Wednesday, May 25, 2016

Documentation requirements for the initial visit - X RAY and Date of Initial treatment

The following documentation requirements apply for initial visits whether the subluxation is demonstrated by x-ray or by physical examination:

1. History: The history recorded in the patient record should include the following:

*** Chief complaint including the symptoms causing patient to seek treatment;

*** Family history if relevant; and

*** Past medical history (general health, prior illness, injuries, or hospitalizations; medications; surgical history).

2. Present illness: Description of the present illness including:

*** Mechanism of trauma;

*** Quality and character of symptoms/problem;

*** Onset, duration, intensity, frequency, location, and radiation of symptoms;

*** Aggravating or relieving factors;

*** Prior interventions, treatments, medications,secondary complaints; and

*** Symptoms causing patient to seek treatment.

Note: Symptoms must be related to the level of the subluxation that is cited. A statement on a claim that there is “pain” is insufficient. The location of the pain must be described and whether the particular vertebra listed is capable of producing pain in that area.

3. Physical exam: Evaluation of musculoskeletal/ nervous system through physical examination. To demonstrate a subluxation based on physical examination, two of the following four criteria (one of which must be asymmetry/misalignment or range of motion abnormality) are required and should be documented:

*** P - pain/tenderness: The perception of pain and tenderness is evaluated in terms of location, quality, and intensity. Most primary neuromusculoskeletal disorders manifest primarily by a painful response. Pain and tenderness findings may be identified through one or more of the following: observation, percussion, palpation,
provocation, etc. Furthermore, pain intensity may be assessed using one or more of the following; visual analog scales, algometers, pain questionnaires, and so forth.

*** A - asymmetry/misalignment: Asymmetry/ misalignment may be identified on a sectional or segmental level through one or more of the following: observation (such as,  osture and heat analysis), static palpation for misalignment of vertebral segments, diagnostic imaging.

*** R - range of motion abnormality: Changes in active, passive, and accessory joint movements may result in an increase or a decrease of sectional or segmental mobility. Range of motion abnormalities may be identified through one or more of the following: motion palpation, observation, stress diagnostic imaging, range of motion, measurement(s).

*** T -tissue tone, texture, and temperature abnormality: Changes in the characteristics of contiguous and associated soft tissue including skin, fascia, muscle, and ligament may be identified through one or more of the following  procedures: observation, palpation, use of  instrumentation, test of length and strength.

Note: The P.A.R.T. (pain/tenderness; asymmetry/  misalignment; range of motion abnormality; and tissue tone, texture, and temperature abnormality) evaluation
process is recommended as the examination alternative to the previously mandated demonstration of subluxation by X-ray/MRI/CT for services beginning January 1, 2000. The acronym P.A.R.T. identifies diagnostic criteria for spinal dysfunction (subluxation).

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 the spinal joint involved or to the direction of position assumed by the particular bone named. 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 as shown in the following table:

Area of spine     Names of vertebrae    Number of  vertebrae      Short form  or other  name   Subluxation ICD-10 code

Neck Occiput     Cervical  Atlas Axis      7         Occ,  CO  C1-C7   C1  2         M99.00  M99.01

Back         Dorsal or  Thoracic  Costovertebral    12          D1-  D12  T1-T12  R1-  R12  R1-  R12     M99.02
Low back      Lumbar          5             L1-L5                M99.03

Pelvis              Ilii, R and L (I, Si)        I, Si                    M99.05

Sacral            Sacrum,  coccyx            S, SC             M99.04

In addition to the vertebrae and pelvic bones listed, the Ilii (R and L) are included with the sacrum as an area where a condition may occur which would be appropriate for chiropractic manipulative treatment. There are two ways in which the level of the subluxation may be specified in patient’s record.

*** The exact bones may be listed, for example: C 5, 6;

*** The area may suffice if it implies only certain bones such as: occipito-atlantal (occiput and Cl (atlas)), lumbo-sacral (L5 and Sacrum) sacro-iliac sacrum and

Following are some common examples of acceptable descriptive terms for the nature of the abnormalities:

*** Off-centered;

*** Misalignment;

*** Malpositioning;

*** Spacing - abnormal, altered, decreased, increased;

*** Incomplete dislocation;

*** Rotation;

*** Listhesis - antero, postero, retro, lateral, spondylo; and

*** Motion - limited, lost, restricted, flexion, extension, hypermobility, hypomotility, aberrant.

Other terms may be used. If they are understood clearly to  refer to bone or joint space or position (or motion) changes of vertebral elements, they are acceptable.
X-rays As of January 1, 2000, an X-ray is not required by  Medicare to demonstrate the subluxation. However, an x-ray may be used for this purpose if you so choose.
The x-ray must have been taken reasonably close to (within 12 months prior or three months following) the beginning of treatment. In certain cases of chronic
subluxation (for example, scoliosis), an older X-ray may be accepted if 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.

A previous CT scan and/or MRI are acceptable evidence if a subluxation of the spine is demonstrated.

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

*** Recommended level of care (duration and frequency of visits);

*** Specific treatment goals; and

*** Objective measures to evaluate treatment effectiveness.

Date of the initial treatment

The patient’s medical record.

*** Validate all of the information on the face of the claim, including the patient’s reported diagnosis(s), physician work (CPT® code), and modifiers.

*** Verify that all Medicare benefit and medical necessity requirements were met.

Monday, May 23, 2016

Chiropractic three CPT CODES - 98940, 98941, 98942 with AT modifer


In 2014, the comprehensive error testing program (CERT) that measures improper payments in the Medicare feefor- service (FFS) program reported a 54 percent error rate on claims for chiropractic services. The majority of thoseerrors were due to insufficient documentation or other documentation errors.

Medicare coverage of chiropractic services is specifically limited to treatment by means of manual manipulation (that is, by use of the hands) of the spine to correct a subluxation. The patient must require treatment by means of manual manipulation of the spine to correct a subluxation, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function. Additionally, manual devices (that is, those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors 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.

Chiropractors are limited to billing three Current Procedural Terminology (CPT®) codes under Medicare: 98940 (chiropractic manipulative treatment; spinal, one to two regions), 98941 (three to four regions), and 98942 (five regions).When submitting manipulation claims, chiropractors must use an acute treatment (AT) modifier to identify services that are active/corrective treatment of an acute or chronic subluxation. The AT modifier, when applied appropriately, should indicate
expectation of functional improvement, regardless of the chronic nature or redundancy of the problem.

Documentation requirements

The Social Security Act states that “no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the  mounts are being paid or for any prior period.

Friday, May 20, 2016

What is Par fee and Non par fee in Medicare

Q. I’ve been using the “First Coast Service Options fee schedule look-up” for Part B -- what do par fee, nonpar fee, and limiting charge mean?
A. Amounts listed under “par fee” represent the potential Medicare allowance for a physician or nonphysician practitioner who has signed a Medicare participation agreement (form CMS-460). (Click here for more information about the CMS-460.) Signing this agreement means the provider has agreed to accept Medicare allowances as payment in full; the benefits are therefore assigned to the provider.
Amounts listed under “nonpar fee” represent the potential Medicare allowance for a physician or nonphysician practitioner who has NOT signed a participation agreement; these allowances are generally 95 percent of the amount for a participating provider in the same area. Nonparticipating providers may choose to accept Medicare assignment or not.
The limiting charge is the maximum amount a nonparticipating provider may legally charge a beneficiary when filing an unassigned claim. The limiting charge for a service is 115 percent of the nonpar amount.

Q. Where can I obtain fee schedule policy indicators? For example, how can I find the global surgery days for a service? What about relative value units (RVUs) for a particular code?
A. Policy indicators for procedure codes in the Medicare physician fee schedule database (MPFSDB) are available in First Coast Service Options’ fee lookup tool. Select Medicare Physician and Nonphysician Practitioner Fee Schedule (MPFS) from the drop-down list enter a date of service, location, and procedure code, and select submit. Then select the “more” links in the modifier field to view MPFS policy indicators.
These Indicators include: global surgery including pre-operative, intra-operative, and post-operative days, PCTC (professional/technical component), multiple surgery, bilateral surgery, assistant surgery, cosurgery, team surgery, physician supervision requirements, and base codes for multiple endoscopy procedures. For more information regarding these indicators, click here.
Also included are work, practice expense and malpractice expense geographic practice cost indices (GPCIs) and relative value units (RVUs). Note: the allowances Medicare contractors use in their claims payment system use these factors, in combination with an annual conversion factor, but allowances are not calculated at the local level. The allowances are furnished to contractors by CMS after all calculations have been completed.

Q. In the fee schedule lookup tool -- what do the question marks in the column headers mean?
A. These are Tooltips. When the cursor is placed over the “?” on any of these items, helpful tooltips will appear, providing a description for each category.

Wednesday, May 18, 2016

Where Can I Check the Fee schedule for DME, physician fee?

Q. Where can I find fee schedules for my location and line of business?
A. Select your location (Florida, Puerto Rico, or the U.S. Virgin Islands) and line of business (Part A or Part B) on the homepage of the First Coast Service Options (First Coast) Medicare provider website. This will allow you to view information that pertains specifically to your geographic location as well as your type of business. After you have selected your location, you may easily select your line of business and go directly to the ”Fee Schedules” page in one step -- just select “Fee Schedules” from the category list on the Part A or Part B homepage.

You can also access the “Fee Schedules” page for your line of business from the “Quick Find” drop-down menu located in the left-hand navigation area on each page of the website.
Once you have arrived on the “Fee Schedules” page (Part A or Part B), you’ll have access to:

• The latest news and information about fee schedules in the “News” information box
• Location-specific fee information for Part A and Part B for most Medicare-covered procedure codes with First Coast’s easy-to-use, interactive look-up tool.
• Printable Part B portable document format (PDF) fee schedules and text-only fee schedule data files that can be imported into a spreadsheet or database.
• Fee schedules and fee schedule-related information from previous payment years in First Coast’s comprehensive archive

Q. Where can I find fees for durable medical equipment, prosthetics/orthotics, and supplies?
A. Fees for local and joint jurisdiction durable medical equipment, prosthetics/orthotics, and supplies (DMEPOS) may be found in First Coast Service Options’ fee schedule lookup and on the Centers for Medicare & Medicaid Services (CMS) website at:

Q. Where can I find fees for physician fee schedule services?
A. Fees for fee schedule services paid under the Medicare physician fee schedule database (MPFSDB), for Part A as well as Part B, may be found in First Coast Service Options’ fee schedule lookup, and under fee schedule data files for compressed, tab-delimited files. Additional information may be found here for Part A or here for Part B, and on the Centers for Medicare & Medicaid Services (CMS) website at: external link.

Q. Where can I find fees for clinical laboratory services?
A. Fees for clinical laboratory services may be found in First Coast’s fee schedule lookup and under fee schedule data files for compressed, tab-delimited files. Additional information may be found here, and on the Centers for Medicare & Medicaid Services (CMS) website at: external link.

Sunday, May 15, 2016

Policy Guideline for provider performed unlisted CPT code


Some services or procedures performed by providers might not have specific Current Procedure Codes (CPT) or HCPCS codes. When submitting claims for these services or procedures that are not otherwise specified, unlisted codes are designated. Unlisted codes provide the means of reporting and tracking services and procedures until a more specific code is established.

According to the Current Procedural Terminology Instructions for use of the CPT Codebook, select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code. Any service or procedure must be adequately documented in the medical record.

Supporting Documentation Requirements

Because unlisted and unspecified procedure codes do not describe a specific procedure or service, it is necessary to submit supporting documentation when filing a claim. Pertinent information should include:

• A clear description of the nature, extent, and need for the procedure or service.

• Whether the procedure was performed independent from other services provided, or if it was performed at the same surgical site or through the same surgical opening.

• Any extenuating circumstances which may have complicated the service or procedure.

• Time, effort, and equipment necessary to provide the service.

• The number of times the service was provided.

When submitting supporting documentation, designate the portion of the report that identifies the test or procedure associated with the unlisted procedure code. Required information must be legible and clearly marked.

Provider Billing Guidelines and Documentation

• Claims submitted with unlisted procedure codes and without supporting documentation will be denied.
• Please submit paper claims for unlisted procedure codes. Electronic claims for unlisted procedure codes may be denied, as attachments are not accepted electronically at this time.
• Claims submitted with an unlisted procedure code will be denied if determined that a more appropriate procedure or service code that most closely approximates the service performed is available.
• No additional reimbursement is provided for special techniques/equipment submitted with an unlisted procedure code.
• Unlisted procedure codes appended with a modifier may be denied. (Exception: Unlisted codes for DME, orthotics and prosthetics require appropriate NU, RR or MS modifier.)
• When performing two or more procedures that require the use of the same unlisted CPT code, the unlisted code should only be reported once to identify the services provided (excludes unlisted HCPCS codes; for example, DME/ unlisted drugs).

Medical Record Documentation and Physician Queries
Harvard Pilgrim will not accept retrospectively amended medical records or physician queries beyond 30 days from the service date. Harvard Pilgrim considers medical record documentation and/or physician queries upon review as the official record to support services provided for the basis of coverage or reimbursement determination. Clinical documentation or physician queries amended over 30 days from the service will not be accepted to defend reimbursement, increase reimbursement, or consideration of a previously denied claim.