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2013 AAPC 2480 South 3850 West, Suite B Salt Lake City, Utah 84120 800-626-CODE (2633), Fax 801-236-2258 www.aapc.com AAPC Workshops Mastering Documentation Review

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2013AAPC2480 South 3850 West, Suite BSalt Lake City, Utah 84120800-626-CODE (2633), Fax 801-236-2258www.aapc.com

AAPC Workshops

Mastering Documentation Review

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Mastering Documentation ReviewBy: Yvonne D Dailey, CPC, CPB, CPC-I

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ii AAPC 1-800-626-CODE(2633) CPT®copyright2012AmericanMedicalAssociation.Allrightsreserved.

Introduction

AAPC Disclaimer This course was current when it was published. Every reasonable effort has been made to assure the accuracy of the information within these pages. Readers are responsible to ensure they are using the codes, and following applicable guidelines, correctly. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free, and will bear no responsibility or liability for the results or consequences of the use of this course. This guide is a general summary that explains guide-lines and principles in profitable, efficient health care organizations.

US Government RightsThis product includes CPT®, which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995), as applicable, for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provision of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

AMA DisclaimerCPT® copyright 2012 American Medical Association. All rights reserved.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT® is a registered trademark of the American Medical Association.

The responsibility for the content of any “National Correct Coding Policy” included in this product is with the Centers for Medicare and Medicaid Services and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, nonuse or interpretation of information contained in this product.

About the AuthorYvonne founded Dailey Billing Services, in 2001 to provide electronic medical billing services and has over 10 years experience in the medical billing and coding field. As a Certified Professional Coder (CPC) she teaches her clients the “key role” for correct coding and documentation and its affect on the reimbursement process. She has experience as an adjunct instructor for business schools in her area and is currently PMCC instructor providing seminars for physicians, their staff and new coders. She is a past President for Monmouth Ocean and Toms River local chapters, and AAPC National Advisory Board for 2007–2009.

Notice Regarding Clinical Examples Used in this BookAAPC believes it is important in training and testing to reflect as accurate a coding setting as possible to students and examinees. All examples and case studies used in our study guides and exams are actual, redacted office visit and procedure notes donated by AAPC members.

To preserve the real world quality of these notes for educational purposes, we have not rewritten or edited the notes to the stringent grammatical or stylistic standards found in the text of our products. Some minor changes have been made for clarity or to correct spelling errors originally in the notes, but essentially they are as one would find them in a coding setting.

© 2013 AAPC2480 South 3850 West, Suite B, Salt Lake City, Utah 84120800-626-CODE (2633), Fax 801-236-2258, www.aapc.com

All rights reserved.CPC®, CPC-H®, CPC-P®, CIRCC®, CPMA®, CPCO™, and CPPM® are trademarks of AAPC.

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Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

MedicalBillingCycleProcess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

InsuranceVerificationandPatientDemographics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Case1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

SampleofMedicareandMedicaidHealthcareIDCards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

ProviderDocumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Case2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Case3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

CodeLinkage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Case4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

ApplyingModifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Case5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

ChargeEntry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

AetnaPolicy............................................................................ 24

LCDL27480-ChiropracticServices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Case6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

ClaimSubmission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

Case7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

CommonBillingErrors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

AccountsReceivableFollowUp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

DenialManagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

Appeals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Case8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Case9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Case10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Reporting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

Conclusion.....................................................................51

HealthInsuranceClaimForm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

Suffixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

SlidePresentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

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IntroductionIn modern healthcare practice, the provider, coder, and biller must work together to ensure compliance and a healthy rev-enue cycle. During this session, you will learn to identify errors that will effect reimbursement and compliance. We will review the entire patient medical record. Documentation is not limited to the provider’s progress note. Every piece of paper in the patient’s chart—from the copy of the insurance card, to the patient registration, to billing charge tickets and any diagnostic test order requests—is part of the “medical documentation,” and contributes to the billing process.

Specifically, the session will cover:

z Medical billing cycle processes z The most common deficiencies in documentation z The importance of linking the codes correctly z Missing elements during charge entry z How to handle denials, and tools to use z Putting all the pieces of the revenue cycle together

Throughout the presentation, we will review cases to determine errors or missed revenue opportunities. You will be pro-vided time to review the case on your own and your presenter will review each case with you.

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MedicalBillingCycleProcessThe medical billing cycle consists of 10 steps:

1. Insurance verification2. Patient demographics3. Provider documentation4. Coding – CPT®, ICD-9-CM, and HCPCS Level II5. Charge entry6. Claim submission7. Payment posting8. A/R follow up9. Denial Management

10. Reporting

Every step must be successful if a claim is to be paid. Coordinating provider documentation (step 3), coding (step 4), and claim submission/billing (step 6) is especially crucial. In practices with separate coding and billing departments, the two must communicate. For instance, coders must be told about denials due to coding errors. One of the most detrimental things a practice can do is write off denials without researching, correcting errors, and appealing payer mistakes.

To understand how the 10 steps of the medical billing cycle tie together, we must first understand the role each of us plays in the success of the revenue cycle.

Role ResponsibilitiesReceptionist/Scheduler Schedule patient appointments

Greet the patient

Verify insurance and eligibility

Discuss insurance coverage with the patient

Provider Perform patient encounters

Document the patient’s condition and treatment plan in the medical record

In some practices, select the codes for billing

Medical Coder Interpret the medical record based on the documentation Depending on the practice, they may add modifiers and procedures

Charge Entry Clerk / Biller Verify case information for accuracy for claim submission

Submit claims

Payment Clerk Apply all payments received to patient account (this includes zero payment EOBs)

Account Representative Research denials/rejections, processes corrections, resolve insurance billing or payment problems, and establish payment plan with patient

Administrator Generate and review reports to support the billing process: Reports include daily, weekly, monthly, quarterly and yearly tasks

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Insurance Verification and Patient DemographicsUsually, front desk personnel verify insurance and patient demographic information. This is vital to the revenue cycle.

When a patient walks through the door, reception is the first point of contact. Patients will complete neces-sary paperwork and return it to the receptionist. The patient’s identification and insurance card must be copied and placed in the chart. These should be verified at each encounter. Instead of asking, “has anything changed,” ask the patient specific questions. For example: What are your home address and your current insurance? If the patient is a returning patient, verify the insurance with the informa-tion you have on file prior to the patient’s appointment, so you can review and correct any discrepancies.

Be sure reception reviews the documents for accuracy and legibility. Failure to do so can cause billing and compliance issues. And if reception is not able to read the documents, neither will the charge entry person.

Example

The practice has two patients with very similar names. One is named Rafael Lewis Gonzales and the other Rafael Luis Gonzales. Both patients were born 8/4/1990.

Rafael Luis Gonzales was seen today; however, no one recognized that the charge ticket the receptionist printed to accompany the chart was for Rafael Lewis Gonzales. As a result, the office billed for the wrong patient. This can cause a number of issues for the practice and the patient. There is a very good chance the patients are treated for different conditions. By submit-ting the claim for the wrong patient, you are diag-nosing him with a condition he does not have. It can also cause the patient not seen to receive a bill that is not his or her responsibility. Car-rier EOBs may alert patients to fraudulent bill-ing. This type of bill would be considered fraud because the patient was not seen.

The error will also cause an administrative burden for the office. If the error is found, the practice must refund for the patient that was not seen, and bill for the patient who was seen. Hopefully timely filing would not have passed by the time the error was discovered. If the mistake were uncovered in an audit, it would be a nega-tive audit finding.

Another error that can occur if insurance verification is not performed correctly prior to the patient being seen, is collection of the incorrect copayment amount. Copays are increasing; with some carriers, the copays are as high as $60. And the copay may differ between a primary care physician (PCP) and a specialist.

Example

A GYN provider is often considered a PCP, rather than a specialist. If you collect the specialist fee, but the carrier views the GYN as a PCP, you are placing your practice at risk because you have now collected more than that to which you were entitled.

The receptionist should collect the copay at the time of service. Sending statements for copays becomes costly: In some cases, it will cost you more to send the statements then you will collect for the copay. According to payer con-tracts, the practice is required to collect the copay. Failure to collect the copay is considered fraud because your office agreed to collect the copayment when the contract was signed.

Often, a new provider is not yet credentialed, but is seeing patients. This should not occur. When bringing on a new provider, it is crucial that he or she is credentialed as soon as possible, so you do not delay payment. If the patient doesn’t have out-of-network coverage, and sees a provider who is not credentialed, the service is technically non-billable. It is fraudulent to bill the service under another provider’s name. Only the treating provider (or a mid-level provider following incident to rules, when appropriate) may bill the claim.

Some HMO plans require the patient to see a certain PCP. If your provider is not the listed PCP, the claim will be denied or process incorrectly such as being processed out of network or as a specialist. The patient would need to con-tact his/her insurance and request to change PCP before being seen. Allow the patient to use the phone at the office to make the call, so that the service may be billed.

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Case 1Date:5/25/2015

Name:JaneDoe

Patient’s PCP:JamesSmith,MD(InternalMedicine)

CC:PatientpresentswithSTDevaluation

HPI:15-year-oldfemalecomesinandstates“myboyfriendcalledmeandtoldmehewenttoaPlannedParenthoodclinicandtestedpositiveforherpes”

ROS:

Constitutional:deniesweightchangeorfatigue

GI:deniesdiarrhea

Allergies:cats,dust,grass

Psych:depression

PAST Medical/Family/Social History

Medical History:Vaccinationsreviewed,irregularmenstrual

Family:ovariancancer-grandmother

PHYSICAL EXAMINATION:

BP120/60Ht5’1Wt:125

Examperformedwithnursepresent

GeneralAppearance:MildDistress

Heart:Regularrateandrhythm,noextraheartsounds

Respiratory:Lungscleartoauscultationbilaterally

Extremity:Normalrangeofmotion

PLAN:

Orderlabs

GenitalCulture:Routine

VDRLSerum

DIAGNOSIS:

ExposuretobodilyfluidsV15.85

PROCEDURE:NewpatientofficevisitSendpatientforlabworkupOrderlabs:GenitalCultureVDRLSerumJamesSmith,MD

Visitdetails:Patientpaid$10copayatthetimeoftheservice

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CopyofpatientInsuranceCardprovided.

Aetna

BBBVFDS

Jane Doe

PCP $10 SP $35

PCP: Cristiaan D’Angelo

DATE OF SERVICE

PROCEDURE CODE

MOD COE SERVICE DESCRIPTION UNITS CHARGESNEGOTIATED AMOUNT

ADJUST PAYMENTPT RESP

EMPL CODES

05/25/2013 99203 New Patient Level III 1 145.00 83.45 61.55 48.45 35.00 CO-45

PR-3

Total 145.00 83.45 61.55 48.45 35.00

EXPLANATION CODE DESCRIPTION:

3 Co-payment Amount

45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement. (Use Group Codes PR or CO depending upon liability

CO Contractual Obligations

PR Patient Responsibility

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Case 1 ReviewIn this case, the carrier processed the claim as a special-ist requiring a higher copayment from the patient. This is an error and the patient cannot be billed the additional copay amount. The claim should have been processed as a PCP. By reviewing the insurance card, the practice should see the patient is assigned to a different PCP. This can be resolved by having the patient contact his or her insurance to change the PCP prior to the office visit.

The documentation provided for this encounter does not support the code submitted. The provider performed an expanded problem focused history (brief HPI, extended ROS, and pertinent PFSH), an expanded problem focused exam (limited exam of four organ systems), and low MDM (New problem to the examiner, 1 data point for labs, low risk). The code should be submitted as 99202.

The claim will need to be corrected for the coding error, as well as for the processing error for the type of provider.

If receptionist/scheduler has performed the insurance verification, and the patient does NOT have coverage, the receptionist should inform the patient that full payment is expected at the conclusion of the service. The receptionist should provide an estimate of the fee and reschedule the patient, if necessary.

Proper review of the insurance card is crucial for claim submission. It will also help identify if the provider par-ticipates with the patient’s insurance. Carriers have many different product lines and your provider might not be contracted with all of them.

Let’s review the two insurance cards, below:

INNER CIRCLE

Both cards are from the same carrier; however, card #1 is an EPO (Employer Preferred Organization). Although the provider is contracted with St. Barnabas, the provider may not be contracted with the “inner circle” plan, which is an exclusive network within St Barnabas.

As you can see, insurance verification (step 1) plays an important role in a successful revenue cycle. Although it requires effort, this step saves time by identifying and cor-recting any problems at the start of the transaction, thereby limiting potential revenue loss.

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Here are additional examples of Medicare and Medicaid cards

2

What’s Changing on the Health Care ID Cards? Our health care ID cards will display the new UnitedHealthcare logo in the top left corner of the ID card and there will be an additional name modification to the right of the logo for our Medicare and Medicaid plans:

• AmeriChoice Medicaid plan is now: UnitedHealthcare Community Plan • SecureHorizons Medicare plan in 2012 will be: UnitedHealthcare Medicare Solutions • Cobranded AARP® Medicare plans will continue to have the AARP logo but the sub-brand will change

from SecureHorizons to UnitedHealthcare

Additionally, the cards include an industry-standard bar code for machine readability of the information printed on the card.

What’s NOT Changing on the Health Care ID Cards? Our claims process, claim addresses and customer service numbers are not changing.

What Do the New Cards Look Like Compared To the Old Cards?See below to see how the cards will look for each line of business. Highlights are included for changes to the cards.

Samples of Commercial, Medicare and Medicaid Health Care ID cards Commercial Plans – Sample Cards

Former ID Card

Rebranded ID Card

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Current ID Card

Rebranded ID Card

Medicare Plans – Sample Cards

(Note: Draft Only. Health care ID card is still in design to be effective Jan. 1, 2012.)

(Note: Draft Only. Health care ID card is still in design to be effective Jan. 1, 2012.)

Current ID Card

Rebranded ID Card

3

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Former ID Card

u NEW Logov NEW website addressw Sample ID cards are examples from the New Jersey Health Plan

Medicaid Plans – Sample Cards

4

Rebranded ID Card

Rebranded ID Card

v

v

u

u

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Provider DocumentationDocumentation supports reimbursement; therefore, we must be sure that the information is straightforward and accurate, and that it “flows” in chronological order. It’s important to realize that the patient documentation also services as legal documentation. Some of the most common deficiencies found in documentation are:

z Lack of patient signature, such as: { ABN not signed { Financial policy not signed

z Physician orders/scripts missing, incomplete, or not current, and/or illegible

z Missing pages within the documentation z Missing or wrong date of service z Missing and/or not properly used CPT®/HCPCS Level II modifiers

z Missing clinical significance/medical necessity for lab orders

z Failure to document procedures z Detail missing from the patient encounter

Any of the above may cause a claim to be downcoded or denied, may lead retraction of the previous payment, or may cause the practice to be placed on prepayment review.

Note that if we fail to obtain the patient’s signature on either the ABN or financial policy, we cannot bill the patient, in some instances. Every patient should leave your office with a signed copy of your office financial policy, and you should stick to it. If you have a cancelation fee, charge it. If you have a bounced check fee, charge it.

Real example: A practice had an airtight financial policy, which included billing the patient’s credit card for balances over 60 days. Patients not only signed the financial policy, but provided the practice with their credit card informa-tion. In one case, a patient’s credit card was charged and patient decided to dispute the charge with their credit card company, stating the practice used the card without their consent. During the appeal process, the practice had to show that the patient indeed had given consent to charge the credit card. Because the financial policy spelled out how the credit card would be charged, and patient signed it acknowledging the policy, the credit card company reversed the dispute in favor of the provider.

Note: States have different rules on payment collections. Consider having your financial policies reviewed by a healthcare attorney.

A final problem, now growing with the use of EMRs, is cloned documentation. Templates may cause every patient encounter to look the same (or very, very similar).

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Case 26/19/2013

Nurse Note:Patientbroughtinbymombecausehesteppedonanail.

HPI:15-year-oldmalebroughtinbymomwithforeignbodyinhisfoot.Theoccurrencewastodayat11am.Location:RTfoot.Degreeofpainismoderate.Degreeofdysfunction:Painwithweightbearing.Steppedonarustynailwhilewalkingbarefootinthegarageandwentapproximately0.5inchesintotheRTfoot.

ROS:

Constitutional:Fever

Neurologic:Negative

Allergies:NKA

PAST Medical/Family/Social History

Medical History:Vaccinationsreviewed,Tetanusisnotuptodate.

PHYSICAL EXAMINATION:

General Appearance:MildDistress

Heart:Regularrateandrhythm,noextraheartsounds

Respiratory:LungsCleartoauscultationbilaterally

Extremity:Normalrangeofmotion.Normaltone.Puncturewoundsoleofthefootatthefirsttoe,swellingandrednesstoanteriorfoot,thereisasmallrustynailembeddedinthesubcutaneoustissue.FROMofankleandtoes.

PLAN:

Td0.5ml

Rx:Keflex500mg,Ibuprofen600mg

DIAGNOSIS:

Foreignbodyinfoot

PROCEDURE:Verbalconsentobtained.AreaanesthetizedwithLidocaine2%withoutepinephrine,2mlused.Foreignbodywasremovedbymakingasmallincisionandremovingwithforceps.Bleedingcontrolled,Steri-Stripsanddressingapplied.Patienttoler-atedprocedurewell.

JSmith,MD

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Case 2 ReviewIn this case, we see many errors. First, the date of service is incorrect. The documentation states the patient was seen on 6/19/2013, but the claim was submitted for 6/20/2013. This creates a compliance risk because in an audit, this would be a finding. It creates an administrative burden because the office needs to process a corrected claim.

The diagnosis code billed for the open wound is not as specific as it should be. Because the patient has an open wound with a foreign body, the correct diagnosis code is 892.1 Open wound of foot except toe(s) alone, complicated. The second listed diagnosis (729.6) is not supported by the documentation. This is not a retained foreign body—it is a foreign body with an open wound. The procedure code is also incorrect. The provider did not perform an arthroscopic procedure of the ankle. The correct code for the foreign body removal from the subcutaneous tissue in the foot is 28190 Removal of foreign body, foot; subcutaneous.

For this date of service, the provider is billing an E/M with the procedures. If the E/M is supported, append modifier 25; otherwise, the E/M will be denied. Billing the E/M for this encounter is questionable. When minor procedures are valued, there is a component of E/M factored in. The NCCI Policy Manual states, “E/M services on the same date of service as the minor surgical procedure is included in the payment for the procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service. However, a significant and separately identifiable E/M service unrelated to the deci-sion to perform the minor surgical procedure is separately

reportable with modifier 25. In this case, the provider per-forms an exam of other than the affected area.”

The vaccine supply is billed, but not the administration. This is a common missed charge. Any time a medication or vaccine is administered in the office, we expect to see a charge of the supply, as well as for the administration. There are some instances when you will not see a charge for both (e.g., the patient brings the medication in, the supply is provided as part of a clinical trial, or the provider was given the vaccine for free). In those cases, there would be a charge for the administration, only.

The provider documents the order for the vaccine, but there is no documentation that the vaccine was adminis-tered. When billing for administrations, you need to see the order documented, as well as the actual administration, which will include the medication/vaccine, the dose, the route, and the identity of who administered the vaccine. In this case, the vaccine and the administration should not be billed because we do not have documentation of the administration. If the vaccine was administered, we need a diagnosis code to support it, which in this case is V06.5.

CodingAs we saw in case 2, missing or improperly used CPT®/HCPCS Level II codes and modifiers can have a huge impact, not only with compliance, but with revenue. For code combinations with NCCI edits, review the documen-tation to determine if modifiers can be used to notify the payer when it is appropriate to reimburse for all the codes separately.

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Case 3DOS: 6/1/2013

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DATE OF SERVICE

PROCEDURE CODE

MOD COESERVICE DESCRIPTION

UNITS CHARGES ALLOWED ADJUST PAYMENT PT RESPREMARK CODES

6/01/2013 36226 1 520.00 346.69 173.31 277.35 69.34 CO-42PR-3

6/01/2013 36224 1 520.00 346.01 173.99 276.81 69.20 CO-42PR-3

6/01/2013 36223 1 475.00 0.00 0.00 0.00 0.00 M15

6/01/2013 36225 1 470.00 0.00 0.00 0.00 0.00 M15

6/01/2013 36227 1 165.00 109.55 55.45 87.64 21.91 CO-42PR-3

Total 2,150.00 802.25 402.75 641.80 160.54

EXPLANATION CODE DESCRIPTION:

3 Co-payment Amount

42 Charges exceed our fee schedule or maximum allowable amount

CO Contractual Obligations

PR Patient Responsibility

M15 Separately billed services/tests have been bundled as they are considered components of the same procedure. Separate payment is not allowed.

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Case 3 ReviewTo determine the errors in this case, review the CPT® coding guidelines for selective catheterization of the cer-vicocerebral arteries. 36223 was appropriately denied. You can only select one code from 36222-36224 when per-formed on the ipsilateral (same) side. 36225 should be paid because the procedure was performed on the opposite side. The correct codes and modifiers are 36226, 36224-50, 36225-59, 36227.

Small deficiencies can have a huge impact on compliance and reimbursement. Let’s examine how we commonly leave money on the table.

Because billers and coders don’t always have access to the provider’s documentation, we don’t code all billable ser-vices. It is important if you do have access to the documen-tation that you review the progress note/operative note in its entirety. Many coding mistakes occur if you code from

the operative note headers instead of reading the note in its entirety. A good coder/biller should be able to quickly identify when a charge is missing, or if there is an error with the codes selected by the provider for submission.

Commonly missed charges include:

z Missing charges for supplies z Missing charges for services and procedures z Missing charges for devices z Not collecting payment at time of services (e.g., copays or self pays)

z Established patient vs. new patient

The most common services/procedures missed are the administration code for a vaccination and the venipuncture charge. Although the fee schedule for vaccine administra-tion seems cheap, when you consider how many vaccines are administered in the office per year, this small fee adds up.

Example

Practice gives 250 influenza vaccines during a flu season.

Based on the 2013 Novitas Solution fee schedule for the influenza vaccine, which are as follows:

G0008 Influenza Vaccine

State ReimbursementAmount Times250

New Jersey 01 $29.80 $7, 450.00

New Jersey 99 $28.48 $7, 120.00

Herearethefeesfortheactualvaccine:2013NovitasSolutions

Code Description

EffectiveforDatesofServiceonorafterJanuary1,2013

EffectiveforDatesofServiceonorafterApril1,2013

EffectiveforDatesofServiceonorafterJuly1,2013

EffectiveforDatesofServiceonorafterOctober1,2013

Q2035 Afluria vacc, 3 yrs & >, im 11.543 11.543 11.543

Q2036Flulaval vacc, 3 yrs & >, im

9.833 9.833 9.833

Q2037 Fluvirin vacc, 3 yrs & >, im 14.051 14.051 14.051

Q2038Fluzone vacc, 3 yrs & >, im

12.046 12.046 12.046

Q2039

Not oth-erwise specified flu vaccine

Individual Consideration

Individual Consider-ation

Individual Consider-ation

Inthisinstance,theadministrationcostsmorethanthevaccine.

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DATE OF SERVICE

PROCEDURE CODE

MOD COE SERVICE DESCRIPTION UNITS CHARGES ALLOWED ADJUST PAYMENT PT RESPREMARK CODES

6/15/2013 99213 Established Patient Level III

1 100.00 0.00 0.00 0.00 100.00 PR-B16

Total 100.00 0.00 0.00 0.00 100.00

EXPLANATION CODE DESCRIPTION:

B16 New Patient qualifications were not met

PR Patient Responsibility

Another common coding error is not reporting “new” versus “established” patient appropriately. If the practice submits an established patient code for a new patient encounter, revenue is being lost. A new patient encoun-

ter has a higher fee schedule than an established patient encounter. If you submit a new patient code and the encounter does not meet new patient criteria, the claim will be downcoded or denied.

In this example, the payer changed the code to an estab-lished patient code and denied the claim making it patient responsibility. There are a number of issues with this denial. Without review of the medical record, how would the payer know the correct code to change from new to established? Why would this be patient responsibility? To resolve this denial, review the patient’s medical record and the visit history to determine if he is a new patient. If the patient is established, review the documentation to deter-

mine the correct code. Contact the payer to determine why this is patient responsibility.

Code LinkageNot linking the codes correctly can also have an effect on compliance and reimbursement. You must properly link the CPT®/HCPCS Level II codes to the correct diagnosis code.

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Case 4Date of Procedure:6/20/2013

Surgeon:PamSmith,MD

Assistant:None

Preoperative Diagnoses:

1.Paininlefthip

2.Degenerativearthritisoflefthip

3.Trochantericbursitis,lefthip

Procedures:

1.Intraarticularinjectionofthelefthipjointunderfluoroscopiccontrol

2.Injectionoftrochantericbursaunderfluoroscopiccontrol

Anesthesia:None

Findings:Thepatienthadseverearthritisandbursitisinherlefthip

Procedure:Thepatientwasplacedonthetableinthesupineposition.Atime-outwascalledandthepatientwasidentifiedastoherperson,site,andtypeofsurgerybythenursingstaffandoperatingorthopaedicsurgeon.Theleftgroinwasthenpreppedanddrapedintheusualfashion.A22-gaugespinalneedlewasintroducedunderdirectfluoroscopiccontroldowntotheanteriorneckofthefemur.Wewentdowntothebone,withdrew1mmandinjected2mLofDepo-Medrol1mLofCarbocaine.Theneedlewaswithdrawn.Therewasnoexcessivebleeding.

Wethenpreppedanddrapedthetrochantericbursaarea,identifiedwithC-armcontrol,andusing22-gaugespinalneedleunderdirectC-armcontrol,wewentdowntothebone,withdrew1mm,andinjected1mLofDepo-Medrol80mg/mLplus3mLof0.5%plainMarcaine.Theneedlewaswithdrawn.Noexcessivebleeding.

Thepatienttoleratedtheprocedurewellandlefttheoperatingroomingoodcondition.Thepatientwascheckedbymewhileawakeintherecoveryroomandwasfoundtohaveanobjectivelyandsubjectivelyintactneurovascularstatusofbothlowerextremities.Thepatientvoicednounduecomplaints.

Postoperative Condition:Good

Tissue Removed:None

Codes reported for this case: 62311-LTInjection(s),ofdiagnosticortherapeuticsubstance(s)(includinganesthetic,antispasmodic,opioid,steroid,othersolution),

notincludingneurolyticsubstances,includingneedleorcatheterplacement,includescontrastforlocalizationwhenperformed,epiduralorsubarachnoid;lumbarorsacral(caudal)

77003 Fluoroscopicguidanceandlocalizationofneedleorcathetertipforspineorparaspinousdiagnosticortherapeuticinjectionprocedures(epiduralorsubarachnoid)

77002 Fluoroscopicguidanceforneedleplacement(eg,biopsy,aspiration,injection,localizationdevice)

719.45 Paininjointinvolvingpelvicregionandthigh

715.15 Osteoarthrosislocalizedprimaryinvolvingpelvicregionandthigh

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Case 4 ReviewIn this case, based on the provider’s documentation, the biller/coder billed the wrong service. The procedure code should be 20610 for a joint injection, instead of 62311 for a spine injection. The biller/coder also included a diagnosis (719.45) that should not be reported because it is a sign and symptom of the definitive diagnosis. The practice must contact the carrier to retract the payment received, and the claim now needs to be resubmitted with the proper code. The correct codes for this case are 20610-LT, 77002-26 (if performed in a facility setting), 715.15, 726.5. The diagnosis that was not reported which should be is the bursitis reported with 726.5 Enthesopathy of hip region. If performed in the office, code for the Depo-Medrol.

Another area of the documentation that should be reviewed is the order in which the procedure codes are placed on the claim form.

Example—HowBillingCanAffectRevenue

BilledOutintheCorrectOrderProcedure 1 $2,000 (100%)

Procedure 2 $150 (50%)

Total paid out $2,075

BilledOutintheReverseOrderProcedure 2 $150 (100%)

Procedure 1 $,2000 (50%)

Total paid out $1,150

Difference in revenue $925

Applying ModifiersModifiers may be needed to support the services billed. Without the proper modifiers, we do not tell the full story to the payer. For example, if an unrelated E/M is performed during the postoperative period, we will receive a denial unless we append modifier 24 to alert the payer that we understand E/M is bundled during this time period, but the circumstances of this encounter qualify for payment.

Usually, the coder or the charge entry personnel is responsible for making sure the appropriate modifiers are appended prior to claim submission. There may be times when multiple modifiers are needed to fully describe an encounter.

Modifiers can also tell the payer what kind of provider per-formed the service, or when patients are under hospice care

(which will change the responsible party for the claim). Modifiers GV and GW are used for Medicare when the patient is in hospice.

Example

CMSprovidesthefollowingcodingguidelinesforPartBHospicemodifierGVandGW

CodingGuidelines:PartBHospiceModifiersGVandGW

When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for services that are related to the treatment and management of his terminal illness during the period his hospice benefit election is in force, except for professional services of an “attend-ing physician” who is not an employee of the designated hospice and does not receive com-pensation from the hospice for those services. Professional services of an “attending physician” are submitted with the GV modifier if all condi-tions are met (description below). Any services provided to a patient enrolled in hospice that are not related to the treatment and management of the patient’s terminal illness are submitted with the GW modifier (description below).

For purposes of administering the hospice ben-efit provisions an “attending physician” is defined as follows (must meet all requirements):

• An individual who is a doctor of medicine, doctor of osteopathy or a nurse practitioner.

• Is identified by the beneficiary as having the most significant role in the determination and delivery of his medical care at the time hospice coverage is elected.

• Is not an employee of the hospice and does not receive compensation from the hospice.

The following applicable modifiers must be used when billing for services of a patient enrolled in hospice. The appropriate modifier usage will depend on who is providing the service, what ser-vices are being provided and if the services are for/related to the reason the patient is enrolled in hospice.

GVModifier

Attendingphysiciannotemployedorpaidunderarrangementbythepatient’shospiceprovider

This modifier should be used by the attending physician when the services are related to the patient’s terminal condition and are not paid

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under arrangement by the patient’s hospice provider. Also, this modifier must be submitted when a service meets the following conditions, regardless of the type of provider:

• The service was rendered to a patient enrolled in a hospice.

• The service was provided by a physician or non-phy-sician practitioner identified as the patient’s attend-ing physician at the time of that patient’s enrollment in the hospice program.

DonotsubmittheGVmodifierinthefollowingconditions:

• The service was provided by a physician employed by the hospice.

• The service was provided by a physician not employed by the hospice and the physician was not identified by the beneficiary as his attending physician.

GWModifierServicenotrelatedtothehospiceterminalcondition

This modifier should be used when a service is rendered to a patient enrolled in a hospice and the service is unrelated to the patient’s terminal condition. All providers must submit this modifier when:

• The service(s) provided are unrelated to the patient’s terminal condition.

• Claims are submitted for treatment of a non-terminal condition to the Part A MAC with condition code 07.

The following charts should be used to determine when the services of a hospice patient should be covered and when to report the appropriate modifiers.

The Billing Physician Is the Attending Physician

Report the GVModiier

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All Other Providers Medicare Claims Processing Manual (Chapter 11 - Processing Hospice Claims) *

Report the GVModiier

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Case 5Date:5/25/2013

Name:JohnDoe

Patient’s hospice provider:CristiaanD’Angelo

PCP:PatientpresentwithCOPDexacerbation

HPI:87-year-oldmalecomesinwithexacerbatedCOPD

ROS:

Constitutional:deniesweightchangeorfatigue

GI:deniesdiarrhea

Allergies:NKDA

Psych:depression

Patientispresentlyinhospice.

PAST Medical/Family/Social History

Medical History:Vaccinationsreviewed

Family:breastcancer-mother

PHYSICAL EXAMINATION:

BP120/60Ht:5’6Wt:180

Patientpresentedwithmilddyspneaasevidencebyaccessorymuscleusage.Auscultationrevealsdiminishedbreathsoundswithaudibleanteriormildendexpiratorywheezingbilaterally,andahyperresonantpercussionnote.Patientistachypneic@23BPM,andatachycardiaof107BPMwasnoted.

PLAN:

2Perforomisttreatmentsgiveninoffice

DIAGNOSIS:

COPDexacerbation

Procedure:

Establishedofficevisit

2nebulizertreatmentsintheoffice(Perforomist)

JohnSmith,MD

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Case 5 ReviewMissing from the documentation is the dosage of perfo-romist being administered. In this case the patient is under hospice care and is covered by Medicare. There is no indi-cation the patient’s diagnosis for entering hospice care. If the COPD is the terminal illness, report the procedures with modifier GV. If not, report the services with modifier GW.

ChargeEntryBefore a claim can be submitted, the charges need to be entered into the practice management system. This is not as simple as one might think: There will be times when payer policy will determine how charges are entered. After reviewing the patient’s demographics and insurance eligi-bility, the next step would be to review carrier policy to see if it changes how the charges are billed.

 

 

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Example

FirstPriorityHealth/LiferequirethefollowingtobilloutanannualGYNexam:

AnnualGynExam:ProcedureCode

Description

S0610Annual GYN Exam - New Patient (Report w/ diagnosis code V72.31)

S0612Annual GYN Exam - Established Patient (Report w/ diagnosis code V72.31)

The payer does not cover 99281-99397 for annual GYN exams.

Aetnadoes,however,coverthefollowing:RoutineGYN S0610, S0612, S0613, 99381-99397, 99401-99404, 99201–99205, and

99211-99215 are considered to be preventive if the primary diagnosis code is one of the follow-ing: V72.3, V72.31,V72.6, V76.2, V76.46, V76.47, V84.02, V84.04

PapSmear-PreventiveG0101, G0123-G0124, G0141-G0148 and P3000, P3001, Q0091, 88141-88155, 88164-88167, 88174-88175 are considered to be preventive if the primary diagnosis code is one of the follow-ing: V72.3, V72.31,V72.6, V76.2, V76.46, V76.47, V84.02, V84.04

PelvicExamsG0101A carrier may dictate which codes are entered for reimbursement, so it’s important to know and understand a payer’s policy. Also, most payers require that the ordering/performing physician be listed on the claim. With the requirement under the Affordable Care Act to reimburse preventive services, more private payers are accepting the HCPSC Level II codes for preventive services. Before submitting codes 99381-99397, review payer policy to determine if they require the HCPCS Level II codes that are billed to Medicare.

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Aetna PolicyNote:Someplanshavelimitationsorexclusionsapplicabletochiropracticcare.Pleasecheckbenefitplandescriptionsfordetails.

I. Aetna considers chiropractic services medically necessary when all of the following criteria are met:A.Thememberhasaneuromusculoskeletaldisorder;and

B.Themedicalnecessityfortreatmentisclearlydocumented;and

C.Improvementisdocumentedwithintheinitial2weeksofchiropracticcare.

Ifnoimprovementisdocumentedwithintheinitial2weeks,additionalchiropractictreatmentisconsiderednotmedicallynecessaryunlessthechiropractictreatmentismodified.

Ifnoimprovementisdocumentedwithin30daysdespitemodificationofchiropractictreatment,continuedchiropractictreatmentisconsiderednotmedicallynecessary.

Oncethemaximumtherapeuticbenefithasbeenachieved,continuingchiropracticcareisconsiderednotmedicallynecessary.

Chiropracticmanipulationinasymptomaticpersonsorinpersonswithoutanidentifiableclinicalconditionisconsiderednotmedi-callynecessary.

Chiropracticcareinpersons,whoseconditionisneitherregressingnorimproving,isconsiderednotmedicallynecessary.

Manipulationisconsideredexperimentalandinvestigationalwhenitisrenderedfornonneuromusculoskeletalconditions(e.g.,attention-deficithyperactivitydisorder,dysmenorrhea,epilepsy,andgastro-intestinaldisorders,notanallinclusivelist)becauseitseffectivenessfortheseindicationsisunproven.

Manipulationofinfantsisconsideredexperimentalandinvestigationalfornon-neuromusculoskeletalindications.

Chiropracticmanipulationhasnoprovenvaluefortreatmentofidiopathicscoliosisorfortreatmentofscoliosisbeyondearlyadoles-cence,unlessthememberisexhibitingpainorspasm,orsomeothermedicallynecessaryindicationsforchiropracticmanipulationarepresent.

II. Aetna considers the following chiropractic procedures experimental and investigational:A.ActiveReleaseTechnique(seeCPB0388-ComplementaryandAlternativeMedicine)

B.ActiveTherapeuticMovement(ATM2)

C.AppliedSpinalBiomechanicalEngineering

D.AtlasOrthogonalTechnique

E.BioenergeticSynchronizationTechnique

F.BiogeometricIntegration

G.BlairTechnique

H.ChiropracticBiophysicsTechnique

I.CoccygealMeningealStressFixationTechnique

J.CranialManipulation

K.DirectionalNon-forceTechnique

L.FAKTR(FunctionalandKineticTreatmentwithRehab)Approach

M.GonzalezRehabilitationTechnique

N.KorenSpecificTechnique

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O.Manipulationforinfantcolic

P.Manipulationforinternal(non-neuromusculoskeletal)disorders(AppliedKinesiology)

Q.Manipulationunderanesthesia(seeCPB0204-ManipulationUnderAnesthesia)

R.MoireContourographicAnalysis

S.NetworkTechnique

T.NeuralOrganizationalTechnique

U.NeuroEmotionalTechnique

V.Sacro-OccipitalTechnique

W.Spinaladjustingdevices(ProAdjuster,PulStarFRAS,Activator)

X.UpledgerTechniqueandCranio-SacralTherapy

Y.WebsterTechnique(forbreechbabies)

Z.WhitcombTechnique(seeCPB0388-ComplementaryandAlternativeMedicine).

III. Aetna considers the following diagnostic procedures experimental and investigational:A.Computerizedradiographicmensurationanalysisforassessingspinalmal-alignment

B.Neurocalometer/Nervoscope-seeCPB0029-Thermography

C.Para-spinalelectromyography(EMG)/SurfacescanningEMG-seeCPB0112-SurfaceScanningandMacroElectromyography

D.Spinoscopy-seeCPB0112-SurfaceScanningandMacroElectromyography

E.Thermography-seeCPB0029-Thermography.

PreventiveorMaintenanceChiropracticManipulation:

Preventiveormaintenancechiropracticmanipulationhasbeendefinedaselectivehealthcarethatistypicallylongterm,bydefini-tionnottherapeuticallynecessarybutisprovidedatpreferablyregularintervalstopreventdisease,prolonglife,promotehealthandenhancethequalityoflife.Thiscaremaybeprovidedaftermaximumtherapeuticimprovement,withoutatrialofwithdrawaloftreatment,topreventsymptomaticdeteriorationoritmaybeinitiatedwithpatientswithoutsymptomsinordertopromotehealthandtopreventfutureproblems.

Preventiveservicesmayincludepatienteducation,homeexercises,andergonomicposturalmodification.Theappropriatenessandeffectivenessofchiropracticmanipulationasapreventiveormaintenancetherapyhasnotbeenestablishedbyclinicalresearchandisnotcovered.

Supportivecarehasbeendefinedastreatmentforpatientswhohavereachedmaximumtherapeuticbenefit,butwhofailtosustainbenefitandprogressivelydeterioratewhenthereareperiodictrialsoftreatmentwithdrawal.

Continuationofchiropracticcareisconsideredmedicallynecessaryuntilmaximumtherapeuticbenefithasbeenreached,whenthepatientfailstoprogressclinicallybetweentreatments,orwhenpre-injury/illnessstatushasbeenreached.Oncethemaximumtherapeuticbenefithasbeenachieved,continuingchiropracticcareisnotconsideredmedicallynecessaryandthusisnotcovered.

Activecorrectivecareisongoingtreatment,renderedafterthepatienthasbecomesymptomaticallyandobjectivelystable,topre-ventarecurrenceofapatient'sconditionbycorrectingunderlyingabnormalspinalbiomechanicsthatappeartobethecauseoftheinitialinjury.Theefficacyofactivecorrectivecareisnotsupportedbyscientificevidenceandisnotcovered.

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CPT® Codes / HCPCS Codes / ICD-9 CodesCPT®codescoveredifselectioncriteriaaremet:98940989419894298943

CPT® codes not covered for indications listed in the CPB:22505

93760

93762

Other CPT® codes related to the CPB:20552

20553

95831-95857

95860-95887

95905-95913

95937

96000-96004

97001-97799

Other HCPCS codes related to the CPB:G0151Servicesperformedbyaqualifiedphysicaltherapistinthehomehealthorhospicesetting,each15minutes

S3900Surfaceelectromyography(EMG)

S9131Physicaltherapy;inthehome,perdiem

ICD-9 codes covered if selection criteria are met (0-3 years of age):333.83Spasmodictorticollis

343.0-343.9Infantilecerebralpalsy

353.0-353.9Musculardystrophiesandothermyopathies

714.0-714.9Rheumatoidarthritisandotherinflammatorypolyarthropathies

720.0-724.0Dorsopathies

732.0-732.9Osteochondropathies

754.0-754.9Congenitalmusculoskeletaldeformities

755.50-755.59Otheranomaliesofupperlimb,includingshouldergirdle

755.60-755.69Otheranomaliesoflowerlimb,includingpelvicgirdle

756.10-756.19Anomaliesofspine

756.4Chrondrodystrophy

840.0-847.9Sprainsandstrains[limbsandback]

848.1Sprainsandstrainsofjaw

848.3-848.5Sprainsandstrainsofotherribs,sternum,andpelvis

905.1-905.9Lateeffectsofmusculoskeletalandconnectivetissueinjuries

907.3-907.5Lateeffectsofinjuriestonerveroot(s),spinalplexusandothernervesoftrunk,peripheralnervesofshouldergirdleandupperlimb,andperipheralnervesofpelvicgirdleandlowerlimb

953.0-953.9Injurytonerverootsandspinalplexus

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955.0-955.9Injurytoperipheralnerve(s)ofshouldergirdle

956.0-956.9Injurytoperipheralnerve(s)ofpelvicgirdleandlowerlimb

957.0Injurytosuperficialnervesofheadandneck

ICD-9 codes covered if selection criteria are met for adults and children (4 years of age and older):307.81Tensionheadache

333.83Spasmodictorticollis

339.00-339.89Otherheadachesyndromes

343.0-343.9Infantilecerebralpalsy

346.00-346.93Migraine

353.0-353.9Nerverootandplexusdisorders

354.0-354.9Mononeuritisofupperlimbandmononeuritismultiplex

355.0-355.9Mononeuritisoflowerlimb

359.0-359.9Musculardystrophiesandothermyopathies

524.60-524.69Temporomandibularjointdisorders

714.0-714.9Rheumatoidarthritisandotherinflammatorypolyarthropathies

715.00-715.98Osteoarthrosisandallieddisorders

716.00-716.99Otherandunspecifiedarthropathies

717.0-717.9Internalderangementofknee

719.00-719.99Otherandunspecifieddisordersofjoint

720.0-724.9Dorsopathies

725.0-729.9Rheumatism,excludingtheback

732.0-732.9Osteochondropathies

733.5Osteitiscondensans

733.6Tietze'sdisease

733.7Algoneurodystrophy

734Flatfoot

736.00-736.9Otheracquireddeformitiesoflimbs

738.2Acquireddeformityofneck

738.4Acquiredspondylolisthesis

738.5Otheracquireddeformityofbackorspine

738.6Acquireddeformityofpelvis

738.8Acquireddeformityofotherspecifiedsite

738.9Acquireddeformityofunspecifiedsite

739.0-739.9Nonallopathiclesions,notelsewhereclassified[allowedbyCMS]

754.0-754.9Congenitalmusculoskeletaldeformities

755.50-755.59Otheranomaliesofupperlimb,includingshouldergirdle

755.60-755.69Otheranomaliesoflowerlimb,includingpelvicgirdle

756.10-756.19Anomaliesofspine

756.4Chondrodystrophy

784.0Headache

839.00-839.9Other,mulitple,andill-defineddislocations[includingvertebra]

840.0-847.9Sprainsandstrains[limbsandback]

848.1Sprainsandstrainsofjaw

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848.3-848.5Sprainsandstrainsofotherribs,sternum,andpelvis

905.1-905.9Lateeffectsofmusculoskeletalandconnectivetissueinjuries

907.3-907.5Lateeffectsofinjuriestonerveroot(s),spinalplexus(es)andothernervesoftrunk,peripheralnervesofshouldergirdleandupperlimb,andperipheralnervesofpelvic,girdleandlowerlimb

953.0-953.9Injurytonerverootsandspinalplexus

955.0-955.9Injurytoperipheralnerve(s)ofshouldergirdle

956.0-956.9Injurytoperipheralnerve(s)ofpelvicgirdleandlowerlimbs

957.0Injurytosuperficialnervesofheadandneck

ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):314.00-314.01Attentiondeficithyperactivitydisorder

345.00-345.91Epilepsyandrecurrentseizures

520.0-579.9Diseasesofthedigestivesystem

625.3Dysmenorrhea

652.11-652.13Breechorothermalpresentationsuccessfullyconvertedtocephalicpresentation

[Webstertechnique]

737.30-737.32Scoliosis[andkyphoscoliosis],idiopathic;resolvinginfantileidiopathicscoliosis;andprogressiveinfantileidiopathicscoliosis

780.33Posttraumaticseizures

780.39Otherconvulsions[seizuredisorderNOS]

789.7Colic(infantile)

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LCD L27480 - Chiropractic Services

CMS IOM Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240

CMS IOM Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1

CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 17, Section 60.1

Transmittal B-01-58, Change Request 1820

Transmittal 1805, Change Request 2717

Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation(i.e., by use of hands) of the spine, for the purpose of correcting a subluxation. For the purpose of Medicare, a subluxation is defined as a motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered, although contact between joint surfaces remains intact.

No other diagnostic or therapeutic service furnished by a chiropractor or under his or her order is covered. This means that for example, if a chiropractor orders, takes, or interprets an X -ray, or any other diagnostic test, the X-ray or other diagnostic test, can be used for claims processing purposes,but Medicare coverage and payment are not available for those services. This prohibition does not affect the coverage of X -rays or other diagnostic tests furnished by other practitioners under the program. For example, an X-ray or any diagnostic test taken for the purpose of determining or demonstrating the existence of a subluxation of the spine is covered when it is ordered, taken, and interpreted by a physician who is a doctor of medicine or osteopathy.

The word "correction" may be used in lieu of "treatment". Also, a number of different terms composed of the following words may be used to describe manual manipulation:

• Spine or spinal adjustment by manual means;• Spine or spinal manipulation• Manual adjustment; and• Vertebral manipulation or adjustment

Manual devices (i.e., those that are hand-held with the thrust of the force of the device being controlled manually) may be used by a chiropractor in performing manual manipulation of the spine. However, no additional payment is available for use of the device, nor does Medicare recognize an extra charge for the device itself.

Indications

The patient must have a significant health problem in the form of a musculoskeletal or a neuro -musculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient's condition and provide reasonable expectations of recovery or improvement of function. The patient must have a subluxation of the spine as demonstrated by X-ray or physical exam.

Most spinal joint problems may be categorized as follows:

• Acute subluxation: A patient's condition is considered acute when the patient is being treated for a newinjury, identified by X-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression, of the patient's condition.

• Chronic subluxation: A patient's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered . (Medicare Benefit Policy Manual 100 -2, 15, 240.1.3)

It must be clear in the patient's medical record in which category the patient falls (acute or chronic subluxation), and all the requirements addressed in the "Documentation Requirements" section of this policy must be recorded in the patient's medical record and be available to the contractor upon request.

Indications and Limitations of Coverage and/or Medical Necessity

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

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For Medicare purposes, a chiropractor must place an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. However the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary.

The chiropractor must also indicate the treatment phase or month of treatment for the services provided. In addition, it should be documented in the patient's medical record whether the patient has had an exacerbation (flare up while being treated) or recurrence (recurring after 90 days or more of no treatments) of a previous condition. Medicare covers additional manipulations when an exacerbation or recurrence occurs. This must clearly be documented and reflective of the patient's presenting symptomatology and treatment history.

• Exacerbations: An exacerbation is a temporary marked deterioration of the patient ’s condition due to flare up of the condition being treated. This must be documented in the patient ’s clinical record, including the date of occurrence, nature of the onset or other pertinent factors that will support the reasonableness and necessity of treatments for this condition.

• Recurrence: A recurrence is a return of symptoms of a previously treated condition that has been quiescent for 90 or more days. This may require the reinstitution of therapy.

The following number of chiropractic manipulation services per beneficiary are considered reasonable and necessary if the medical record supports the service:

1. Twelve chiropractic manipulation treatments per 30 days.2. Thirty chiropractic manipulation treatments per 365 days.

Covered diagnoses are displayed in four groups in this policy. It is not expected that substantially more than the following number of treatments per diagnostic group will usually be required. If 30 visits are performed for group D, then this will also serve as the maximum number of visits for the year.

a. Twelve chiropractic manipulation treatments for Group A diagnoses.b. Eighteen chiropractic manipulation treatments for Group B diagnoses.c. Twenty-four chiropractic manipulation treatments for Group C diagnoses.d. Thirty chiropractic manipulation treatments for Group D diagnoses.

Location of Subluxation: The precise level of the subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine. This designation is made in relation to the part of the spine in which the subluxation is identified:

There are two ways in which the level of subluxation may be specified.

1. The exact bones may be listed, for example: C5, C6, etc.2. The area may suffice if it implies only certain bones such as: occipito -atlantal (occiput and C1 (atlas)),

lumbo-sacral (L5 and Sacrum) sacro -iliac (sacrum and ilium).

The following are some common examples of acceptable terms that may be used to describe the nature of the abnormalities: off-centered, misalignment, malpositioning, spacing (abnormal,

Area of Spine Names of Vertebrae Number of Vertebrea Short Form or Other NameNeck Occiput Occ. CONeck Cervical 7 C1 thru C7Neck Atlas C1Neck Axis C2Back Dorsal or 12 D1 thru D12Back Thoracic T1 thru T12Back Costovertebral R1 thru R12Back Costotransverse R1 thru R12Low Back Lumbar 5 L1 thru L5Pelvis Ilii (R and L) I, SI

Sacral Sacrum, Coccyx S, SC

Note:

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altered, decreased, increased), incomplete dislocation, rotation, listhesis (antero, postero, retro, lateral, spondylo), motion (limited, lost, restricted, flexion, extension, hypermobility, hypomotility, aberrant). Other terms may be used and are acceptable when they are understood clearly to refer to the bone or joint space or position (or motion) changes of vertebral elements.

Limitations

1. Maintenance TherapyUnder the Medicare program, chiropractic maintenance therapy is not considered to be medically reasonable or necessary, and is therefore not payable. Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. The AT modifier must not be placed on the claim when maintenance therapy has been provided. Claims without the AT modifier will be considered as maintenance therapy and denied. Chiropractors who give or receive an ABN from beneficiaries shall follow the instructions in Pub. 100-04,Medicare Claims Processing Manual, Chapter 23, Section 20.9.1.1 and include a GA (or in rare instances a GZ) modifier on the claim.

2. ContraindicationsDynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement. A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust, but does not rule out the use of dynamic thrust. The doctor should discuss this risk with the patient and record this in the chart. The following are

to dynamic thrust:

?Articular hyper mobility and circumstances where the stability of the joint is uncertain;?Severe demineralization of bone;?Benign bone tumors (spine);?Bleeding disorders and anticoagulant therapy; and?Radiculopathy with progressive neurological signs.

Dynamic thrust is near the site of demonstrated subluxation and proposed manipulation in the following:

• Acute arthropathies characterized by acute inflammation and ligamentous laxity and anatomic subluxation or dislocation; including acute rheumatoid arthritis and ankylosing spondylitis;

• Acute fractures and dislocations or healed fractures and dislocations with signs of instability;• An unstable os odontoideum;• Malignancies that involve the vertebral column;• Infection of bones or joints of the vertebral column;• Signs and symptoms of myelopathy or cauda equina syndrome;• For cervical spinal manipulations, vertebrobasilar insufficiency syndrome; and• A significant major artery aneurysm near the proposed manipulation.

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Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type andthe policy should be assumed to apply equally to all claims.

999x Not Applicable

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in

relativecontraindications

absolutely contraindicated

Coding Information Bill Type Codes

Revenue Codes

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the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

Italicized and/or quoted material is excerpted from the American Medical Association, codes.

National policy limits the coverage of Chiropractic services to the "hands on" manual manipulation of the spine for symptomatology associated with subluxation. Therefore, CPT code is not a Medicare benefit.

98940 Chiropract manj 1-2 regions

98941 Chiropract manj 3-4 regions

98942 Chiropractic manj 5 regions

98943 Chiropract manj xtrspinl 1/>

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The level of the subluxation must be specified (by using the appropriate ICD-9 code) on the claim and must be listed as the primary diagnosis. The neuromusculoskeletal conditions and/or symptoms necessitating the treatment must be listed as the secondary diagnoses. All ICD-9 diagnosis codes must be coded to the highest level of specificity, and the primary diagnosis must be supported by an X-ray or physical examination.

739.0 - 739.5NONALLOPATHIC LESIONS OF HEAD REGION NOT ELSEWHERE CLASSIFIED - NONALLOPATHIC LESIONS OF PELVIC REGION NOT ELSEWHERE CLASSIFIED

307.81 TENSION HEADACHE

719.48 PAIN IN JOINT INVOLVING OTHER SPECIFIED SITES

723.1 CERVICALGIA

724.1 - 724.2 PAIN IN THORACIC SPINE - LUMBAGO

724.5 BACKACHE UNSPECIFIED

724.8 OTHER SYMPTOMS REFERABLE TO BACK

728.85 SPASM OF MUSCLE

784.0 HEADACHE

CPT/HCPCS Codes

NOTE:spinal

ICD-9 Codes that Support Medical Necessity

For procedure codes , , and :

Group A Diagnoses

Group B Diagnoses

CurrentProcedural Terminology (CPT)

98943

98940 98941 98942

Primary Diagnosis Codes

Secondary Diagnosis Codes

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720.1 SPINAL ENTHESOPATHY

721.0 - 721.2CERVICAL SPONDYLOSIS WITHOUT MYELOPATHY - THORACICSPONDYLOSIS WITHOUT MYELOPATHY

721.6 ANKYLOSING VERTEBRAL HYPEROSTOSIS

721.90 - 721.91SPONDYLOSIS OF UNSPECIFIED SITE WITHOUT MYELOPATHY -SPONDYLOSIS OF UNSPECIFIED SITE WITH MYELOPATHY

724.79 OTHER DISORDERS OF COCCYX

729.1 MYALGIA AND MYOSITIS UNSPECIFIED

729.4 FASCIITIS UNSPECIFIED

739.8 NONALLOPATHIC LESIONS OF RIB CAGE NOT ELSEWHERE CLASSIFIED

846.0 - 846.3LUMBOSACRAL (JOINT) (LIGAMENT) SPRAIN - SACROTUBEROUS(LIGAMENT) SPRAIN

846.8 OTHER SPECIFIED SITES OF SACROILIAC REGION SPRAIN

847.0 - 847.4 NECK SPRAIN - SPRAIN OF COCCYX

353.0 - 353.4BRACHIAL PLEXUS LESIONS - LUMBOSACRAL ROOT LESIONS NOT ELSEWHERE CLASSIFIED

353.8 OTHER NERVE ROOT AND PLEXUS DISORDERS

722.91 - 722.93 OTHER AND UNSPECIFIED DISC DISORDER OF CERVICAL REGION - OTHERAND UNSPECIFIED DISC DISORDER OF LUMBAR REGION

723.0 SPINAL STENOSIS IN CERVICAL REGION

723.2 - 723.5 CERVICOCRANIAL SYNDROME - TORTICOLLIS UNSPECIFIED

721.3 LUMBOSACRAL SPONDYLOSIS WITHOUT MYELOPATHY

721.41 - 721.42SPONDYLOSIS WITH MYELOPATHY THORACIC REGION - SPONDYLOSISWITH MYELOPATHY LUMBAR REGION

721.7 TRAUMATIC SPONDYLOPATHY

722.0DISPLACEMENT OF CERVICAL INTERVERTEBRAL DISC WITHOUTMYELOPATHY

722.10 - 722.11DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY - DISPLACEMENT OF THORACIC INTERVERTEBRAL DISC WITHOUT MYELOPATHY

722.4 DEGENERATION OF CERVICAL INTERVERTEBRAL DISC

722.51 - 722.52DEGENERATION OF THORACIC OR THORACOLUMBAR INTERVERTEBRALDISC - DEGENERATION OF LUMBAR OR LUMBOSACRAL INTERVERTEBRAL DISC

722.6 DEGENERATION OF INTERVERTEBRAL DISC SITE UNSPECIFIED

722.81 - 722.83POSTLAMINECTOMY SYNDROME OF CERVICAL REGION -POSTLAMINECTOMY SYNDROME OF LUMBAR REGION

Group C Diagnoses

Group D Diagnoses

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724.01 - 724.03 SPINAL STENOSIS OF THORACIC REGION - SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION

724.3 - 724.4SCIATICA - THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED

724.6 DISORDERS OF SACRUM

738.4 ACQUIRED SPONDYLOLISTHESIS

756.11 - 756.12CONGENITAL SPONDYLOLYSIS LUMBOSACRAL REGION -SPONDYLOLISTHESIS CONGENITAL

839.01 - 839.08 CLOSED DISLOCATION FIRST CERVICAL VERTEBRA - CLOSEDDISLOCATION MULTIPLE CERVICAL VERTEBRAE

839.20 - 839.21CLOSED DISLOCATION LUMBAR VERTEBRA - CLOSED DISLOCATION THORACIC VERTEBRA

839.41 - 839.42 CLOSED DISLOCATION COCCYX - CLOSED DISLOCATION SACRUM

953.0 - 953.4 INJURY TO CERVICAL NERVE ROOT - INJURY TO BRACHIAL PLEXUS

953.5 INJURY TO LUMBOSACRAL PLEXUS

953.8 INJURY TO MULTIPLE SITES OF NERVE ROOTS AND SPINAL PLEXUS

Conditions that are listed in the "ICD-9 Codes that Support Medical Necessity" section of this policy.

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD -9 Codes that Support Medical Necessity" section of this policy.

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1. All documentation must be maintained in the patient ’s medical record and available to the contractor upon request.

2. Every page of the record must be legible and include appropriate patient identification information (e.g.,complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.

3. The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed.

Documentation of a subluxation may be demonstrated by an X-ray or by a physical examination. All levels of subluxation identified must be documented in the patients' medical record, regardless of the current treatment plan.

1. Demonstrated by X-ray: An X-ray may be used to document a subluxation but is not required. The X -raymust have been taken at a time reasonably proximate to the initiation of a course of treatment. Unlessmore specific X-ray evidence is warranted, an X -ray is considered reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of a course of chiropractic treatment. In certain cases of chronic subluxation (e.g., scoliosis), an older X -ray may be acceptedprovided the beneficiary's health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent. (For more specific information

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

Other InformationDocumentation Requirements

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on the coverage/noncoverage guidelines of chronic conditions and maintenance therapy see the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy). A previous CT scan and/or MRI of the spine may be used, in lieu of an X -ray, when a subluxation of the spine is demonstrated. The time frames specified for X -rays are also applicable for MRIs and CT scans.

2. Demonstrated by Physical Examination: A physical examination may be used to document a subluxation. Evaluation of musculoskeletal/nervous system to identify:(P) Pain/tenderness evaluated in terms of location, quality, and intensity;

(A) Asymmetry/misalignment identified on a sectional or segmental level;

(R) Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or decrease of sectional or segmental mobility); and

(T) Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament;

To demonstrate a subluxation based on physical examination, two of the four criteria mentioned underthe "Demonstrated by Physical Examination" section of this policy are required, one of which must be asymmetry/misalignment or range of motion abnormality.

The history recorded in the patient's medical record should include the following:

?Symptoms causing patient to seek treatment;?Family history if relevant;?Past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical

history)?Mechanism of trauma;?Quality and character of symptoms/problem;?Onset, duration, intensity frequency, location and radiation of symptoms;?Aggravating or relieving factors; and?Prior interventions, treatments, medications, secondary complaints.

In addition to the above documentation requirements the following documentation requirements apply whether the subluxation is demonstrated by X -ray or by physical examination:

For the Initial Visit:

1. History as stated above;2. Description of the present illness including:

?Quality and character of symptoms/problem;?Onset, duration, intensity frequency, location and radiation of symptoms;?Aggravating or relieving factors; and?Prior interventions, treatments, medications, secondary complaints.?Symptoms causing patient to seek treatment. These symptoms must bear a direct relationship to

the level of subluxation. The symptoms should refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo or osteo), rib (costo or costal) and joint (arthro) and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and foot pain and numbness. Rib and rib/chest pain are also recognized symptoms, but in general other symptoms must be related to the level of the subluxation that has been cited. A statement on a claim that there is "pain" is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined.

3. Evaluation of musculoskeletal/nervous system through physical examination.4. Diagnosis: The primary diagnosis must be subluxation, including the level of subluxation, either so stated

or identified by a term descriptive of subluxation. Such terms may refer either to the condition of thespinal joint involved or to the direction of position assumed by the particular bone named.

5. Treatment Plan: The treatment plan should include the following:

?Recommended level of care (duration and frequency of visits);?Specific treatment goals; and?Objective measures to evaluate treatment effectiveness.

6. Date of the initial treatment.

For Subsequent Visits:

1. History

?Review of chief complaint;

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?Changes since last visit;?System review if relevant.

2. Physical exam

?Exam of area of spine involved in diagnosis;?Assessment of change in patient condition since last visit;?Evaluation of treatment effectiveness.

3. Documentation of treatment given on day of visit

For All Visits:

Diagnoses reported on a claim must reflect those that are being ACTIVELY treated at the time the service is rendered and not historic, for the purposes of this policy.

Please see Article A47798, Chiropractic Services, for additional information.

N/A

In accordance with CMS Ruling 95 -1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

If a national or local policy identifies a frequency expectation, a claim for a test/service that exceeds that expectation may be denied as not reasonable and necessary. Documentation may be submitted with the claim for individual consideration if reporting increased frequency of services.

Anderson GB, Lucente T, Davis AM, et al. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. 1999; 341(19):1426-31.

Chapman-Smith D. NCMIC Group Inc.; 2000.

Cherkin DC, Deyo RA, Battié M, et al. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain.

1998; 339(15):1021-9.

Cox JM, Feller J, Cox-Cid J. Distraction Chiropractic Adjusting: Clinical Application and Outcomes of 1,000 cases. 1996; 3(3):45-59.

American Medical Association; 1999.

Haldeman S, Chapman-Smith D, Petersen DM. An Aspen Publication; 1993.

Haldeman S, Chapman-Smith D, Petersen DM. Jones & Bartlett Publishers, 2005.

12th ed. American Medical Association; 1999.

9th rev. Clinical Modification; 1998.

OIG Report OEI-07-07-00390, Inappropriate Medicare Payments for Chiropractic Services; Published May 2009

Carrier Medical Directors' Chiropractic Clinical Workgroup

Other Contractor's Policies

Novitas Solutions Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups that include representatives from the Chiropractic specialty.

Additional Information

Appendices

Utilization Guidelines

Sources of Information and Basis for Decision

Advisory Committee Meeting Notes

N Engl J Med

The Chiropractic Profession.

N Engl J Med

Top Clin Chiro

Current Procedural Terminology (CPT) 2000.

Guidelines for Chiropractic Quality Assurance and Practice Parameters.

Guidelines for Chiropractic Quality Assurance and Practice Parameters.

Medicare's National Level II Codes, HCPCS, 2000 .

Medicode's International Classification of Diseases .

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Case 6Patient:MarkDoe Initial Visit Date:7/24/2012

Date:3/9/2013 Treatment Phase:Acute/Corrective

Subjective:Patientpresentstodayforafollow-upappointment.Hischiefcomplaintisoneofongoing(frequent,5/10)sharpbeltlinelowerbackpainwithoutanyradiationintothelowerextremity.DistributionisacrosstheL5/S1spinallevelandintobothsacroiliacjoints.Therearenoassociatedsensorimotorcomplaints.Onsethasbeengradualandinsidiousoverthepastseveralweekswithoutanyapparentmechanismofinjury.Thereisnohistoryoftraumatotheregion.Hereportsthatstandinginonepositionforgreaterthan10minutesintensifieshispain.Hisworkasanoperatingroomnurserequireshimtostandforlongperiodsoftime.Resthasofferedmildandtemporarypainreduction.Hedeniesanyincreaseinpainwithcoughing,sneezing,orbearingdownwithstool.Hehasnotseenanotherhealthcareproviderforthiscomplaint.Thepatientisoverallsubjectivelyimprovedtoday.HereportsthatheappreciatedareductioninbothpainfrequencyandintensityfollowinghisvisitonFriday.

Objective:Physicalexaminationrevealsa52-year-oldmaletobeinmoderatedistresstodayduetoacutelowerbackpain.Observedposturaldistortionsincludeaforwardheadcarrywithbilaterallyslouchedshouldersandakyphoticupperthoracicspine.Thereisanincreaseintheusuallumbarlordosiswithanteriorpelvictilt.Theleftshoulderandrightiliumaremildlyelevated,withaslightdegreeofassociatedrotationaltortiontothepelvis.Minor’ssignisonceagainobservedtoday.Hisgaitpatternremainsslowanddeliberatewithanotabledecreaseintheswingphaseofthenormalgaitcycle.Heisabletotransitionfromapronetoasupinepositiononthechiropractictablewithgreatereasetoday.Neurologicalsystemisgrosslyintactwithoutfocalradicularfindings.Motor,reflex,andsensoryevaluationofthelowerextremitiesisunremarkablebilaterally.Pathologicreflexesareabsentthroughout.Valsalva’smaneuverisnotreproductiveofanypain.Supinestraightledraiseisbilaterallynegative,butresultsinhamstringtight-nessoneachside.Softtissueandjointpalpationfindingsareoutlinedbelow:

• Bilateral quadratus lumorum: moderate hypertonicity with active myofascial trigger points greater on the right side

• Bilateral lumbar paraspinals: moderate hypertonicity with active myofascial trigger points greater on the right side

• Bilateral gluteal group/piriformis: moderate hypertonicity with latent myofasical trigger points greater on the right side

• Bilateral hamstrings: mild to moderate hypertonicity with active myofascial trigger points greater on the right side

RightsacroiliacjointextensionrestrictionL4/L5rightrotationrestrictionL1/2leftrotationrestriction

T9/10/11extensionrestrictionT3/4extensionrestrictionC6/7leftlateralflexionrestriction

C4/5rightrotationrestrictionC1/2rightlateralflexionrestriction

ASSESSMENT:Acuteexacerbationofchronicmechanicallowerbackpainwithoutsciatica.Thepatientissubjectivelyandobjec-tivelyimprovedtoday.Hehasahistoryofpriorbackpainepisodeswithgoodresolvethroughchiropracticcareinthepast.Hisprognosisisgoodforbothpainandspasmreduction,aswellasfortherestorationofnormalspinalbiomechanics.Therearenocontraindicationstospinalmanipulation.Imagingisnotindicatedatthistime.Continuewithtreatmentatthefrequencyprescribedbelow.

DIAGNOSIS:846.0LumbosacralSprain/Strain

739.4SacralSegmentalDysfunction

728.85Myospasm

739.3LumbarSegmentalDysfunction

739.2ThoracicSegmentalDysfunction

739.1CervicalSegmentalDysfunction

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PLAN:Treatmentwillincludediversifiedspinalmanipulation,deeptissuemassage,andrehabilitativetherapies.Thepatient’spres-entconditionnecessitatesatreatmentfrequencyof2visitseveryweekforthenext2weeks.Thefollowingserviceswererenderedattoday’sdateofservice:

z 98940-Spinalmanipulationtothecervicalandthoracicspine(abovelistedrestrictions;1-2regions)

z 97140ManualTherapy:FlexionDistractionMobilizationandManualTractionandJointMobilizationandMyofascialReleasefor1unitsfor15minutestothelumbarspine,sacralregion,andlowerextremity.

z 97110-TherapeuticExercisefor1unitfor15minutes;Passiverangeofmotionstretchesofthelowerextremitybilaterallytoincreaseflexibility.Isometricstrengtheningofthelowerextremitybilaterally.Proprioceptiveneuromuscularfacilitationofthelowerextremitybilaterally.(abovelistedmuscles)2setsof2repseach

Doctor In:4:00PM

Doctor Out:4:35PM

Total Patient Time:35minutes

MikeSmith,MD

WewillreviewthepropercodingifthisclaimwassubmittedtoMedicareaswellasadenialreceivedfromAetnaforthiscase.TheMedicareandAetnapoliciesareprovidedaswellasasampleABN.

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Aetna EOBDATE OF SERVICE

PROCEDURE CODE

MOD COESERVICE DESCRIPTION

UNITS CHARGES ALLOWED ADJUST PAYMENT PT RESPREMARK CODES

03/09/2013 97110 1 65.00 0.00 0.00 0.00 0.00 1

03/09/2013 97140 59 1 50.00 0.00 0.00 0.00 0.00 1

03/09/2013 98940 1 50.00 0.00 0.00 0.00 0.00 1

Total 165.00

EXPLANATION CODE DESCRIPTION:

1 W89 The payment for this service is included within the negotiated rate. The patient is not responsible for this amount.

Case 6 ReviewWhen you review the policies provided, the proper modi-fier to identify the chiropractic service is included in the policy. For this payer, claims for chiropractic services are submitted to a third party for review. If insurance verifica-tion was performed properly, the claim would have been submitted to the correct party and the claim would not have been denied.

ClaimSubmissionIf everyone works together, the following steps should run smoothly. Prior to claim submission, all documents have been reviewed and proper codes and modifier are selected. Set up edits in the billing system or use a claim scrubber to identify errors prior to claim submission. Submitting clean claims the first time speeds up the payment process. Work on the front end will eliminate the need to chase after reimbursement.

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Case 7Date: 10/20/2012

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Case 7 ReviewFor this case, an E/M is performed but it is not marked on the encounter form. The provider added a note for cerumen removal. The biller entering the charges should review the documentation because additional diagnoses (other than the impacted cerumen) are listed. If the encounter was posted as indicated on the encounter form, there is a missed opportu-nity for payment of the E/M service. Because the procedure and the E/M where performed on the same date, modifier 25 is required. The provider should also bill for the influ-enza vaccine and administration.

Common Billing ErrorsThe following is a list of the most common errors encoun-tered by Medicare and some tips on how you can avoid them. You can discover more about these on the CMS Web site (www.cms.gov) in their Medlearn Matters article SE0712.

z The patient cannot be identified as a Medicare patient. Always use the Health Insurance Claim Number (HICN) and name as it appears on the patient’s Medicare card. If the patient has a middle initial be sure to include as this can cause the claim to reject as it didn’t match the name on the carrier file.

This is a common denial for all insurance types. Make sure you verify the patient’s insurance and make a copy of the patient’s insurance card so mistakes with insurance IDs are not made. This denial will result if the wrong number is submitted, or if the claim is submitted to the wrong insur-ance company.

HIC Format—A correct Medicare HIC number consists of nine numbers immediately followed by an alpha suffix. Take particular care when entering the HIC number for members of the same family who are Medicare beneficia-ries. A husband and wife may have an HIC number that share the same Social Security numbers; however, every individual has his or her own alpha suffix at the end of the HIC number. To ensure proper claim payment, it is essen-tial that the correct alpha suffix is appended to each HIC. No hyphens or dashes should ever be used.

z Line Item 32 of the CMS 1500 requires the place where the service was actually rendered to the patient including the name and address—and a valid ZIP code—for all services unless it was in the patient’s home. Be aware that any missing, incomplete, or invalid information recorded in this required field will result in the claim being returned or rejected in the system as not able to process.

Be sure the location where the services were performed is properly reported on the claim. Most practice management systems allow you to enter in and save all the addresses for the locations you render services.

The referring or ordering physician’s name and NPI are not present on the claim. You must include this information in Item 17 and 17a on all diagnostic services, including con-sultations. Don’t forget the National Provider Identifiers (NPIs).

z E/M procedure codes and the place of service do not match. (Example: Procedure code 99283, which is an emergency room visit, is submitted with place of ser-vice 11, (office)).

z When you bill services for more than one provider within your group, you must put the individual pro-vider number in Item 24k, as Item 33 can only accept one individual provider number. Also, make sure the provider number on the claim is accurate and it belongs to the group. Don’t forget about the NPIs. Keep in mind that a group will have multiple NPIs (a group NPI and the individual NPI for each provider within the group).

z Diagnosis codes being used are either invalid or trun-cated. Diagnosis codes are considered invalid usually because an extra digit is added to make it five digits. All codes are not created equal. Make sure to code to the highest level of specificity.

z Make sure your practice management system is updated with new, deleted, and revised ICD-9-CM codes each year when the new codes are effective (October 1st of each year).

z Procedure code/modifier was invalid on the date of service. Claims are being submitted with deleted pro-cedure codes.

z New, revised, and deleted CPT® and HCPCS Level II are released each year and effective on January 1st.

z When Medicare is considered secondary payer, Item 11, 11a, 11b, and 11c must be completed each and every time.

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AccountsReceivableFollowUpClaims follow up is crucial. One of the most common mistakes practices make is to set up an automatic rebill of unpaid claims without researching claim status. This will cause duplicate claim denials.

Most payers provide the ability to check claim status online, or automated over the phone. Staff should be assigned to follow up on claim status when payment has not been received.

Payment posting is performed when the remittance advice is received. Staff assigned to payment posting must verify the correct payment has been received. Most practice management/billing systems have a feature for automated payment posting. For this process to work correctly, and to avoid underpayment, best practice is to load the fee sched-ule for each payer so that when an incorrect payment is received, it is identified on a report for research by a biller or A/R representative.

Another common error by practices is to not post zero pay-ments. These are your denial. If they are not posted, you have no way of knowing the claim was denied. Post the zero payment and the denial remark code so you can gen-erate reports to determine total dollars associated with, and the reasons for, denials.

DenialManagementMost denial represents internal errors. How do we fix them?

Most rejections are data entry errors (wrong ZIP code, wrong ID or misspelled names); whereas, denials may require more investigating. All denials should be tracked and documented to ensure prior training is given to avoid future errors. It makes your staff accountable for the errors. It also assists with compliance, should your office get audited. You are showing that the proper steps were taken and documented.

When a denial is received:

1. Review all documentations, such as:a) patient registration formb) patient insurance card front and backc) provider’s documentationd) charge ticket and charge entry e) explanation of benefitf) post denial and/or rejection into system

2. If it’s a simple data entry error, you may be able to: a) correct claim and resubmit

3. If the wrong code and/or patient was billed: a) a letter of explanation should be drafted and sub-

mitted with a corrected claim.b) If provider was paid in error, send a letter to car-

rier to retract payment. There are many reasons a claim can be denied. The steps above should steer you in the right direction. Every denial is unique, and should be handled based on why it was denied or rejected.

AppealsThe practice should monitor unpaid claims via monthly reports, and make sure follow up is being performed. Appeals should be submitted for claims inappropriately denied or not paid at the contracted rate. It is essential for a practice to complete this process to avoid the loss of prac-tice revenue.

Appeals can be costly. Assess the reasons behind the need for the appeals and fix the problem up front if possible. Often, appeals or resubmissions ae required because the patient was improperly registered.

Another key area to watch is denials for medical necessity. This is an opportunity for the practice to update forms and provide additional staff education. Any time a trend is noticed in denials, it should be communicated to all involved to correct the problem in the future. Catching the problem and finding the solution early helps to maintain a stable revenue stream. By assessing the reason for appeals, the practice can cut down on the need for them by provid-ing quality training and communication.

Steps for Success1. Analyze the reason for the denial. Is there a trend

with this payer (or all payers)?2. Keep documentation of every correspondence with

the payer.3. Don’t stop with “no.” Getting the right insurance

representative on the phone to “win” is important. If you believe the claim was clean, submitted properly, and that the payer has an obligation to pay, appeal the denial. Start with your insurance representative and move up the chain of command to the plan’s chief medical officer. The plan’s medical director will often provide a strong ally and resource for the practice physician.

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Case 8 Service:OB/GYN

DATE:03/11/2013

PRE-OP DIAGNOSIS:Pelvicpainandrectocele

POST-OP DIAGNOSIS:Same,pluspostoperativeadhesions

SURGEON:JOHNSMITH,MD

ANESTHESIA:General

OPERATION:Laparoscopicenterolysisandrectocelerepair

FINDINGS:Thepatienthadboweladhesionstotheapexofthevaginaorthevaginalcuff.Therewerenootherabnormalitiesnoted.Theperitonealsurfaceappearedotherwiseintactandwithoutevidenceofotherinflammation.Withrespecttotherectoceleitwasrepairedadequatelywithoutdifficulty.Allcountswerecorrectattheendoftheprocedure.Therewerenocomplicationsnoted.

ESTIMATED BLOOD LOSS:Minimal

DRAINS: None

COMPLICATIONS:Noneknown

CONDITION:Stable

DESCRIPTION OF OPERATION:Thepatientwasidentifiedandtheprocedurewasverified.ThepatientwaspreppedanddrapedintheusualsterilefashioninamodifieddorsallithotomypositionutilizingtheadjustableAllenstirrups.Thehipswereflexedtojustlessthan90degreesofthetable.Thebladderwasdrainedofallurine.Thesubumbilicalareaoftheabdomenwasinjectedwiththesolutionof0.25%Marcainewithepinephrine.AnincisionwasmadewiththescapelandtheEthionOpoiviewtrocarsystemwasuti-lizedforagaslessentryintotheabdomen.Onceconfirmationoftheintra-abdominalplacementwasmade,theCO2wasconnectedandmaintainedat15,andthepatientwaspalcedinTrendelenburg.A5mmportwasplacedintheleftlowerquadrantunderdirectvisualization.Thefindingswereasabove.Thesmallbowelwasabletobemovedoutofthecul-de-sacforbettervisualization.Theadhesionswerenotedonthedescendingcolon.Theyweretakendownsharply.Nootherabnormalitieswereidentified.Thelaparo-scopicportionofthecasewascompleted.Thetrocarswereremovedunderdirectvisualization.Theincisionwasclosedwitha0Vicrylinthefascialleveland4-0Monocryltobothskinincisions.Attentionwasthenfocusedatthevaginalaspectofthecase.Thevaginalintrodtuswasgrapsedwith2Allleclamps.ThisareawasinjectedwithsamediluteWarcainesolution.Thediamond-shapedwedgeofthevaginalmucouswasexcised.Ithenunderminedtheposteriorvaginalwallseparatingitfromtheunderlyingrecto-cele.Therectocelewasrepairedwithaninterrupted3-0Vicrylsuture.Excessvaginalmucouswasexcised.Theremainingvaginalmucouswasclosedinarunninginterlockingmanner.Aperinorrhaphywasincludedintherepair.Therewasnobleedingnotedattheendofthecase.Thepatientdidtoleratetheprocedurewell.Shewasawakenedandtakentotherecoveryroominstablecondi-tion.Allcountswerecorrectattheendoftheprocedure.

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DATE OF SERVICE

PROCEDURE CODE

MOD COESERVICE DESCRIPTION

UNITS CHARGES ALLOWED DEDUCT COINS PAYMENTGRP/CARC

CARC-AMT

03/11/2013 44005 1 2000.00 2000.00 0.00 0.00 1249.60 OA-23 750.40

03/11/2013 45560 1 1000.00 1000.00 0.00 0.00 785.60 OA-23 214.40

Total 3,000.00 3,000.00 0.00 0.00 2035.20 964.80

EXPLANATION CODE DESCRIPTION:

23 The impact of prior payment(s) adjudication including payments and/or adjustments

OA Other adjustments

Case 8 ReviewFor this case, the procedure is processed as a secondary review of the insurance verification: The payer is the primary payer and the patient does not have secondary coverage. The claim is coded correctly. Contact the payer to have the claim repro-cessed so that proper reimbursement is received.

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Case 9Patient:JohnDoe

Account:0001

Date of Procedure:02/02/2013

Surgeon:JohnSmith,MD

Preoperative Diagnosis:Acromioclavicularjointsynovitis,rightshoulder

Procedure:Rightdistalclavicleresection/Mumfordprocedureofrightshoulder

Anesthesia:General

Estimated Blood Loss:Minimal

Complications:None

Procedure in Details:Patientwasbroughttotheoperatingroomandplacedontheoperatingtableinasupineposition.Heunder-wentsuccessfulinductionofgeneralanesthesia.Hewasadministeredpreoperativeantibiotics.Hethereforepositionedonbeach-chairposition.Therightshoulderwaspreppedanddrapedinstandardsterilefashion.Oncecompleted,longitudinalincisionwasmadedirectlyoverthedistalmarginofclavicle.Itwastakendownthroughskinwitha#15blade.DissectionwascompletedthroughsubcutaneoustissueidentifyingthedorsalcapsuleoftheACjoint.Thiswasincisedtransverselyandtheperiosteumalongthedistalmarginoftheclaviclewassubperiosteallyelevated.Usingoscillatingsaw,thedistalmarginoftheclaviclewasthenresected.Thiswasremovedusingcombinationofhookosteotomewhichwasusedtocompletethecut.

Edgesoftheosteotomieswerethenraspedtosmoothmargins.PassivemanipulationoftheshoulderdemonstratednocontactandmaintenanceofgapattheACjoint.Thewoundwasthoroughlyirrigatedandcarewastakentomakesurethattherewasnoboneremainingfromtheresectionsitewhichmaylaterimpinge.

Using0Vicrylsuture,thecapsulewasthenreapproximatedtoitself.LocalanestheticwasinfiltratedbothintothejointaswellasintolocaltissueusingMarcainewithepinephrine.Subcutaneousclosurewascompletedwith3-0Vicrylsutureandrunning3-0Prolenesutureusedinsubcuticularfashionforskinclosure.Steri-Strips,steriledressingandslingwereapplied.

Hewasawakenedfromgeneralanesthesia,extubated,andtransferredtotherecoveryroominstablecondition.

DATE OF SERVICE

PROCEDURE CODE

MOD COESERVICE DESCRIPTION

UNITS CHARGES ALLOWED DEDUCT COINS PAYMENTREMARK CODES

02/02/2013 29824 RT 1 21,595.00 0.00 0.00 0.00 0.00 3384

Total 21,595.00 0.00 0.00 0.00 0.00

EXPLANATION CODE DESCRIPTION:

3384 Procedure code denied, code does not correspond with the attached documentation (resubmit only denied services)

Case 9 ReviewIn this case, the documentation does not support the procedure billed. After reviewing the documentation, the correct code is 23120 Claviculectomy; partial. The code submitted is for an arthroscopic procedure, which was not performed. Although, the provider refers to the procedure as Mumford, the detail of the operative note does not support the code billed. This is an example of why you must review the operative note in its entirety, instead of coding from the operative note headers.

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Case 10Date: 3/11/2013

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Codes submitted include: 99213-25 250.02,401.198928 724.4J1040 724.3,729.120552 724.3,729.1

DATE OF SERVICE

PROCEDURE CODE

MOD COESERVICE DESCRIPTION

UNITS CHARGES ALLOWED DEDUCT COINS PAYMENTREMARK CODES

03/11/2013 99213 25 1 85.00 72.13 0.00 14.43 57.70 CO-45

03/11/2013 98928 1 85.00 65.30 0.00 13.06 52.24 CO-45

03/11/2013 20552 1 125.00 54.40 0.00 10.88 43.52 CO-45

03/11/2013 J1040 1 40.00 8.59 0.00 1.72 6.87 CO-45

Total 250.00 128.29 0.00 25.66 102.63

EXPLANATION CODE DESCRIPTION:

45 Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.

CO Contractual Obligation

This claim was coded and processed correctly. Multiple procedures are performed in addition to the E/M. With proper modifier use and diagnosis code linkage, the claim is processed with no errors.

ReportingYou’ll need reports to effectively monitor A/R. Most prac-tice management systems have reports available to help monitor the A/R. Common reports include denial reports, aging reports, and A/R analysis report.

The denial management report should be run by payer and denial type. This will allow you to quickly analyze trends with payers or common denials. Researching the cause of the denials will help you identity internal errors. This will allow you to monitor the entire billing process to find problems and fix them. It will also identify specific payers you may have a problem with. If the same payers are consistently a problem, contact the payer representative for resolution.

The aging report breaks down the outstanding A/R in buckets of age and payer type. This allows you to deter-mine the priority of the follow up efforts. The A/R analysis report will provide more detail which will also help with drilling down to the details for claim follow up.

ConclusionEach step discussed must be performed in order for your medical billing process to work effectively. If a step is missed, it will result in denials or inappropriate payments. Attention to details is a must. Monitor the success of each step and make improvements quickly should you find an error. Use your resources. In order to be successful, you must stay up to date on all payment policies for each one of your payers. Things change often and if you are not dili-gent in staying up to date, errors will occur.

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Presentation

Mastering Documentation Review

Mastering Documentation Review

Written by: Yvonne Dailey, CPC, CPC-I, CPBPresented by:

Mastering Documentation Review

Mastering Documentation Review

AAPC DisclaimerThis course was current when it was published. Every reasonable effort has been made to assure the accuracy of the information within these pages. Readers are responsible to ensure they are using the codes, and following applicable guidelines, correctly. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free, and will bear no responsibility or liability for the results or consequences of the use of this course. This guide is a general summary that explains guidelines and principles in profitable, efficient health care organizations.

AMA DisclaimerCPT® copyright 2012 American Medical Association. All rights reserved.Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT® is a registered trademark of the American Medical Association.The responsibility for the content of any “National Correct Coding Policy” included in this product is with the Centers for Medicare and Medicaid Services and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, nonuse or interpretation of information contained in this product.

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Mastering Documentation Review

Introduction

• Medical billing cycle processes• Most common deficiencies in documentation• The importance of linking the codes correctly• Missing elements during charge entry• How to handle denials and tools to use • Putting all the pieces of the revenue cycle together

Mastering Documentation Review

1. Insurance Verification

2. Patient Demographic

Entry

3. Provider Documentation

4. CPT and ICD-9- Coding

5. Change Entry

6. Claims submission

7. Payment Posting

8. A/R Follow-Up

9. Denial Management

10. Reporting

Medical Billing Process

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Ten Step Process• Ten Step Process• Four Crucial/Key Steps

– Insurance Verification– Provider Documentation– Coding– Billing

Mastering Documentation Review

What is YOUR Role in this Process?Role Responsibilities

Receptionist/Scheduler Schedule patient appointmentsGreet the patientVerify insurance & eligibilityDiscuss insurance coverage with the patient

Provider Perform patient encounters Document the patient’s condition and treatment plan in medical recordIn some practices, select the codes for billing

Medical Coder Interpret the medical record based on the documentation Depending on facility, may add modifiers and procedures

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What is YOUR Role in this Process?Role Responsibilities

Charge Entry Clerk/Biller Verify case information for accuracy for claim submissionSubmit claims

Payment Clerk Apply all payments received to patient account (this includes zero payment EOBs)

Account Representative Research denials/rejections, process corrections, resolve insurance billing or payment problems, and establish payment plan with patient

Mastering Documentation Review

What is YOUR Role in this Process?Role Responsibilities

Administrator Generate and review reports for supporting the billing process

These reports include daily, weekly, monthly, quarterly, and yearly tasks

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Insurance Verification• The first step/First contact with patient – Cycle starts

– The MOST important step in process, but often most ignored • Determine if the provider is in network • Inform patient prior to service of problems with insurance coverage• New patient vs. established patient• No time• Loss of revenue• Identify if prior authorization/precertification and/or referral are needed• ABN required• Determine the referring provider• What questions to ask?

Mastering Documentation Review

Insurance Verification

• Insurance verification– Questions to ask:

• Does the patient have a deductible?– Has it been met?

• Does the patient have co-insurance/What is the percentage?

• Does the patient have a Co-Pay/How much is it? • Coverage start and end dates

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Insurance Verification

Scenario:Practice has two patients, one named Rafael Lewis Gonzales and the other Rafael Luis Gonzales. Both born 8/4/1990.

Rafael Luis Gonzales was was seen today; however, no one noticed that the charge ticket the receptionist filled out was for Rafael Lewis Gonzales.

Now the office billed for the wrong patient.

Mastering Documentation Review

Insurance VerificationA GYN provider is often considered a PCP, not a specialist. If you collect the specialist fee, but a particular carrier views the GYN as PCP, you are placing your practice at risk because you have collected more than what you were entitled to.

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Patient Demographics • Review intake form to ensure the information is accurate• Did the patient sign the financial policy?• Make a copy of the insurance card – front and back• Make a copy of patient ID – front and back• Are ALL forms signed and dated?• Collect copay, deductible, and/or co-insurance • Update intake forms annually • Start and end dates for insurance carriers – REQUIRE IT• Review at each visit – also review ID for changes

Mastering Documentation Review

• Please review the progress note, insurance card, and EOB for Case 1.

• We will review the case after you have completed it.

Case 1

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Case 1

• EOB states patient’s responsibility is $35• Why is the copay incorrect?• Do we collect the difference from patient, or

carrier?• What are the necessary steps to correct this?• Is the claim coded correctly?

Mastering Documentation Review

Insurance Verification

INNER CIRCLE

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• Lack of patient signature on all proper documentation: – ABN not signed– financial policy not signed

• Physician missing, or wrong date of service • Missing and/or not properly appended CPT®/HCPCS

Level II modifiers• Clinical significance/medical necessity for lab orders• Increased use of EMRs:

– Cloned documentation

Documentation

Mastering Documentation Review

• Please review the progress note and section of claim form provided Case 2.

• We will review the case after you have completed it.

Case 2

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Case 2

• What is the correct dx. code?• What’s missing on the 1500 form? • Can we bill for the E/M?

Mastering Documentation Review

Impact on Compliance and Reimbursement

• Lost revenue • Payment disputes (with patient and carriers)• Audit risks• Compliance risks

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Mastering Documentation Review

• Please review the operative note and remittance advice provided Case 3.

• We will review the case after you have completed it.

Case 3

Mastering Documentation Review

Case 3

• What impact does modifier 59 have on this case?

• What’s the difference in revenue? • Codes submitted: 36226, 36224, 36223, 36225,

36227• Correct codes and modifiers: 36226, 36224-50,

36225-59, 36227

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Missed Charges = Lost Revenue

• We often see money left on the table • Missing charges for supplies• Missing charges for services & procedures • Missing charges for devices• Not collecting payment at time of services

(e.g., copays or self pays) • Established patient vs. New patient

Mastering Documentation Review

Missed Charges = Lost Revenue

• Most common service/procedure missed are vaccination administration and venipuncture charges

• Small charges add up• Let’s take a look at the flu vaccine…

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Missed Charges = Lost Revenue

• If we were to take the administration fee alone for a typical flu season – 250 patients – and multiple it by the reimbursement fee schedule for the administration

State Reimbursement Amt. 250 patients seen during the flu season

New Jersey 01 $29.80 $7,450.00New Jersey 99 $28.48 $7,120.00

Mastering Documentation Review

Missed Charges = Lost Revenue

• New Patient vs Established Patient fee difference

State Reimbursement Amt. For new pt. 99203

Reimbursement Amt. For established pt. 99213

New Jersey 01 $120.79 $81.33Difference of $39.46

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New Patient vs. Established Patient Fee Difference

DOS CPT® MOD SERVICE DESCRIP UNIT CHARGE ALLOW ADJ PAY PT REM

6/15/2013 99213 Established Patient Level III

1 100.00 0.00 0.00 0.00 100.00 PR-B16

Total 100.00 0.00 0.00 0.00 100.00

EXPLANATION CODE DESCRIPTION:

B16 New Patient qualifications were not met

PR Patient Responsibility

Mastering Documentation Review

CPT® & ICD-9 Coding

• Coder is responsible to review for accuracy • Don’t leave money on the table• Medical billing and coding is like a puzzle – all

pieces must link together accordingly • Medical necessity must be met • Know your carrier guidelines and policies

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• Please review the operative note and billed codes for Case 4.

• We will review the case after you have completed it.

Case 4

Mastering Documentation Review

Case 4

• What was billed does not match provider documentation

• What steps are necessary to correct this?

• Why is it important that billers have access to all documentation?

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CPT® & ICD-9 Coding

Mastering Documentation Review

Applying Correct Modifiers

• Must be supported by documentation

• Fully describes the encounter

• Positive and negative effect on reimbursement

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Applying Correct Hospice Modifiers GV and GW

• Modifier GV - Attending physician not employed or paid under arrangement by patient’s hospice provider

• Modifier GW - Service not related to hospice terminal condition

Mastering Documentation Review

• Please review the progress note, insurance card, and encounter form for Case 5.

• We will review the case after you have completed it.

Case 5

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Case 5

• Which modifier is needed: GV or GW?

• Would the provider need any other mod?– Why or why not?

• How many billable charges are there?

Mastering Documentation Review

Carrier Policies Determine Billing Codes

The flu vaccine can be billed a number of ways: • Medicare (depending on your Medicare Carrier)

Q2037 – Flu Vaccine (Q code depends on the ACTUAL vaccine administered to patient)

G0008 – Administration of Flu Vaccine

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• Commercial carrier:90658 – Flu Vaccine90471 – Administration of vaccine

• Changes if it was the FluMist

Carrier Policies Determine Billing Codes

Mastering Documentation Review

Carrier Policies Determine Billing Codes• Billing for annual exam - First Priority Life/Health

First Priority Life Procedure code Description

Does not cover99281-99397

S0610 Annual exam – new pt. report with dx. v72.31

S0612 Annual exam – est. pt. report with dx. v72.31

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Carrier Policies Determine Billing CodesAetna – Billing for annual exam

Routine GYN S0610, S0612, S0613, 99381-99397, 99401-99404, 99201–99205, and 99211-99215 are considered to be preventive if the primary diagnosis code is: V72.3, V72.31,V72.6, V76.2, V76.46, V76.47, V84.02, or V84.04

Mastering Documentation Review

Carrier Policies Determine Billing CodesAetna – Billing for annual exam

Pap Smear - PreventiveG0101, G0123-G0124, G0141-G0148 and P3000, P3001, Q0091,88141-88155, 88164-88167, and 88174-88175 are considered to be preventive if the primary diagnosis code is: V72.3, V72.31,V72.6, V76.2, V76.46, V76.47, V84.02, or V84.04

Pelvic Exams G0101

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• Please review the progress note, Medicare policy, Aetna policy, encounter form, ABN, claim form, and remittance advice for Case 6.

• We will review the case after you have completed it.

Case 6

Mastering Documentation Review

Case 6

• What can we bill under Aetna but not under Medicare?• What note must be on the claim for Medicare?• Would we need an ABN for Medicare?

– Why or why not?

Let’s complete the charge ticket for each carrier • What’s different on the 1500?• To where do we mail the Aetna claim ?

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Putting It All Together • Enter all charges• Review BEFORE submission• Based on the provider’s documentation• Review for lost revenue (administration, supplies, etc.)• Samples of things to review:

– NPI, referring provider information, onset date, DOB, DOS – Know payer policies for what is billed – Are any modifiers needed – Review provider documentation

Mastering Documentation Review

• Please review the progress note and encounter form for Case 7.

• We will review the case after you have completed it.

Case 7

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Case 7

Mastering Documentation Review

Case 7

• How many billable charges are there?• Is there anything missing?• Will it require a modifier?• Do you need a referring and/or ordering provider?• Does it make a difference if this is a Medicare pt. or a Commercial pt.?

– Why or why not?• Do we need to review documentation?

– Why?

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• The patient cannot be identified• Address for the place of service, including a valid ZIP

code• E/M procedure code and place of service do not

match• NPI missing or invalid• Diagnosis codes invalid or truncated

Common Billing Errors

Mastering Documentation Review

• Procedure code/modifier invalid

• Information needed when Medicare is a secondary payer

Common Billing Errors

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• Do not set to auto rebill every 30 days

• Run reports from practice management system

• Assign staff for claims follow up-make accountable

Claims Follow Up

Mastering Documentation Review

• Monitor payments to make sure they are correct

• Post adjustments so that A/R is not inflated

• Post zero payments with the denial remark codes

Payment Posting

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Denial Management1. Review all documentations, such as:

a) patient registration formb) patient insurance card, front and backc) provider’s documentationd) charge ticket and charge entry e) Explanation of benefit/remittance advicef) posted denial and/or rejection message into system

Mastering Documentation Review

Denial Management2. For a simple data entry error, you may be able to:

a) correct claim and resubmit

3. If the wrong code and/or patient was billed: a) Draft and submit a letter of explanation with a corrected claim

b) If provider was paid in error, send a letter to carrier to retract payment

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Denial Management

• In many cases, practice denials represent internal errors • Loss of revenue or delayed revenue• Track denials• Train staff on payer policies, coding, billing (your findings)• Monitor • Make staff members accountable

Mastering Documentation Review

1. Analyze the reason for the denial• Is there a trend with this payer (or all payers)?

2. Keep documentation of every correspondence with the payer

3. Don’t stop with “no”

Appeals-Steps for Success

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• Please review the operative note and remittance advice for Case 8.

• We will review the case after you have completed it.

Case 8

Mastering Documentation Review

• Is the claim coded correctly?

• Is it processed by the payer correctly?

• How should you resolve the problem if it is not paid correctly?

Case 8

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• Please review the operative note and remittance advice for Case 9.

• We will review the case after you have completed it.

Case 9

Mastering Documentation Review

• Is the claim coded correctly?

• Is it processed by the payer correctly?

• How should you resolve the problem if it is not paid correctly?

Case 9

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86 AAPC 1-800-626-CODE(2633) CPT®copyright2012AmericanMedicalAssociation.Allrightsreserved.

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Mastering Documentation Review

• Please review the progress note and remittance advice for Case 10.

• We will review the case after you have completed it.

Case 10

Mastering Documentation Review

• Is the claim coded correctly?• Is it processed by the payer correctly? • How should you resolve the problem if it is not paid

correctly?• What feedback would you give the provider

regarding documentation?

Case 10

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• Monitor A/R• Common reports:

– Aging • Payer type• Dollar amount

– A/R Analysis

Reporting

Mastering Documentation Review

Questions?

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88 AAPC 1-800-626-CODE(2633) CPT®copyright2012AmericanMedicalAssociation.Allrightsreserved.

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Mastering Documentation Review