  It is not intended as a template.  Feel free to email your thoughts or suggestions to  Dr. Gwilliam will take those into account and mak...
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Practices have finally settled in to ICD-10 and continue to become familiar with code navigation and commonly used codes.  The ChiroCode Help Desk is available as a resource for support and clarification on coding and other related topics.  Common inquiries that are submit to the Help Desk include, "When will there be more codes, and will any code updates affect chiropractic coding?"

Pre-ICD-10, instructors and training programs did a great job encouraging practices to continue ICD-10 training beyond the 10/1/15 implementation date.  The days of memorizing every code we use is part of the past.  Practices must take a proactive approach to best ensure appropriate code use and minimize risk of error.  

So, when will there be updates to ICD-10?  Importantly, In October, 2011, four years prior to what would become the official ICD-10 implementation date, a partial freeze was implemented in anticipation of ICD-10.  This partial freeze limited code updates to both ICD-9 and ICD-10 code...
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A Message from Dr. Lewis Bazakos, Chiropractic Summit Chairman: “Friends, it is imperative that we all “answer the call” when you see these alert bulletins in your e-mail box.  Please take a look at the alert bulletin below and contact your representative and senators in Washington and urge that they cosponsor this legislation.  All it takes is a few mouse clicks and your time and effort will be helping your profession and our patients.  If you have previously contacted your federal officials on these issues, please do so again.  If you haven’t, please do so today.  Thank you!”

Last year, three separate pieces of legislation were introduced in the U.S. House of Representatives and one in the U.S. Senate that would expand patient access to the essential services provided by doctors of chiropractic in several federal health care delivery systems.   It is very important that doctors of chiropractic and chiropractic students immediately contact their elected officials in Washi...
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The following information about 97110 is pulled straight from page 288 in the 2016 ChiroCode DeskBook.  It is one of twenty CPT codes in Chapter 5.2, Common Procedure Codes.  Each code gets a thorough, but concise, review in this newly expanded chapter.  First, the code is explained, then important tips are listed.  And finally, each code is given a list of suggested diagnoses and modifiers, as appropriate.  More general tips about documentation for Physical Medicine and Rehabilitation codes also appear on pages 283 and 284 as well.  This information was gleaned from various sources, including our very own HelpDesk, Medicare LCDs, and the AMA CPT Assistant newsletter, but remember that different rules may apply for different payers.  See the 2016 DeskBook for help with more codes.



     Therapeutic exercise incorporates...
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Q: We feel comfortable with ICD-10 but have several questions. How can we best continue to familiarize with ICD-10 and also address individual questions that may come up?

A: ICD-10 training should not stop as of 10/1/15. Practices are encouraged to continue training, particularly if you have multiple of questions and uncertainties. We recommend that you visit for this training. Extended module based training is available here as well as sample cases and an expanded review of codes and code use.

Additionally, the ChiroCode help desk, found at is a member based service that allows for questions to be submit and answered by one of our experienced coders....
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ICD-10-CM has two types of excludes notes which are not interchangeable. Each type of note performs a specific function.

An “Excludes1” note is used when two conditions cannot occur together. For instance, a deformity is either congenital or acquired, but cannot be both. This type of note is a “pure” type of exclusion. Another way of saying this is, “NOT CODED HERE!” An “Excludes1” note indicates codes that should never be used at the same time as the code located directly above the “Excludes1” notation. When this term appears, think “consider these codes instead” or “only one code can apply.” The codes are mutually exclusive.

      Example: M43.Ø- Spondylolysis
                   Excludes1 congenital spondylolysis (Q76.2)

M43.Ø- is for acquired spondylolysis, and the Q76.2 is for congenital spondylolysis and the two should never appear together o...
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Did you know that inconsistent and un-reviewed fee schedules can lead to some of the 

following occurrences:

•Prompt an audit or some level of claims review

•Cause claims delays

•Increase provider liability in case of an audit or investigation

•Potentially lead to being paid less than the actual value of a service rendered

•Losing patients or losing referrals due to overpriced fees and higher patient out-of-pocket

•Lead to patient complaints and/or complaints from peer providers in your area

•Liability and penalties for use of dual fees

•Liability and penalties due to excessive and/or improper discounting

Many providers are unsure of where their fee schedule actually came from or when it was last 

reviewed.  As a component of compliance and for other preventive purposes, fee schedules 

should be evaluated once per year.  Just as CMS routinely (usually once per year) updates fees 

for all regions and we adjust accordingly, all other...
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Q. What is the best way to diagnose pregnancy for the purposes of chiropractic care?

A  When reporting pregnancy for the purposes of chiropractic care, the best ICD-10 code to use is Z33.1, which indicates "pregnant state, incidental".  This code is sufficient in identifying to payers and within documentation that the patient is pregnant but importantly, does not imply that the chiropractor is somehow treating or monitoring the pregnancy.  Though this code is not required to be included on claim forms, it can be helpful in communicating the "whole story" to payers as they process and review claims for payment.  If included on a claim form, note that you would never list this code first because it does not describe the reason the patient is being treated....
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Chapter 20 External Causes of Morbidity includes codes from V00 to Y99.  They were greatly expanded in ICD-10-CM.  They are intended to provide data for injury research and evaluation of injury prevention strategies.  These codes capture how the injury or health condition happened (cause), the intent (unintentional or accidental; or intentional, such as suicide or assault), the place where the event occurred, the activity of the patient at the time of the event, and the person’s status (e.g. civilian, military).  Therefore they don’t actually describe a condition, rather they just provide additional data.  

The chapter includes codes that begin with the letters V, W, X, and Y and they are broken up into 29 blocks, such as V90-V94 Water transport accidents, W00-W19 Slipping, tripping, stumbling and falls, and W50-W64 Exposure to animate mechanical forces.  There is no national requirement for mandatory external cause code reporting, but voluntary reporting is encouraged.  It may ...
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Q: We usually submit 97124 for massage, however, we were told to use 97112 for billing massage instead.  Is this a correct code?
A:  No.  The definition for 97112 is: Neuromuscular Reduction of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, 1 or more areas, each 15 minutes.
97112 is also defined as an "active" therapy which means the patient must be actively and physically participating in the therapy.  
A massage is a "passive" therapy in which the therapy is being provided to the patient vs the patient physically participating.  
Please reference your current year ChiroCode DeskBook for more information.  ...
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This chart defines the 2014 Medicare error rates.  Notably, chiropractic tops this chart with an Improper Payment Rate of 54.1%.  For further clarification, the chart also breaks down the common Types of Error that contribute to the Improper Payment Rate.  

This chart communicates a great message to providers and the chart content should be taken into consideration as providers work to make improvements in billing and documentation in effort to best protect their revenue cycle.  

Insufficient documentation by chiropractors was determined to be 92.2% of the provider errors which resulted in Medicare improper payments.   The other statistics provided on the chart are certainly of interest as well and should be evaluated by each practice as you work to make changes and improvements in coding, billing and documentation procedures within your practice.  

The 2016 ChiroCode DeskBook serves as a valuable resource to providers as you take steps to better understand documentation, codi...
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Q: A patient presents and the doctor discovers the patient has high BP.  Makes note of it in his chart.  On the second visit he checks the patient’s BP again.  Does that warrant a E/M code (possibly 99211 or 99212) or would that be included in the pre-assessment part of the CMT (98940-98943)?  
A: 99211 should not be billed separately on the same visit as a CMT.  The CMT is a more global procedure which includes components of the 99211.  If billed together, 99211 will be denied as "incidental to the primary procedure."
CMT services (98940-98943) have an E/M component built in to them.  Again, the provider may verify benefits with individual payers to determine if 99211 can be reimbursed separately on the same visit as a CMT service. 
With only the information prov...
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As in previous years, it is recommended that you hold all Medicare claims for up to the first two weeks in 2016. As of this time, Medicare has not released the new Physician Fee Schedule for 2016. Although the Sustainable Growth Adjustment has been repealed, the details of this correction has not been fully worked out. The new deductible for Medicare in 2016 is $166. 

On October 30, 2015, the CY 2016 Medicare Physician Fee Schedule (MPFS) final rule was published in the Federal Register. In order to implement corrections to technical errors discovered after publication of the MPFS rule and process claims correctly, Medicare Administrative Contractors will hold claims containing 2016 services paid under the MPFS for up to 14 calendar days, (i.e., Friday, January 1, 2016 through Thursday, January 14, 2016). 

As this subject develops, we will keep you informed as to the outcome. Medicare claims for services rendered on or before Thursday, December 31, 2015 are unaffected by the 2016...
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The 2016 PQRS Guidelines are available!  See the following link for your guidebook to successfully reporting PQRS in 2016.
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A common topic of interest in chiropractic practices includes the billing department and whether or not the primary duties of insurance claims submission would be best kept in-house or outsourced to a professional billing service.  Multiple factors weigh-in on this topic, and rightfully so.  Things that providers are, and should be considering, include the following:

Employee Role:  Do you have the right person/people for this job?  While data entry, coding, billing, collection and follow-up systems can be taught, the duties and responsibilities of this role must never be taken lightly.  The person or people in charge of this department are second in line to the doctor in keeping the practice doors open.  Additionally, the understanding and correct application of guidelines, attention to detail, efficiency, integrity, and communication skills necessary to manage this role will serve as significant protection for your practice.

Training:  What tools do you have and utilize to ensu...
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Q: What type of documentation is required for a Medicare patient with degenerative joint disease who gets adjusted once or twice a month for occasional flare-ups of the D. J. D. region? The noted adjustments give good relief of the patient's symptoms.

A:  These adjustments would be considered clinically appropriate, but they would not be considered medically necessary unless you could document functional improvement as a result of the adjustment. This type of care meets the definition of maintenance care, and should be documented as such.  The patient should be offered an ABN, and if they select option 1, Medicare should be billed even though payment is not expected....
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It is incorrect to assume that when insurance isn't involved, there are no rules that apply to discounts.  Time-of-Service (TOS) or Prompt Pay Discounts (PPDs) are a common occurrence in chiropractic.  According to the Office of the Inspector General (OIG), a prompt pay discount is "designed to reduce the health system's accounts receivables and costs of debt collection, and to boost its cash flow."  It's a discount that "bear(s) a reasonable relationship to the amount of collection costs that would be avoided."  The OIG advises that for PPDs there may be a greater discount for those that pre-pay, pay before leaving the office, or pay within 30 days.  However, a Time of Service (TOS) discount means the payment is made at the time service is rendered, as the name implies.  

What You Need to Know about TOS and PPDs:

First, each state makes the rules about these discounts and if they are even allowed.  The first step for any practice considering discounts should be to call their loc...
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Many specialties, including chiropractors, perform services that may be deemed "experimental, investigational and unproven."  Individual payer coverage determinations, as well as state boards, generally offer specific information defining this type of procedure and any other notice or guideline that providers must be aware of and adhere to.

The terms "unproven, experimental or investigational" are generically defined as:  A supply, procedure, therapy or device whose effectiveness has not been demonstrated  by required scientific evidence and properly authorized by governing entities in order to be acknowledged as medically effective for the improvement of function for specific conditions or treatment.  

To be clear, by being defined as "unproven, experimental or investigational", it does not imply that these procedures do not work.  It means that the required protocol and the scientific research and evidence have not been fulfilled and/or approved in order to qualify these proced...
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The following is an excerpt from the newly revised "Common Procedure Codes" section in the 2016 ChiroCode DeskBook.  In this chapter we have provided an explanation, coding tips, suggested diagnoses, and modifier guidance for all your top CPT codes.  If you find this sample helpful, make sure you order your own copy of the 2016 DeskBook.  Special pricing is still available until 12/31/2015.

97012 Traction, mechanical, one or more areas

The force used to create a degree of tension of soft tissues and/or to allow for separation between joint surfaces. The degree of traction is controlled through the amount of force (pounds) allowed, duration (time), and angle of pull (degrees) using mechanical means. Terms often used in describing pelvic/cervical traction are intermittent or static (describing the length of time traction is applied), or auto traction (use of the body’s own weight to create the force).
Coding Tips

This code may only be billed once per patient, p...
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Q:  We received a denial for mechanical traction (97012) stating that we must show FDA approval for our traction unit.  Can insurance require this?

A:  Yes, it is common and included within 97012 that the traction unit be approved by the FDA.  Many payor policies include this guideline as well and it is becoming more commonly enforced by payors.  If expecting payment, you must comply with standard coding and payor guidelines....
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Q: We cannot find codes to identify the left or right side of the spine, such as with low back pain. Do we add digits 1 or 2 to the code to clarify left or right?

A: No. Codes pertaining to the spine are not specific to laterality. The codes that do require laterality specificity are for the extremities. Do not add any characters or numbers to any codes that do not specifically require this in the coding instructions. This will result in erroneous coding and a rejection or denial. Please carefully review coding instructions before making an assumption that something on a code needs added....
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As The Lease Coach since 1993 and co-authors of Negotiating Commercial Leases & Renewals 

For Dummies, we have found that chiropractic tenants often overlook a great deal when 

negotiating a commercial lease renewal. One of the biggest mistakes is assuming that everything 

will go smoothly. Rarely do things ever go as planned and you always have to account for 

Murphy’s Law. Renewing your commercial lease takes just as much time, effort, negotiating 

expertise and careful consideration as your initial lease – if not more! The following are just five 

of the most common oversights we have witnessed of chiropractic tenants … please don’t make 

the same mistakes!

1) Renewing With No Deposit

If your lease agreement requires you to make a deposit for the initial lease term, then it is 

unacceptable for that deposit to continue indefinitely. Ask yourself, are you a security risk? 

Likely not! Have your rental payments been made on time? When The Lea...
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Most exams require a complaint or diagnosis of some sort of condition to justify medical necessity.  However, DOT exams are performed for administrative purposes, so it seems counter intuitive to list a diagnosis code.  It turns out that there is a whole chapter of codes that describe "contact with health services".  Chapter 21 codes all start with the letter Z and they explain reasons for encounters that are not due to a disease or injury.  

Z02 is the category for an "encounter for administrative examination".  A couple of good ones in there that might work for a DOT exam are:
Z02.1 Encounter for pre-employment examination
Z02.4 Encounter for examination for driving license
Z02.6 Encounter for examination for insurance purposes
Z02.89 Encounter for other administrative examinations

Always check with a specific payer, but remember that ICD-10 has code options for almost any circumstance. 
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Q: For Medicare, does a treatment plan have to be done on day one? What about waiting for X-rays?

A: You need to have a treatment plan before starting treatment. If the x-ray results change what you would do, then change the treatment plan accordingly when the results become available....
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The facet joints are a pair of joints in the posterior aspect of the spine.  Their proper name is zygapophysial joints.  These joints can become inflamed due to trauma or overuse and cause back pain.  This is called facet syndrome.  

Unfortunately there was no ICD-9 code for this condition.  However, diagnosis coding guidelines (in ICD-9 and ICD-10) inform us that codes with "other", "other specified", or "not elsewhere classified" in the description are for conditions that are not described elsewhere.  In ICD-9 this led us to use 724.8 Other symptoms referable to the back.  While this code said nothing about facets, it was still the most correct choice.

Unfortunately the GEMs mapping to ICD-10 for this code is M54.08 Panniculitis affecting region of neck and back, sacrococcygeal region.  This is defined as inflammation of subcutaneous adipose tissue, which is not consistent with facet syndrome.  This is a great example of how doctors who rely only on GEMs are headed for trouble....
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Q: Our Medicare contractor is auditing claims with 98942. Do you have any suggestions for a template for documentation to warrant the use of 98942?

A: Using the code 98942 indicates that you determined that it was medically necessary to adjust all 5 of the spinal regions. You documentation needs to reflect that fact, including that the patient had complaints in all five regions. The 98942 is a favorite target of auditors because many providers adjust full spine without establishing medical necessity for all five regions. Essentially, each area must have a patient complaint, relevant objective findings, a clear plan for resolution, and demonstrable progress....
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Q:  We are receiving denials for payors.  Our coding appears to be in order.  What could the problem be?

A:  The first thing to evaluate is the coding that you have selected.  We have received various coding examples from practices that are in fact using too many or too few numbers/characters on ICD-10 codes.  Please reference archived ChiroCode ICD-10 training webinars for a brief refresher on ICD-10 coding guidelines and how codes are to be selected.  

Secondly, if you are confident in your code selection, you should contact the payor directly to inquire.  Some payors have had obstacles with processing and if this is the case, you will need to learn what/if any steps are required on your behalf to ensure your claim(s) are reprocessed quickly and correctly.  
By contacting the payor, you may also learn that there is not a processing obstacle at hand but rather a policy guideline pertaining to ICD-10 that has been implemented which has caused your claim to be rejected or denied....
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As you know, the PQRS (Physician Quality Reporting System) includes the reporting of particular G codes to communicate with Medicare, details of the Functional Outcome Assessment and Pain Assessment and Follow-Up measures. These measures must be completed on at least 50% of an eligible professional's active patients to avoid penalty.  

Recently, letters have been sent out to practices informing practices that they have not satisfactorily reported those PQRS measures and therefore, a negative payment adjustment (penalty) will be assessed from 2016 Medicare reimbursements.  

If you have received one of these letters but do believe that you have satisfactorily reported PQRS through 2014, you must act now.  Medicare allows a small window of time (until 11/23/2015) for practices to request an Informal Review in which your PQRS reporting for 2014 will be re-evaluated.  

For instructions to request an informal review, please click here....
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Q:  When initially submitting for a Medicare patient, what is the rule for filling out box 14?  Also, what about box 15?

A:  Medicare requires that box 14 always be filled out.  Their rule though is that the date must be the date that the patient presented for care for the current complaint.  This differs from other carriers where Box 14 is usually to be dated with the date of the incident.   Box 15 is required to be left blank by Medicare.  Here is a link for the CMS claim form instructions:
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Separate Procedure
Not understanding this term results in confusion and frustration. The helpful CPT definition is:

“The codes designated as ‘separate procedure’ should not be reported in addition to the code for the total procedure or service of which it is considered an integral component.

“However, when a procedure or service that is designated as a ‘separate procedure’ is carried out independently or considered to be unrelated or distinct from other procedures/services provided at that time, it may be reported by itself, or in addition to other procedures/services by appending modifier 59 to the specific ‘separate procedure’ code to indicate that the procedure is not considered to be a component of another procedure.”

Routine muscle and range of motion testing is a component of a physical examination within the E/M service. However, in such routine examinations there could be findings that indicate a need for more definitive and quantifiable data. In suc...
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The official guidelines for ICD-10-CM define the conventions used in the code set.  In section 1.A.6, we learn the following about some common abbreviations in the Tabular List:

NEC “Not elsewhere classifiable” This abbreviation in the Tabular List represents “other specified”. When a specific code is not available for a condition the Tabular List includes an NEC entry under a code to identify the code as the “other specified” code.

NOS “Not otherwise specified” This abbreviation is the equivalent of unspecified....
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Q: Our Medicare contractor is auditing claims with 98942. Do you have any suggestions for a template for documentation to warrant the use of 98942?

A: Using the code 98942 indicates that you determined that it was medically necessary to adjust all 5 of the spinal regions. You documentation needs to reflect that fact, including that the patient had complaints in all five regions. The 98942 is a favorite target of auditors because many providers adjust full spine without establishing medical necessity for all five regions. Essentially, each area must have a patient complaint, relevant objective findings, a clear plan for resolution, and demonstrable progress....
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GEMs, or General Equivalence Mappings were created by the National Center for Health Statistics, CMS, and other industry groups.  Our book contains the official data.  The reason that many of the codes are unspecified is because the ICD-9 codes are not very specific, so it would be incorrect to map them to codes that don't match.  As such, we instruct coders to use GEMs as step one, then turn to the suggested code in the Tabular List.  It is here where someone with a little knowledge of the code set can confidently browse and select a more specific code, if available.  It is also important to apply the guidelines for each code, and these cannot be found in the GEMs data.  

GEMs are only approximations.  Using GEMs or other simple shortcut will regularly lead to codes that are not reimbursable.  The smart way to use GEMs is as step one.  Step two is to look up the suggestion in the Tabular List.  Step three is to browse nearby categories for better options.  Step four is to identify ...
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Q: What if my Medicare patient refuses to fill out the outcome assessment questionnaire?

A: The patient doesn't have to fill one out, but be sure to note it in your documentation and inform the patient that Medicare requires that you demonstrate functional improvement in order for them to determine if the care is medically necessary. In other words, the patient may have to pay for the care out of pocket if they don’t want to follow Medicare’s protocols.  Outcome Assessment Questionnaires are not technically required, but Medicare cares enough about them that they created PQRS measure #182 just to see if we use them.  ...
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There are two categories to choose from for spinal disc disorders:



Each one has the same fourth character options:

0= disc disorder with myelopathy

1= disc disorder with radiculopathy

2= other disc displacement

3= other disc degeneration

4= Schmorl’s nodes (not available for the cervical region)

8= other disc disorders

9= unspecified disc disorder

The fifth character provides detail about the anatomical location within that spinal region.

Here are a couple of tips to keep in mind when using these codes:

-It may be helpful to consider that “disc disorders” include protrusions, bulges, and herniation, and this is the term used for the fourth characters “0” or “1”. “Disc displacement” for the fourth character “2” also could include those things, but it does not include cord or nerve root complications.

 -Don’t code radic...
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Q:  What specifically are provider signature requirements?  Also, does a provider signature need to be time or date stamped to be official?


A:  There are very specific signature requirements to follow.  The link below provides each of those details for reference.  Also, no, there currently is not a requirement for the provider signature to be time or date stamped.  The last bullet on page 3 of the following link provides information on that specific subject.
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Applies to: Part B JE Claims Only (California, Hawaii, Nevada, American Samoa, Guam, Northern Mariana Islands)

Procedure Codes: 98940-98943

Background: Claims are denying when billed with a payable primary diagnosis code of M99.01, M99.02, M99.03, M99.04 and M99.05. Chiropractic Services Local Coverage Determination (LCD) L34242.

Noridian Action Needed: The LCD is being updated to contain the appropriate diagnosis codes. Once complete, Noridian will identify the claims denied incorrectly and adjust them.

Provider Action: NA

Date Reported: 10/14/15

Date Resolved:

Last Updated Oct 14, 2015...
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Q:  Do we need to populate each of the 12 spaces available for diagnosis?

A:  No.  There is not a distinct number of diagnosis required for claim submission.  However, you must use adequate and appropriate diagnosis to fully support each of the services rendered.

Q:  Do we need to add x's to ICD-10 codes to make each code 7 characters in length?

A:  No.  ICD-10 codes can be up to 7 characters in length.  Most codes do not require 7 characters.  The ChiroCode ICD-10 manual as well as the online tool has included all x's on codes where they belong.  If using one of these coding resources, you will not add additional x's to any codes.

Q:  Our claims are being rejected.  What is the reason for this?

A:  First, check each of your diagnosis used to ensure that you have not inappropriately added any digits or characters to a code that is not required by ICD-10 guideline and coding instructions.  Secondly, check to make sure that your software isn't including t...
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Sprains and strains were combined within a single code in ICD-9, but in ICD-10 they are separated into two distinct codes.  Injury codes in ICD-9 were grouped by injury type, but in ICD-10 they are grouped by anatomic location.  Note the organization of the blocks in Chapter 19.  The second character identifies the anatomic location.

Chapter 19. Injury, poisoning and certain other consequences of external causes (S00-T88)
 S00-S09 Injuries to the head
S10-S19 Injuries to the neck 
S20-S29 Injuries to the thorax 
S30-S39 Injuries to the abdomen, lower back, lumbar spine, pelvis and external genitals 
S40-S49 Injuries to the shoulder and upper arm 
S50-S59 Injuries to the elbow and forearm 
S60-S69 Injuries to the wrist, hand and fingers 
S70-S79 Injuries to the hip and thigh 
S80-S89 Injuries to the knee and lower leg 
S90-S99 Injuries to the ankle and foot  

For most of these blocks, the third character is the one that designates the type of injury.  The "3" is for spra...
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Modifiers are used to help describe the encounter, and used to further explain the procedure to the payer. Modifiers will be used if the procedure does not fit or clearly explain the entire encounter.  

There are two types of modifiers:

Informational modifiers that do not impact reimbursement
Pricing or Payment modifiers that always impact reimbursement
Claims processing requires the pricing modifier in the first position to be processed correctly.

There are two levels of modifiers used to alter a procedure

Level I Modifiers – CPT modifiers are two digits and updated by the AMA (American Medical Association)
Level II Modifiers – HCPCS modifiers are alpha numeric characters and are updated by CMS.
Modifiers are used to help describe the encounter, and used to further explain the procedure to the payer. Or if the procedure does not fit or explain the entire visit. Some of the common reasons for using a Modifier may be:
 The procedure was more complicated than anticip...
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Q: What are the essential differences between ICD-­9 and ICD-­10?

A: The biggest difference is the appearance of the codes. They are alphanumeric and up to seven characters long. There are five times as many codes because ICD­-10 includes things that were not part of ICD-­9, such as anatomical details, laterality, and encounters or episodes of care. But the codes are still grouped into chapters, separated by body system, or condition. And they are still organized into three character categories of related conditions, and these characters are followed by a decimal....
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Chiropractic’s favorite word finally gets its due in ICD-10-CM…or does it?

There is a word that has long been held as sacred to the Chiropractic profession.  It is the so-called vertebral “subluxation.”  Medicare defines it reasonably well on behalf of the chiropractic profession:
“A motion segment, in which alignment, movement integrity and/or physiological function of the spine are altered although contact between joint surfaces remains intact.  For the purposes of Medicare, subluxation means an incomplete dislocation, off-centering, misalignment, fixation, or abnormal spacing of the vertebra anatomically.”

A recent OIG report about chiropractic says:
"Medicare requires that chiropractic claims have a primary diagnosis of “subluxation” for payment, but there is no diagnosis code that contains the word “subluxation.” CMS has instructed chiropractors to use the diagnosis codes that indicate nonallopathic lesions of the spine."

These were the 739 codes ...
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Q: Any warnings about crosswalks from ICD­-9 to ICD­-10?

A: Crosswalks based on the GEMs (General Equivalence Mappings) database will often point to unspecified codes, or offer only the “A” as the seventh character when there may be many more options. Medicare has warned providers not to code directly from crosswalks. Rather they suggest that coders look up the main terms in the alphabetic index from the provider documentation. Regardless, crosswalks can be a useful first step. Once they provide an approximation, the coder can then go to the tabular list to confirm the code.  The ChiroCode ICD-10 book contains GEMs for the codes chiropractors are most likely to use.  Readers can then turn to the tabular list to track down the specific code....
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An effort to decrease abuse of filling for procedure codes, the National Correct Coding Initiative NCCI) edits were developed by the Centers for Medicare and Medicaid Services (CMS).

The NCCI edit program is used by carriers and third party administrators in an effort to thwart abusive billing practices of codes that should not be used together.

For doctors of chiropractic, three common therapeutic procedure codes are identified by the edits when billed with chiropractic manipulative treatment (CMT) codes: 98940, 98941, and 98942. These procedure codes are 97112 neuromuscular re-education, 97124 massage therapy, and 97140 manual therapy.

Exceptional circumstances

There are exceptions to the NCCI edits. One is when the 59 modifier is used to indicate to the carrier that a “distinct procedural service” is involved and the procedures should be paid separately. Unfortunately, the 59 modifier is also an oft-abused and erroneously used modifier. This prompted CMS to release n...
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Depending on the publisher, there are about 30 pages of guidelines in the ICD-10-CM code set. The bulk of these guidelines, from section 1.C, are chapter-specific.

Chiropractic physicians typically use codes from just four or five of the 21 chapters available in ICD-10-CM. These include, but are not necessarily limited to, the codes from Chapter 6 (Diseases of the Nervous System), Chapter 13 (Diseases of the Musculoskeletal System and Connective Tissue), Chapter 18 (Symptoms, Signs and Abnormal Clinical Findings, not Elsewhere Classified), and Chapter 19 (Injury, Poisoning and Certain Other Consequences of External Causes). Unlike many other healthcare professionals in larger clinic systems, chiropractic doctors rarely have certified coders or staff with any specialized coding training. They are compelled to learn coding and keep up with changes while still running their business and keeping their clinical skills sharp. Reflecting an effort to make it easier for these small clinics,...
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Q: How can the staff start running simulations with active patients as they will code from Oct. 1?

A: Ideally, office software should have the capability to assign both ICD­9 and ICD­10 codes to existing and future patients. And the software should be able to know to use the ICD­9 codes for all dates of service before October 1, and the ICD­10 codes for dates of service after October 1. That way all the cases are already coded for ICD­10 prior to the implementation date. And, as mentioned previously, the provider should make sure documentation supports the codes selected....
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Q: On Oct 1, practices should change patient records to ICD­10 codes and remove all ICD­9 as inactive DX codes. Are there any other “First day” musts?

A: Billing software will hopefully allow providers to add the new codes ahead of time. The only thing that will need to change on the first day, from a billing perspective, is which codes appear on the claim. And this should be automatic. In other words, Wednesday, September 30 should not be that different for office staff than Thursday, October 1 (for those who prepare properly). It may be wise to submit all claims at the end of the day September 30, just to start the next day with a clean slate. Providers should not need to do anything different if they gradually improved documentation during the months and weeks leading to October 1....
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Chapter 19 of the ICD-10 code set covers injury, poisoning, and certain other consequences of external causes.

While chiropractic physicians will primarily use the chronic and recurrent musculoskeletal conditions from Chapter 13, Diseases of the Musculoskeletal System and Connective Tissue, there are several relevant codes from Chapter 19. They include acute musculoskeletal conditions such as sprains and strains of the spine, codes that will be used frequently by chiropractors. They are easily identifiable because they begin with the letter “S.” These codes require the addition of a seventh-character extension that specifies the episode of care or encounter.  Though this information was not relevant to ICD-9 code selection, it must be documented if these codes are used.

The three choices for most of the “S” codes that will be used by chiropractors are:

A: Initial encounter

D: Subsequent encounter

S: Sequela

The official guidelines (with a few changes for 2014)...
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Q:  I have recently started working with a chiropractic practice and am responsible for billing insurance.  I don't have a lot of experience with billing but am concerned that some of the codes we are submitting are incorrect.  I have questioned the doctor about this who just says it's what the office has always used for billing.  I have two questions about this:
1.  Where or how can I find out for sure if we are billing correctly?
2.  If we are not billing correctly and the doctor will not agree to make corrections, am I liable since I am the one doing the data entry and billing?
A:  To address your questions:
1.  Using your current ChiroCode DeskBook, you can review each of the code definitions in comparison to the manner the codes are being used in your practice.  This will give you a very good idea if the codes are being used properly.  Certainly, you would want to review all codes used, including CPT, HCPCS, modifiers and ICD-9 diagnoses.  
If you aren't com...
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As a reminder, because Work Comp and Personal Injury payers are not governed by HIPAA, they do get to elect on an individual basis whether or not to transition to ICD-10 diagnosis as of 10/01/2015.  

Providers are urged to contact those Work Comp and PI payers as soon as possible so as to determine which diagnosis code set must be included on claims.  Understand that without this information, claims submit with the incorrect diagnosis code set will be either rejected or denied, affecting your practice cash flow and creating additional work for your billing personnel.  

ChiroCode has reached out to a few of these payers for you and the information collected is as follows:

State Farm Insurance:  Will transition to ICD-10 on 10/01/2015.  All claims submit with ICD-10 will be processed accordingly.  Additionally, State Farm will continue to process as usual, all claims submit with ICD-9 diagnosis for an indefinite period of time.  

American Family Insurance:  American Family In...
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Q:  My average monthly collections has been way off these past couple of months.  It's lower than average although my practice doesn't seem slower and patient visits are still average of what is expected.  Do you have any ideas or suggestions for why this might be happening?
A:  This question could really expand into a much longer conversation because there are multiple possibilities.  However, to give you a few suggestions to consider, see below.  Either way, it is good that you have noticed this fairly early and can investigate and correct the issue.  It is highly recommended to do a thorough evaluation now and not wait to see if things go back to your expected normal.  Some possibilities for the decline in cash flow include:

1.  Have you recently had a staff change?  Particularly a billing person or front desk person?  If so, this could be an indicator that there is a meeting and training necessary to ensure that required systems in billing or at the front desk are being appr...
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Here we go! CMS has released the End-To-End testing results and they are ready to accept your ICD-10-CM/PCS claims.  They announced they had an 87% acceptance rate, stating “Most rejects were the result of provider submission errors in the testing environment that would not occur when actual claims are submitted for processing”.

CMS stated there were no new ICD-10 related issues in any of the Medicare Fee-For-Service claims processing systems and no rejects due to front end CMS systems issues.

Any issues they encountered in the last end-to-end testing which was in July 2015, were resolved before this last testing began.

Below are the results of the last end-to-end testing on the 29,286 test claims received.

•25,646 test claims accepted

•87% acceptance rate

•1.8%of test claims were rejected due to invalid submission of ICD-10 diagnosis or procedure code

•2.6% of test claims were rejected due to invalid submission of ICD-9 diagnosis or procedure code

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The Medicare LCD (Local Coverage Determination) is an excellent and necessary tool for appropriate Medicare coding.  Medicare LCDs are also excellent tools for training as they contain a comprehensive list of ICD-10 codes that are anticipated to be commonly used among payers for chiropractic services.  

Each state or region has established the Medicare LCD that is specific to that area.  To avoid Medicare billing errors, providers should obtain their local LCD now and familiarize with those ICD-10 codes that are approved by Medicare.  

Every Medicare Contractor has published the "Future" LCD for ICD-10 which will go into effect on 10/1/2015.  To obtain your Medicare LCD, you may simply search the Medicare Coverage Database or visit the website to your local Medicare Contractor and follow the tab labeled 'LCDs'.  

To save your valuable time, ChiroCode has done this for you!  Note that all Medicare Contractors have posted LCDs except for Palmetto GBA.  See the following itemizat...
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Q:  We are considering transitioning over to EHR but it seems like a large transition and we are hesitant to make this change.  Do you have any recommendations?
A:  Yes.  ICD-10 is scheduled to be implemented this coming October 1, without further delay.  This too is a significant transition which comes with the expectation of learning curve that will undoubtedly take extra time and attention.  Those practices that have already or are currently making the transition to an EHR system are not only allowing themselves more efficiency with this transition but also minimizing the overwhelm.  For practices that decide to wait and transition to an EHR system later this fall or early next year may find themselves in complete overwhelm by taking on two large projects at the same time.  It will be impossible to avoid errors, struggle with learning and make the implementation process more difficult than necessary. 
For those that have not transitioned yet, now is a great time.  We are nearin...
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Keep in mind not every ICD-10 will have a character for every place in the code, but may require a seventh character. Codes may not have a fourth, fifth or perhaps even a sixth place, yet a seventh character may still apply. So how is this addressed? To be sure the characters are in the correct position you will use a place holder “X”. Codes can even start with an X (i.e., X00-X009).

The location of the X is very important as well as lower case and uppercase. If the x place holder is used as fourth, fifth or sixth character it needs to be lower case. If it is used at the beginning of a code it must be uppercase indicating the chapter.

ICD-10 Guidelines Placeholder character

The ICD -10-CM utilizes a placeholder character “X”. The “X” is used as a placeholder at certain codes to allow for future expansion. An example of this is at the poisoning, adverse effect and underdosing codes, categories T36-T50.

Where a placeholder exists, the X must be used in the proper ...
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Proper chart note necessitates documenting both the quality and quantity of pain, must this be done on every single visit when you are seeing the patient over a series of scheduled visits? By the same token, must documenting the daily treatment plan always include purpose and time, etc.

Any relevant subjective changes should be documented at each encounter.  Completing the Verbal Numeric Rating Scale and documenting it at every visit is quick, easy, and satisfies PQRS Measure #131.  While this might not change from one visit to the next, it could easily change before a re-exam scheduled two weeks out.

For typical daily visits we recommend that you note any variation from the plan and the response of the patient.  In other words, I don't think it is necessary to repeat the plan at every visit.  Instead, you reference it, which allows you to submit the plan should you receive a records request.  This keeps the daily notes concise, but still provides the detai...
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The sprain and strain codes offer three choices for the final character:

A - initial encounter
D - subsequent encounter
S - sequela

The "A" and the "D"  might be used by payers three ways:

1)The "A" for "initial encounter" applies only to the first visit, and the "D" for "subsequent encounter" is used for all visits that follow.
2)The "A" is used for the first few weeks, while the patient receives passive modalities, then the "D" is used when rehab/exercises begin.
3)The "A" is used for all treatments during the course of care, and the "D" would be applied if the patient switched to "maintenance care".

At this time, it is believed that the third scenario is most likely because the guidelines define "A -Initial encounter" as care that is considered "active treatment", which is similar to the AT modifier requirement for procedure codes.  And the "D - subsequent encounter"  is defined as "aftercare" or "follow-up" which is similar to the definition for "maintenance care". ...
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By: Jeff Grandfield and Dale Willerton - The Lease Coach

When The Lease Coach spoke at Parker Seminars in Las Vegas, we met a number of struggling chiropractors leasing commercial space. These chiropractic tenants desperately need a rent reduction ... right now. With whatever size of practice, business expenses are continually increasing and the high cost of leasing space is closing in on tenants. This can be due to any number of extenuating circumstances which you may have no control over (Obama healthcare as it relates to insurance coverage, for example). Your monthly rental payment to the landlord is one of your biggest monthly expenses. Therefore, reducing this monthly lease payment is imperative for practices like yours to stay viable.
If you were approaching the end of your lease term there would be hope for a rent reduction on the lease renewal. Unfortunately, many chiropractic tenants find themselves in trouble somewhere mid-term into a five- or 10-year lease agreement. If ...
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Q: We would like to offer cash discounts but are unsure how to best do this. Do you have a recommendation?
A: Yes. The OIG has issued an advisory stating that discounts in excess of 15% are considered excessive. This must be taken into consideration as well as any state guidelines that may be in place for you. To learn this information, you would need to contact your state Chiropractic Association and/or your state Chiropractic Board of Examiners. There are often unclear rules regarding discounting or in some states it is prohibited or advised against. Not only for liability purposes but also to ensure compliance with local and federal guideline, we recommend practices to work with a DMPO (Discount Medical Plan Organization) to properly and legally establish your discounted fees. We recommend ChiroHealthUSA (CHUSA). They offer free webinars with a lot of useful information. Even if you don't use the DMPO, you can be assured that you will learn some great information by listening to...
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The time left until the official implementation of ICD-10 on October 1, 2015 is rapidly passing.  Providers and staff that have been proactive in taking necessary steps to best prepare for ICD-10 are going to be those with the greatest advantage post implementation.  The ICD-10 transition is drastically affecting the entire industry; providers, clearinghouses, software, payers, auditors, etc.  Due to this, it is anticipated that not only is there the possibility of provider errors, but also payer or other affiliated errors as well.  The result...potential claims delays, denials, rejections, request for records/audits, decreased cash flow, increase of Accounts Receivable, and more.  

That being said, it is important to know that by chiropractic offices simply being proactive NOW, the likeliness of post-implementation issues can be reduced.  See the following bullets for some pre ICD-10 tips to help minimize your risk on and after October 1.  

Doctors must be involved.
In the past...
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Q:  Our office commonly bills 97012, 97112 and 97530 in addition to the adjustment (98940-98942).  Recently we have been receiving denials on these services from a few payers.  The only code that is being paid is the chiropractic adjustment.  This has never happened before, can you tell me why it might be occurring now?
A:  There will be a denial code on each EOB next to each denied service.  These denials codes are explained in a key provided at the bottom of the EOB or sometimes on the back side.  This would be the easiest and fastest way to determine why you might be receiving denials on these services.  Another option would be to call the payers directly and inquire.
However, based upon your question, there are a few likely possibilities for as to why you are being denied.  Of course, having not seen the EOB's, please note that these are only briefly described possibilities that you may wish to look into.
1.  It's possible that you do not have sufficient diagnoses to support ...
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Q:      Question about 97140.  Is it possible to bill 97140 and receive full compensation for this code performed to the same region as the CMT if the Myo is performed by another person—i.e. massage therapist.  
A:   According to NCCI, CPT 97140 and 98940 can be performed on the same area when delivered during "separate encounters" with the same patient. Two definitions have been provided: 1) Different providers perform the two procedures on the same date of service. For example, if a PT performed the adjudicative physiotherapy procedure and a chiropractor performed the adjustment, it would qualify as a separate patient encounter. This rule includes ONLY licensed providers, such as chiropractors, physical therapists and does not include chiropractic assistants; 2) The same provider performed the two procedures during a second visit on the same date of service. In this case the patient would receive his or her chiropractic adjustment during a visit in the morning, and physical th...
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By Jeff Grandfield and Dale Willerton – The Lease Coach

When The Lease Coach speaks at chiropractic conventions (such as Parker Seminars in Las Vegas), we are magnets for commercial leasing-related questions. Among the most common are concerns relating to assigning or transferring a Lease Agreement. 
As we explain in our new book, Negotiating Commercial Leases & Renewals For Dummies, the most common reason for assigning a lease agreement is to facilitate the sale or purchase of your practice. The assignment clause is one of the most vital organs of a lease agreement and should be included in the offer to lease. Read this carefully. Just because the landlord agrees to give assignment rights to a tenant doesn’t mean they can’t build in many tricky and dangerous conditions that can trip you up or cost you money later. 
One chiropractic tenant selling a practice and assigning or transferring their lease agreement to another chiropractic tenant is not typically a benefit to the l...
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Q:  We are struggling to select the correct new patient exam (99201-99205) and re-exam codes (99211-99215) for our patients.  Is there a resource to help us choose the correct code?

A:  Yes.  Actually, the 2015 ChiroCode DeskBook expanded significantly on this section from what you have seen in previous years editions.  Pages H21-H34 of the 2015 ChiroCode DeskBook contain information, tips and examples to help you fully understand how to best code for new patient exams and re-exams.  
Compliance guidelines require a practice to know which set of documentation guidelines they are using.  There are two sets of guidelines known as the 1995 E/M guidelines and 1997 E/M guidelines.  A provider is free to follow the guidelines that he/she deems most applicable to an individual patient visit, though the two sets cannot be combined.  This topic should really be expanded upon to fully explain the 1995 and 1997 E/M guidelines so please watch for future ChiroCode Alerts where we will provide m...
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A Practice's Responsibility in Managing Medical Expenses

Medical expenses are one of the largest expenses in many United States households. Medical bills and insurance remittance are also possibly the most difficult of all bills for patients to interpret and understand. 

Of course, this lack of understanding often has a negative impact on many things, such as: provider/patient relationship, provider or practice reputation, patients discontinuing care and possibly even legal ramifications for the practice, if errors or fraud are suspected or discovered. By evaluating some fundamental steps, we can help to minimize the concern and confusion that often occurs with patients regarding their medical expenses in our practices.

There is a great need for the improvement of communication with patients. Additionally, many practices should address the proper management of all billing and collections related efforts. By doing this, you are certain to improve the quality of the patient expe...
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Q:  I was told that the United States is one of the last countries to implement ICD-10.  Is this true?  If so, why does is it so complex for the US if we can learn from other countries and avoid the issues they encountered?

A:  Yes, this is true and we (the United States) have had the opportunity to learn from the mistakes and obstacles faced by other countries.  That has allowed those planning for and aiding with the implementation of ICD-10 here in this country to minimize the risk of facing some of those same obstacles.  
There are multiple reasons for why the U.S. is implementing ICD-10 later than many other countries.  A couple of those reasons include:  
1.  Expense.  The expense of ICD-10 preparation and implementation is extreme.  Not only is this expensive for providers in small practices, large practices, hospitals, etc, this is also extremely expensive to 3rd party payers, software vendors and other affiliates such as insurance clearinghouses, etc.
2.  Anot...
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Q:  Do you know when the Medicare LCDs will be available for ICD-10?

A:  Medicare Contractors have already began to publish ICD-10 LCDs (Local Coverage Determination) to individual Medicare Contractor websites.  These LCD's are posted as "Future" LCDs and will not be implemented until 10/1/15.  
To obtain your own LCD, visit your local Medicare carrier website or you can also find these posted here at the primary CMS website.  As a reminder, you are going to find chiropractic LCDs posted in the MAC-Part B category of the CMS website linked above.  
Currently, it appears that most Future LCDs are posted with the exception of those states that have the Medicare Contractors of Palmetto GBA and WPS (Wisconsin Physician Services) Medicare.  For those practices that submit claims to Palmetto GBA or WPS Medicare, do continue checking the websites for those LCDs to be posted.  

Some ICD-10 Medicare LCDs (Local Coverage Determination) are posted to MAC websites.  Check your l...
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Buying vs. Leasing Commercial Practice Space: Pros and Cons for Chiropractic Tenants

As we explain in our new book, Negotiating Commercial Leases & Renewals For Dummies, the most common reason tenants lease space instead of buying a location is because 95 percent of all commercial and office space is for lease and not for sale. 

If you are in an enviable position to purchase property there are several opportunities available to you: a business condo where you occupy the one unit, a strata title unit, small strip plazas or centers where you’re now a landlord to other tenants as well, or standalone buildings on a small parcel of land. Major factors that impact this decision for the average tenant are the long-term commitment of purchasing a building and the ability to obtain the financing. 
For those chiropractic tenants able to purchase, here are a few pros and cons to consider. 


Paying a mortgage is better that paying rent. Lease payments are forever, but your mort...
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Q:  We usually submit 97124 for massage, however, we were told to use 97112 for billing massage instead.  Is this a correct code?
A:  No.  The definition for 97112 is: Neuromuscular Reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities, 1 or more areas, each 15 minutes.
97112 is also defined as an "active" therapy which means the patient must be actively and physically participating in the therapy.  
A massage is a "passive" therapy in which the therapy is being provided to the patient vs the patient physically participating.  
Please reference 2015 ChiroCode DeskBook pages H18 and page H78 for more information.  
The rule of coding requires that the code selected must be the one that most accurately describe the service being provided.

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Recovery Audit Contractors, also known as RAC, is a program that seeks to identify and correct improper payments for services provided to Medicare Parts A & B beneficiaries. This includes both recoupment of overpayments and corrected distribution of underpayments made by CMS.  

RAC began in 2005 as a three-year demonstration project consisting of a limited number of states where abuse of the Medicare Trust Fund was known to be elevated. Due to overwhelming success in just these few states, the Secretary of Health and Human Services was required to transition this to a permanent program in 2006. 

The duties of a Recovery Audit Contractor (RAC), like in its name, has the purpose of determining what they would consider to be improper payments and recovering those funds from providers.  

    There are three types of reviews conducted byaRAC which is defined in the following:
        Automated Review (no medical record needed)
        Semi-Automated Review (claims review using da...
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Is ICD-10 required to be used for services provided starting October 1 or for claims submitted starting October 1st?

ICD-10 IS TO BE USED FOR ALL SERVICES PROVIDED ON OR AFTER 10/1/2015. SERVICES PROVIDED PRIOR TO THIS IMPLEMENTATION DATE WILL USE ICD-9.  Again, providers are encouraged to submit claims on the last business day of September so visits starting 10/1/15 can be coded with the appropriate code set ICD-10.  

Here is a reference for your records:

However, it should be noted that there are a few groups petitioning to allow for a "dual reporting" transition period.  Although this currently appears to be an ongoing discussion it doesn't look like these groups will be successful (see HR 2247).  

Be sure to read future ChiroCode alerts for updates.  Also, visit for ICD-10...
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Q:  How do I figure out how much a Medicare patient should pay if I know some services are covered and some are not? Should I have the patient sign an ABN and collect the Medicare copayment and also collect for services not covered by Medicare. Note: Our office does not accept assignment on Medicare 
A:  The only covered services for Chiropractic are 98940, 98941 and 98942 and coverage is only available when the patient is receiving Active Treatment (AT) and not available for maintenance care.  All other services and supplies provided to the patient in your office are the responsibility of the patient.  You would charge these services at your regular standard rate just the same as all other patients.  
That said, if the patient has an actual secondary policy in which there is additional coverage available (this is not terribly common but does occur periodically), these other services may be billed to the secondary payer for processing but you must have the Medicare denial in or...
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Question: When there is a primary and secondary insurance, which one do I collect the co-insurance or co-payment from, the primary or the secondary?

Answer: It would depend upon the patient deductible and status of the deductible being met as well as the amount of co-insurance or co-payment for both the primary and secondary payers.  Once both deductibles are met, depending upon coverage and benefits, the patient may end up not having to pay any co-insurance at all and if they owe a co-payment instead, it may be the lesser co-payment fee of the two policies.  Unfortunately, this varies entirely based upon individual policy coverage, benefits, deductibles, etc. but can be easily determined.  Please see the reference link for this response for examples.
If both deductibles are met and you're uncertain what to collect, the best thing to do to start with is to collect co-insurance for the payer that is the lowest.  This way, the practice is still collecting something from the patient a...
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