Medicare is a complex topic. For detailed information on this government program, as it relates to chiropractic services, see Chapter 2 in the ChiroCode DeskBook. The following concepts are covered in the DeskBook:
For additional information visit ChiroCode.com. Since 1993 Chiropractors have depended on ChiroCode as a reliable source of information for the Chiropractic community. Because of the dependability and education, ChiroCode has earned much renown. View current and recent webinars, order the ChiroCode DeskBook, (comprehensive go-to chiropractic reimbursement manual) and much more.
Select the title to see a summary and a link to the full article.
September 30th, 2019
CMS and HHS Tighten Enrollment Rules and Increase Penalties
By Wyn Staheli, Director of Research | Published September 30th, 2019
This ruling impacts what providers and suppliers are required to disclose to be considered eligible to participate in Medicare, Medicaid, and Children's Health Insurance Program (CHIP). The original proposed rule came out in 2016 and this final rule will go into effect on November 4, 2019.
There have been known problems ...
The OIG Work Plan: What Is It and Why Should I Care?
By Namas | Published August 9th, 2019 - Last Review/Update August 14th, 2019
The Department of Health and Human Services (HHS) founded its Office of Inspector General (OIG) in 1976 and tasked it with the responsibility to combat waste, fraud, and abuse within Medicare, Medicaid, and the other HHS programs. With approximately 1,600 employees, HHS OIG is the largest inspector general's office within ...
Q/A: What do I Need to Document for Periodic Adjustments on a Medicare Patient?
By Evan Gwilliam DC MBA BS CPC NCICS CCPC CCCPC CPC-I MCS-P CPMA | Published July 22nd, 2019
Question:
What type of documentation is required for a Medicare patient with degenerative joint disease who get adjusted once or twice a month for occasional flare-ups of the D. J. D. region? The noted adjustments give good relief of the patient's symptoms.
Answer:
There is no question that these adjustments would be considered ...
Act Now on CMS Proposal to Cover Acupuncture for Chronic Low Back Pain
By Wyn Staheli, Director of Research | Published July 17th, 2019
Now is the time to comment on a proposal to cover acupuncture for chronic low back pain. This comment period is the part of the HHS response to the opioid crisis. You only have until August 14th to officially comment.
Medicare Supplemental Policies (MediGap) and Extremity Adjustments
By Wyn Staheli, Director of Research | Published February 25th, 2019
The nice thing about MediGap policies is that they pay for some of the healthcare costs that an original Medicare plan (Part B) does not cover. So when a patient has Medicare and a Medicare supplement (MediGap) and their condition is related to an extremity (a noncovered service), Medicare must ...
Q/A: Can a PT Assistant Perform Physical Therapy Modalities?
By Wyn Staheli, Director of Research | Published June 18th, 2018 - Last Review/Update January 30th, 2019
Whether or not a physical therapy assistant (PTA) may perform physical therapy modalities depends on two factors: state law and payer policies. Read here for more.
Medicare Requiring Specific Modifiers on Therapy Services
By Wyn Staheli, Director of Research | Published January 15th, 2018
Medicare's MLN Matters Number: MM10176 was recently revised to identify services subject to their therapy cap. The revision became effective on January 1, 2018 and some providers have begun to receive claim rejections because they are not using the appropriate modifier. The article states the following:
Services furnished under the Outpatient ...
By Wyn Staheli, Director of Research | Published January 15th, 2018 - Last Review/Update January 30th, 2019
Q: When patients have a true Medicare secondary insurance we've always billed other Medicare non-covered codes such as G0283 for electric stimulation with modifier GY because we are aware Medicare will not pay for that service but the secondary insurance does. We just were notified by our MAC that GY is not a valid modifier and I have to enter a GP or other therapy modifier. What is the new proper modifier to enter?
By David Klein CPC, CPMA, CHC | Published October 31st, 2017 - Last Review/Update February 5th, 2019
Recent events regarding delegation of services to ancillary personnel have given rise to concerns regarding the delivery of outpatient physical medicine by Chiropractors, specifically regarding the appropriate use of one-on-one codes as opposed to group therapy code CPT 97150 - Therapeutic procedure(s), group (2 or more individuals). This advisory provides guidance on how to properly use one-on-one and group therapy codes, both independently and together.
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published October 23rd, 2017
The Office of the Inspector General was created to protect the integrity of the U.S. Department of Health and Human Services. They investigate fraud, waste, and abuse in HHS programs and make recommendations to various enforcement agencies. Every few years they investigate chiropractic services. Here is a summary of the reports the ...
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published October 13th, 2017 - Last Review/Update February 5th, 2019
Chiropractors cannot opt-opt of Medicare. Does that only refer to chiropractors that see Medicare patients? Do all Florida chiropractors have to complete Medicare enrollment/credentialing? Bottom line- do ALL chiropractors, no matter where or who, have to complete Medicare enrollment since they cannot Opt-out?
By ChiroCode | Published September 25th, 2017 - Last Review/Update February 5th, 2019
MIPS is a program that allows Medicare to collect data from providers about high quality low cost care that uses technology effectively. There are four categories and providers need to learn about the available measures so that they can pick the ones that make them look the best.
Medicare Improper Payment Report for Chiropractic (2016)
By Wyn Staheli, Director of Research | Published September 1st, 2017 - Last Review/Update October 16th, 2017
The Medicare Improper Payment Report for 2016 has been released by the OIG. Please note that the improper payment rate does not measure fraud. Rather, it estimates the payments that did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from ...
American Chiropractic Association Comments on MACRA 2018 Proposed Rule
By ChiroCode | Published September 1st, 2017 - Last Review/Update January 30th, 2019
Arlington, Va. - The American Chiropractic Association (ACA) recently submitted comments to the Centers for Medicare and Medicaid Services (CMS) in response to the federal agency's proposed rule changes to the Quality Payment Program (QPP) for 2018.
QPP is a new payment model for physicians, including chiropractors, created by the Medicare Access and CHIP ...
By Wyn Staheli, Director of Research | Published February 8th, 2017
In April of 2015, the Sustainable Growth Rate (SGR) formula which is used to calculate the Medicare Physician Fee Schedule (MPFS) Conversion Factor was repealed as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The conversion factor will increase by 0.5% each year until 2019 and ...
By Wyn Staheli, Director of Research | Published February 6th, 2017
On January 17, 2017, a Final Rule was published in the Federal Register outlining changes to the Medicare Appeals process in an order to streamline procedures and reduce the current backlog of appeals at the third and fourth levels of appeal. This new policy takes effect on March 20, 3017. ...
Code Sets - Health Care Provider Taxonomy Code Set Link
By Raquel Shumway | Published January 24th, 2017
Every Provider needs to know their Health Care Provider Taxonomy Codes. The Taxonomy Codes define the provider type, classification, and area of specialization. We have provided a link and instructions to help you locate your code.
Alternative Payment Models (APMs) and Advanced APMs
By Wyn Staheli, Director of Research | Published January 16th, 2017
When CMS Released the NPRM regarding the Quality Payment Program (QPP), it included two payment tracks: MIPS and Advanced Alternative Payment Models (APMs). Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are some examples of APMs. So how do these payment models differ?
According to a fact sheet ...
By Wyn Staheli, Director of Research | Published September 17th, 2016
The Department of Health and Human Services (HHS) oversees all government health care programs. They are administered by various agencies such as the Centers for Medicare & Medicaid Services (CMS), the Veterans Administration (VA) and even at the state level. Here are the basic government programs:
Medicare
Federal Workers’ Compensation
Military and Veterans
Medicaid
Federal ...
Mastering Medicare: When Opting Out is not an Option
By Dr. Ray Foxworth, Certified Medical Compliance Specialist and President of ChiroHealthUSA | Published June 15th, 2016 - Last Review/Update March 5th, 2019
Unlike MDs and DOs, chiropractors may not opt out of Medicare.
When it comes to Medicare, providers and patients alike feel like beating their heads against the wall. Signing up to be a provider or a patient is confusing, understanding what is covered is confusing and just about the time you think you have it figured out, you receive a notice that suggests you don’t.
The hassles of Medicare certainly validate any sane person questioning whether they should see a Medicare patient, but with the rising number of Medicare patients in the US do you really want to limit your patient base?
The Health Insurance Portability and Accountability Act (HIPAA) has been around for quite some time. There are many misconceptions about HIPAA compliance that our office still gets calls about. This page is to help clear up some of these misconceptions.
Occasionally providers are faced with the need to assess the option of making a voluntary disclosure to the government. Here are steps that every provider should consider before disclosing information to the government.
By | Published February 23rd, 2015 - Last Review/Update March 9th, 2016
Q: We have recently enrolled with Medicare and treat only a few patients. However, those claims are being denied. Can you help me to understand why this might be happening?
A: First, I would recommend you carefully review your Medicare Remittance Advice as that will identify the reason Medicare is denying your ...
By | Published February 10th, 2015 - Last Review/Update February 18th, 2016
The Centers for Medicare & Medicaid Services (CMS) uses a network of contractors called Medicare Administrative Contractors (MAC) to process Medicare claims, enroll health care providers in the Medicare program and educate providers on Medicare billing requirements. MACs also handle claims appeals and answer beneficiary and provider inquiries. Even though ...
Q & A: Establishing a Multi-Disciplinary Practice and Being Legal
By | Published December 1st, 2014 - Last Review/Update January 30th, 2017
Q: How do you add another provider type such as a Nurse Practitioner to your practice to provide additional services to patients and legally bill for those services under their license?
A: Multi-disciplinary practices are under scrutiny at the moment by ZPIC, CMS and State Boards. For your reference, just below, there ...
Have you checked your QRUR to find out if you qualify for a CMS bonus (or penalty)?
By | Published November 25th, 2014 - Last Review/Update January 30th, 2017
What? You've never heard of a QRUR?
You have probably heard about Meaningful Use (MU) and penalties that kick in for those who did not attest. And the Physician Quality Reporting System (PQRS) with penalties for those who did not successfully report on at least one patient. The new one ...
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published November 19th, 2014 - Last Review/Update January 30th, 2017
Recovery Audit Contractors, also known as RAC, is a program that seeks to identify and correct improper payments for services provided to Medicare Parts A & B beneficiaries. This includes both recoupment of overpayments and corrected distribution of underpayments made by CMS.  RAC began in 2005 as a three-year demonstration project consisting ...
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published October 16th, 2014 - Last Review/Update January 23rd, 2017
In October of 2000 in the Federal Register the Office of the Inspector General (who investigates fraud against the federal government on behalf of the Department of Health and Human Services) offered general guidelines for health care facilities to set up a “Compliance Program”. This advice has long been pushed ...
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published October 16th, 2014 - Last Review/Update November 29th, 2017
What is the ABN form used for?
The Advanced Beneficiary Notice of Non-Coverage (ABN) is the Notice of Liability that is required to be provided to Medicare patients in the event that the service(s) rendered to them are expected to not be covered. For chiropractic, reason for non-coverage is generally due ...
By Wyn Staheli, Director of Research | Published September 15th, 2014 - Last Review/Update July 12th, 2016
Many procedure codes are considered "timed codes," that is, the number of units are determined by the amount of time spent performing the service. Medicare Claims Processing Manual, Chapter 5 clarification included here.
By | Published July 24th, 2014 - Last Review/Update January 29th, 2016
Are Medicare fees going up? Or down? Results for the following:
Sequestration
Chiropractic Demonstration Project
Electronic Health Record/Meaningful Use
Physician Quality Reporting System - PQRS
Value-Based Modifier
By | Published February 12th, 2014 - Last Review/Update January 27th, 2017
The following information is from the Centers for Medicare & Medicaid Services (CMS) regarding the Electronic Health Records (EHR) payment reduction hardship exemption.
ICD-10 Coding Possibilities for Chiropractic Physicians
By Evan M Wsilliam, DC, CPC, CCPC, NCICS, CCCPC, CPC-I, MCS-P, CPMA | Published September 11th, 2013 - Last Review/Update January 27th, 2017
Right now, it’s hard to say which ICD-10 codes third-party payers will select as medically necessary, but we can make an educated guess based on information from a few sources. More detail is expected from Medicare before the end of 2013. For doctors of chiropractic (DCs), the natural place to start is with the relatively short list of frequently used ICD-9-CM codes for submitting claims. We’ll investigate a handful of diagnosis codes that Medicare recognizes as medically necessary and explore ICD-10-CM code possibilities.
Inappropriate Medicare Payments for Chiropractic Services
By | Published August 30th, 2012 - Last Review/Update January 27th, 2017
OIG released two reports critical of the way chiropractic handled documentation and coding. Their findings are included in this article. Read further to see what documentation is needed for proper payment.
As required by the Social Security Act, Medicare pays only for reasonable and necessary chiropractic services, which are limited to active/corrective manual manipulations of the spine to correct subluxations. A chiropractic service must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.
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December 11th, 2018
Chiropractic Manipulative Treatment and Medicare - Part 2
In this CE webinar, Dr. Gwilliam will continue his discussion from the webinar delivered Dec. 18 about chiropractic manipulative treatment. But this time, it is all about Medicare. If you don't treat Medicare beneficiaries, you should probably listen anyway. Usually whatever Medicare wants is the same thing as all the other payers. Find out the difference between acute, chronic, and maintenance, as well as when to use certain modifiers.
Proving Medical Necessity and Functional Improvement
Medicare is required by law to pay for care that is medically necessary. Medicare considers functional improvement to be the primary indicator of medical necessity for chiropractic care. It is up to you, the doctor, to prove functional improvement and medical necessity with your documentation. Dr. Short will show you how to use common practice tools to document functional improvement, medical necessity and maximum medical improvement. You will learn:
What is Medicare’s definition of medical necessity.
How to prove medical necessity.
How to report this information to Medicare.
How to determine Maximum Medical Improvement.
Earlier this year the Medicare Administrative Contractors revised their Local Coverage
Determinations. There are some changes that will affect how you document your Medicare
visits. Medicare requires that you have a treatment plan with measurable goals. The treatment plan also serves the purpose of providing you and your patient with a roadmap of care. In this
webinar Dr. Short will show you:
What specific elements Medicare requires in each treatment plan.
How to use common clinical tools to develop effective treatment plans.
Why the treatment plan is critical to proving medical necessity and overall patient care.
This webinar will give you practical information that you can apply in your office the next day.
You can obtain the notes for this webinar by subscribing to my e-mail updates at http://www.chiromedicare.net/mailing-list- signup/ or by following the link provided in my e-
mail update. They will be available by the Monday prior to the webinar presentation.
In this webinar, Dr. Gwilliam will go over code updates for 2018. He will show you some new ways to look at Episodes of Care, which is critical for Medicare. You'll learn how to use self audit checklists to make sure you survive the inevitable third party audit. Confession: This webinar is really just a pitch for all of the cool new things we are adding to the 2018 DeskBook, which will be released in October. We will give you the low down on what you need to be successful next year.
If eligible, you need to start reporting for MIPS by October 2th, 2017. Do you know who is exempt? Are you familiar with the quality measures that apply to chiropractors? Do you understand how to report on the Advancing Care Information or Improvement Activities? Don’t worry, Dr. Gwilliam has done all your homework and, in this presentation, you will get the crib notes containing just what you need to know. You don’t need to feel overwhelmed with Medicare regulations, you just need to know what to do.
The New Local Coverage Determinations and What They Mean to You
Earlier this year the Medicare Administrative Contractors revised their Local Coverage Determinations. There are some changes that will affect how you document your Medicare
visits.
In this webinar, Dr. Ron Short will explain the changes to the Local Coverage Determinations and how to utilize them in your practice.
You will learn:
What has changed and how it will affect you
What has stayed the same
How to document Medicare Visits
How to Convert Your Medicare Patients to Cash to Avoid the Penalties of MACRA
The #1 concern reported by CMS about chiropractors is that, as a profession, we do a poor job of understanding maintenance care. Of course, that is THEIR definition of maintenance care. When you better understand the rules of medical necessity in Medicare, you begin to see what they are talking about. The truth is that there is a “gray” area between the distinct “white” of active treatment and the “black” of maintenance treatment, and that gray area is confusing when defining “covered” vs. “not covered” chiropractic care in Medicare. Join us to find out the following critical information in time for the MACRA Section 514 implementation January 1, 2017:
Find out exactly what Medicare deems as maintenance care and how to recognize it with our patients
Learn what your options are for treating your Medicare patient’s maintenance care for cash
Hear scripting that is vital to your patient understanding what’s going on with their coverage, or lack thereof
Properly document the difference between active and maintenance care
Better manage those little incidents that come up for chronic, Medicare patients
Medicare has increased their review of chiropractors recently. What are they looking for? Medicare regulations are specific in what they want in your documentation. In the second of this two part series Dr. Ron Short will review the regulations regarding the subsequent (daily) visit documentation and translate them into practical actions that you can take in your office. In this webinar you will learn:
What Medicare needs to see documented during the daily visit
How to best capture the required information
What element to have on each visit
When to re-examine the patient.
You can obtain the notes for this webinar by subscribing to my e-mail updates at http://www.chiromedicare.net/mailing-list- signup/ or by following the link provided in my e-mail update. They will be available by the Monday prior to the webinar presentation.
Recently, Medicare stated that they expected chiropractic care to be “episodic” in nature. Find out what Medicare expects from your treatment plan to justify medical necessity. How many treatments is too much? What are they looking for in your care? Medicare and ICD-10 Guideline changes in 2017 have resulted in massive audits taking place across the country. Many calls are coming in pertaining to denials and audits. Most are because the doctor and staff are unaware of the regulation changes. Mario Fucinari, DC, CCSP, CPCO, MCS-P, MCS-I is uniquely qualified as being still in active practice, a Certified Medical Compliance Specialist, Certified Compliance Officer and a member of the Carrier Advisory Committee.
Medicare has increased their review of chiropractors recently. What are they looking for? Medicare regulations are specific in what they want in your documentation. In the first of this two part series Dr. Ron Short will review the regulations regarding the initial visit documentation and translate them into practical actions that you can take in your office. In this webinar you will learn:
-What Medicare needs to see documented during the initial visit
-How to best capture the required information
-What you need to make a good treatment plan
-When to start a new episode of care
The Latest Comparative Billing Report and What it Means to You
Medicare recently sent out Comparative Billing Reports to 8500 chiropractors. These reports give these chiropractors information on how their billing patterns compare to their peers both state-wide and nation-wide. In this webinar Dr. Short will explain:
- What was measured in this Comparative Billing Report
- What your numbers should look like
- What action to take if you received a Comparative Billing Report
The Future of Reimbursement: Medicare's Quality Payment Program
You may have heard rumblings about MACRA, MIPS, MU, PQRS, VBM, and some other acronyms from CMS (Medicare.) Don't get overwhelmed, Dr. Gwilliam will take you through the basics and let you know what you need to do in 2017 to avoid a payment adjustment (penalty), and maybe even qualify for incentives (up to 5%! woohoo!) Even if you don't treat Medicare beneficiaries, this model could be the future of payment for healthcare. This is a webinar that you won't want to miss.
Presented by Ron Short DC, MCS-P, CPC
Tuesday @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET
Last October 1 saw the implementation of ICD-10. This coming October 1 will see the end of the grace period where Medicare will start denying claims for improper codes. In this webinar Dr. Ron Short will cover some of the specifics that you will need to consider with the ICD-10 coding and billing the claims to Medicare. In this webinar you will learn:
• What Medicare expects to see in your coding
• Why accuracy in your coding is more important than ever
• What comes next for Medicare reviews and audits
Presented by Tom Necela DC, CPC, CPMA, CCP-P Tuesday @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET In this webinar, Tom Necela, DC, CPC, CPMA, CCP-P will show you TWO simple steps to put a stop to the mystery, the anxiety and the confusion over ...
Presented by Evan Gwilliam DC MBA BS CPC NCICS CCPC CCCPC CPC-I MCS-P CPMA
June 7, 2016
Tuesday @ 10:15 AM PST, 11:15 AM MST, 12:15 PM CST, 1:15 EST Now that the year is almost half over, it is a good time to remember that PQRS needs to be reported on ...
Presented by Ron Short DC, MCS-P, CPC
May 31, 2016
Tuesday @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET
Section 514 of the Medicare Access and CHIP Reauthorization Act of 2015 (MARCA) required CMS “develop educational and training programs to improve the ability of chiropractors to provide documentation … in a manner that demonstrates that such services are … reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” On December 23, CMS uploaded a 20 minute video to the CMS YouTube channel as a response to this requirement.
Proactive Steps to prepare for a Meaningful Use Audit
Presented by Dorel Radivoj, D.C. CPC
May 10, 2016
Tuesday @ 10:15 PM PST, 11:15 PM MST, 12:15 PM CST, 1:15 PM EST
During this presentation, Dr Radivoj will provide insight into the meaningful use audit process, point out potential problem areas and outline the documentation requirements to address an audit.
Presented by Chantal Bryant, Meaningful Use Expert for ChiroTouch and SmartCloud and Jennifer Hay, Meaningful Use Specialist for ChiroTouch and SmartCloud
March 22nd
Tuesday @ 10:15 AM PST, 11:15 AM MST, 12:15 PM CST, 1:15 EST
The presenters will cover need to know information on Meaningful Use and then will be taking MU related questions directly from listeners. Meaningful Use is a comprehensive and often confusing topic. These presenter spend their time "in the trenches" of Meaningful Use and attestation. They will be able to offer clarity to listeners. Attendees are invited to bring their Meaningful Use questions to this webinar to be answered directly by Meaningful Use expert.
Preparing Your Practice for New Reimbursement Models
Presented by Steven Kraus DC, DIBCN, FIACN, FASA, FICC
February 18, 2016
Thursday @ 10:00 AM PT, 11:00 AM MT, 12:00 PM CT, 1:00 PM ET
Requirements for DC’s In order to participate in the new payment methods. Fee for Service is Going Away!
Presented by Ron Short DC, MCS-P, CPC
Tuesday @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET
The Physician Quality Reporting System will affect you and your practice more than ever before. Failure to report PQRS measures this year will result in a 2% cut in your Medicare payments in 2018. It will also result in you being assigned the lowest level Value Based Modifier which could result in an additional cut.
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