The GCA office and Medicare Subcommittee has received numerous calls regarding the new Medicare rule that requires a records review after 25 visits in a 12-month period. Please note the rule is NOT based on a calendar year, but a rolling year.

After the patient's 25th visit in a 12-month period, Medicare will automatically deny the visit, forcing D.C.s to file an appeal and send in records to substantiate the medical necessity.

The Medicare Subcommittee suggests keeping track of Medicare patient visits to determine whether you should expect a denial. If you have a patient who has over 25 visits in a 12-month period (for example July 10, 2011 - July 10, 2012), you have two options:

1. Have the patient sign an ABN and ask for payment up front until the rolling year ends. File appeals on the denials, and have the patient file an appeal, too, or at least write a letter to include in your appeal.
2. Have the patient sign the ABN, but don't make the patient pay up front. Appeal the denial, and ask the patient to write an appeal and/or a letter to include in your appeal.

It is imperative that you file the appeal, and your records demonstrate the need for care, a care plan with goals and that you are making progress with the patient and that the care is not maintenance care.

If the patient is at MMI then put them on maintenance care and make them pay for it. Use the maintenance care ABN for that circumstance.  

GCA has heard doctors say the appeals process is too much to go through for a $30 Medicare visit. However, if we don't file the appeals on care that is medically necessary, then Medicare will incorrectly assume that no one really needs over 25 visits in a year and will implement screens at 20 visits in 12 months next year.

Many doctors of chiropractic have probably received a request for records on one or more Medicare patients from CAHABA, the contractor/payor for Medicare in Georgia. It is vitally important to all of us that you comply with this request and that your records meet the required standards to properly document the medical necessity of your treatment. These reviews are mandated by CMS to all local carriers to assure claims are properly paid. If your records do not substantiate your care, the claim may be denied, or if already paid, you may be required to refund the money.

Please click here to review the record requirements for chiropractic care under Medicare. Please take time to read them and make sure your records meet the standard of care. Also please remember that it is unwise and illegal to change or alter your patient records, but you can make an addendum to your records at any time if so properly noted.

Our Medicare sources have indicated that in a records-review process, these are some of the questions they will be asking about your records, giving consideration to the combined documentation of the initial and subsequent visit(s):

• Does the record show a significant neuromusculoskeletal condition?
• Is there a precise subluxation(s) documented by physical exam or X-ray?
• Does the exam substantiate the condition and the subluxation?
• Is the complaint consistent with the subluxation level(s)?
• Is there a primary diagnosis of subluxation and a secondary ICD diagnosis that bears a direct relationship to the primary level of subluxation?
• Is there a treatment plan?
• Is the adjustment clearly recorded in the record as being done each visit with the specific vertebral segment(s) identified?
• In order to substantiate the need and frequency of ongoing care, does your documentation note a response to treatment, i.e., increased range of motion, increased function, decreased pain, etc?
• Do the subjective complaints and objective findings reflect qualitative and quantitative factors when describing onset, duration, intensity, frequency and location?
• Is the adjustment therapeutic or maintenance (maintenance is non-covered by Medicare)?
  

Initial Visit Requirements

• Relevant history of patient’s condition with detailed description of the present condition(s)
• Evaluation of musculoskeletal/nervous system through physical examination (evidence of subluxations through P.A.R.T.)
• Diagnosis (must contain a subluxation level and corresponding symptom diagnosis)
• Treatment plan
• Recommended level of care (duration and frequency of visits)
• Specific treatment goals
• Objective measures to evaluate treatment effectiveness
• Date of initial treatment
  

Subsequent Visit Requirements

• History
• Review of chief complaint
• Improvement or regression since last visit
• System review, if relevant
• Physical examination
  

CMS states that the following requirements should be included in your patient chart notes to describe the presenting complaint. After completing your case history with the patient, you should be able to ask yourself the questions below and answer them with your documentation:

Requirement                                                                           Ask Yourself

Symptoms causing the patient to seek treatment    Why is patient seeking care?

Mechanism of onset                                              How did the condition/injury happen?

                                                                           Gradual/sudden?

Quality and character of symptoms/problem            Onset, duration, intensity, frequency, location, and radiation of symptoms

                                                                           Do my notes paint a picture of the patient’s symptoms, including specific descriptive remarks that would allow a third-party reader to fully understand this complaint?

Aggravating or relieving factors                               What causes the condition to improve or worsen?

Prior interventions, treatments, medications,           What has been tried in the past and are there

secondary complaints                                           any complicating factors?

Family history, if relevant                                       Are there any factors in the family history that relate to this condition?

Past health history (general health, prior illness,      What aspects of the patient’s health history

injuries, hospitalizations, medication, surgeries)      factor into this current condition?

NOTE: These symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine, muscle, bone, rib and joint and be reported as pain, inflammation or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder and hand problems as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must relate to the spine as such.

Most of the reviews we know of involve a patient that was treated for several months, possibly completed treatment and returned with a new episode or a new condition. It is important that your care plan be updated when this occurs to meet the record keeping requirements. Medicare looks at goals and treatment plans seriously. They must be in your records. One big issue is knowing when to release a patient to Maintenance Care, and when to consider care Active Therapeutic Care(AT). Bear this in mind and take an objective look at the claim being reviewed.

If you have further questions we recommend you take the Medicare seminar offered by GCA September 24 in Macon, GA. Members may contact the GCA office at 770-723-1100 for access to the members-only Insurance Hotline for specific review questions.

Dr. Mark Cotney, GCA Medicare Subcommittee Chair

Insurance Matters: Version 5010 and ICD-10

With the upcoming deadlines for Version 5010 and ICD-10 approaching, providers should be prepared to ensure minimal disruption to their practice. The American Chiropractic Association has created a suggested timeline to assist in this process.

Version 5010
Currently, about 99 percent of Medicare Part A claims transactions and 96 percent of Medicare Part B claims transactions are received by CMS electronically in Version 4010 format. However, Version 5010 will accommodate the changes to the ICD-10 codes (Version 5010 is a pre-requisite of ICD-10 compliance) and provides better specificity in reporting and data collection.

The most important elements of Version 5010 transition success are proper training and education. All practices, large and small, must allow plenty of time for implementation. The Department of Health and Human Services developed a provider action checklist to assist with the transition to Version 5010 that details required actions, questions to ask outside vendors, and questions providers themselves should consider. Click here for the checklist.

ICD-10
The conversion to ICD-10 will enable health care providers to report diagnoses in greater specificity, allowing for more accurate reporting. Many providers are wondering what they should be doing now to prepare for ICD-10. While it is important to learn about what is coming and to understand ICD-10, providers should be aware that there will also be changes and updates.

Taking the time to become informed about this process and to communicate with involved parties (such as insurers, claims clearinghouses, billing services, etc) will help ease the transition. The deadlines for compliance with Version 5010 and ICD-10 are definite, and those who do not use ICD-10 code on or after October 1, 2013 will not be paid.