Providers in Connecticut (98941), Queens, NY (98940), Downstate NY (98941) and Upstate NY (98941)

National Government Services’ Medical Review Department is currently conducting a prepayment review on JK Part B chiropractic services in the states of CT and NY. This article includes the results of these reviews for June, July and August 2014.

Background

During these reviews, documentation is reviewed to adjudicate claims for payment based on the LCD and Medicare coverage guidelines.

Findings

The following results are based upon the completion of the reviews for JK Part B chiropractic providers in CT and NY.

• Connecticut
  • June 2014 - of 23 services billed; 22 (95.7%) were reduced or denied
  • July 2014 - of 161 services billed; 133 (82.6%) were reduced or denied
  • August 2014 – of 221services billed; 188 (85.1%) were reduced or denied
• Queens, NY
  • June 2014 – of 242 services billed; 240 (99.2%) were reduced or denied/li>
  • July 2014 – of 1,401 services billed; 1,246 (88.9%) were reduced or denied/li>
  • August 2014 – of 2,383 services billed; 2,181 (91.5%) were reduced or denied
• Downstate NY
  • June 2014 – of 74 services billed; 72 (97.3%) were reduced or denied
  • July 2014 – of 371 services billed; 339 (91.4%) were reduced or denied
  • August 2014 – of 576 services billed; 461 (80%) were reduced or denied
• Upstate NY
  • June 2014 – of 136 services billed; 124 (91.2%) were reduced or denied
  • July 2014 – of 357 services billed; 313 (87.7%) were reduced or denied
  • August 2014 – of 641 services billed; 588 (91.7%) were reduced or denied

Claims were reduced and/or denied for the following reasons:

• Lack of patient’s specific subjective complaint – A relevant medical history in a patient’s record must indicate a beneficiary subjective complaint(s) and the area(s) of complaint(s) should correlate to the area(s) of subluxation(s) cited and/or treated.
• Lack of functional status – Documentation does not describe a patient’s current level of functioning and activities of daily living, nor treatment goals related to functional levels.
• Lack of objective documentation of specific level(s) of subluxation in the exam – The precise level(s) of subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine. The level(s) of spinal subluxation must bear a direct causal relationship to the patient's symptom(s), and the symptom(s) must be directly related to the level(s) of the subluxation that has been diagnosed. Documentation needs to be clearly legible without the use of abbreviations, checks or circles that provide minimal and unclear information. If using P.A.R.T exam, the documentation requirement must be fully met per policy. Policy requires documentation of two of the four criteria, one of which must be asymmetry/misalignment or range of motion abnormality.
• Lack of area(s) of chiropractic manipulative treatment (CMT)that corresponds to subjective complaint(s) – The specific spinal area(s) that was treated on the day of the visit must be clearly documented and the area(s) treated must correspond to patient’s subjective compliant(s). Documentation needs to be clearly legible without the use of abbreviations, checks or circles that provide minimal and unclear information.
• Treatment plan and goals not documented/not addressed – Documentation of a treatment plan must include the recommended level of care (duration and frequency of visits); specific treatment goals and objective measures to evaluate the treatment effectiveness. The patient’s progress or lack thereof related to the established treatment plan and goals should be addressed on subsequent visits. If treatment continues on without evidence of improvement or the clinical status has remained stable for a given condition, further manipulative treatment is considered maintenance therapy and is a non-covered benefit.
• Documentation supporting maintenance – Maintenance therapy is a noncovered benefit. Examples of maintenance therapy would include long term treatment per history without the documentation supporting exacerbation, subjective complaint of “minimal pain” on multiple visits without showing improvements or no positive response; documentation remains the same or template for multiple visits. Also, documentation of “chronic” condition with no documentation to support an exacerbation and/or improvement.

Other issues that resulted in claim denials include:

• Nonresponse to development letters – When an ADR letter is received, submitting information and appropriate documentation suggested in the ADR letter is required to consider payment of the claim in question. If the requested medical record is not submitted in a timely manner, the services will be systematically denied.
• Illegible Documentation – Medical record must be legible. If the reviewer cannot decipher the documentation, it may result in the denial of a claim.
• Missing or illegible provider signature - Documentation must be legible and include a provider’s signature. The method used can either be electronic or handwritten, stamp signatures are not acceptable. A signature key or signature log can be included with the documentation to identify the author associated to the illegible signature.
• Incorrect rendering physician – The rendering physician on the documentation did not correspond with the rendering physician submitted on the claim form.
• Incomplete or missing beneficiary information – A patient’s medical record must include a legible beneficiary name for identification. Also, the medical record should be clearly dated and correspond to the date of service billed. If this information is missing or incomplete, it may result in denial of a claim.

Recommendations

We recommend that you perform random sample claim audits within your practice to ensure that these errors do not exist. You may also use the errors identified in the prepay audit as a checklist before submitting future claims. Please also take time to review the chiropractic services LCD (L27350) and SIA (A47385) posted on our website under Medical Policy & Review > Medical Policy Center.

The National Government Services Provider Outreach and Education Department can assist with Medicare coverage, medical policy, medical necessity, and documentation questions through the JK Provider Contact Center at 866-837-0241.

Related Content

• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1 (1 MB)
• LCD for Chiropractic Services (L27350)
• SIA for Chiropractic Services (A47385)

Wednesday, November 5; 1:30-3pm ET

To Register: Visit MLN Connects™ Upcoming Calls. Space may be limited, register early.

HHS has issued a rule finalizing October 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10. During this MLN Connects National Provider Call, CMS subject matter experts will discuss ICD-10 implementation issues, opportunities for testing, and resources. A question and answer session will follow the presentations.

Agenda:

• Final rule and national implementation
• Medicare Fee-For-Service testing
• Medicare Severity Diagnosis Related Grouper (MS-DRG) Conversion Project
• Partial code freeze and annual code updates
• Plans for National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)
• Home health conversions
• Claims that span the implementation date

Target Audience: Medical coders, physicians, physician office staff, nurses and other non-physician practitioners, provider billing staff, health records staff, vendors, educators, system maintainers, laboratories, and all Medicare providers.

Continuing education credit may be awarded for participation in certain MLN Connects Calls. Visit the Continuing Education Credit Information web page to learn more.

As part of the Workers' Compensation Board’s effort to improve service and increase efficiency in the unpaid medical bill(s) process, Form HP-1, Health Provider's Request for Decision on Unpaid Medical Bills(s), has been revised. Form HP-1 now directs that the form is sent to the following addresses as appropriate.

When requesting an Administrative Award, Form HP-1 should be sent to the Board’s Centralized Mailing Address: When requesting Arbitration, Form HP-1 and a check for the processing fee should be sent to: The revised Form HP-1 with the new addresses may be obtained at the Board's website here or by following the link "Forms" at the top of the home page.

Please contact the Board at 1-800-781-2362 with any questions regarding Form HP-1. Thank you for your cooperation.

Robert E. Beloten, Chair

Some good news on the Medicare front:

We have been informed that effective July 1, 2014 the 2% reduction for codes 98940, 98941 and 98942 will be eliminated. As you will recall, this 2% reduction was put in place as a result of the demonstration project that was determined not to be cost neutral. This will be removed effective July 1.

Respectfully submitted,
Mariangela Penna DC
NY CAC Representative

SERVICE-SPECIFIC PREPAYMENT REVIEWS OF CHIROPRACTIC SERVICES (CPT CODES 98940 AND 98941)

Attention Services for Jurisdiction K Part B Chiropractic Providers in Connecticut and New York

National Government Services will be conducting service-specific prepayment reviews on CPT code 98940 in the Queens, NY area and CPT Code 98941 in CT and the upstate and downstate NY areas.

A prepayment review consists of a medical review of claims prior to payment. Request for records are most frequently electronically generated and referred as ADS letters. Please note that when medical records are requested for chiropractic services, it is necessary to submit all the specific documentation as notated in the ADS, which would include but is not limited to:

• Services up to three (3) months prior to and including the date(s) of service in question
• Advance Beneficiary Notice of Noncoverage

The primary focus of the audits will be to better identify common billing errors, develop educational efforts, and prevent improper payments. Providers will be receiving ADSs asking for documentation to support the service billed. Medical Review encourages providers to respond with the requested documentation in a timely manner to expedite adjudication of these claims.

Providers can assist in this process by:

• Reviewing all contractor publications and LCDs
• Understanding Medicare coverage requirements
• Ensuring office staff and billing vendors are familiar with claim filing requirements
• Performing self-audits of medical records against billed claims using coverage criteria, LCD, and coding guidelines
• Responding to request(s) for records in a timely manner (CMS requires that providers respond to an ADS within 30 days of the request)
• Ensuring documentation is legible and demonstrates that the patient’s condition warrants the services being reported and billed

Are you a Medicare provider who was unable to successfully demonstrate meaningful use for 2013 due to circumstances beyond your control? CMS is accepting applications for hardship exceptions to avoid the upcoming Medicare payment adjustment for the 2013 reporting year. Payment adjustments for the Medicare EHR Incentive Program will begin on January 1, 2015 for eligible professionals. However, you can avoid the adjustment by completing a hardship exception application and providing supporting documentation that proves demonstrating meaningful use would be a significant hardship for you. CMS will review applications to determine whether or not you are granted a hardship exception. CMS has posted hardship exception applications on the EHR website for:

• Eligible professionals
• Eligible professionals submitting multiple National Provider Identifiers (NPIs)

Applications for the 2015 payment adjustments are due July 1, 2014 for eligible professionals. If approved, the exception is valid for one year.

New Hardship Exception Tipsheets
You can also avoid payment adjustments by successfully demonstrating meaningful use prior to the payment adjustment. Tipsheets are available on the CMS website that outline when eligible professionals must demonstrate meaningful use in order to avoid the payment adjustments.

Want more information about the EHR Incentive Programs?
Make sure to visit the Medicare and Medicaid EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

Are you an eligible professional or part of a group practice participating in PQRS this year? If so, you must satisfactorily report data on quality measures during 2014 to avoid the 2016 payment adjustment.

Review the new fact sheet for guidance on how to avoid the 2016 PQRS Payment Adjustment.

Avoid the 2016 Payment Adjustment
You can avoid the 2016 payment adjustment by meeting one of the following criteria during the one-year 2014 reporting period (January 1–December 31):

If Participating as an Individual Eligible Professional

• Meet the criteria for satisfactory reporting adopted for the 2014 PQRS incentive.

OR

• Participate in PQRS via qualified clinical data registry, qualified registry, or claims reporting and report at least three measures covering one National Quality Strategy (NQS) domain for at least 50 percent of your Medicare Part B Fee-For-Service (FFS) patients.

If Participating as a Group Practice

• Meet the Group Practice Reporting Option (GPRO) requirements for satisfactory reporting.

OR

• Participate in PQRS via qualified registry reporting and report at least three measures covering one NQS domain for at least 50 percent of your group practice’s Medicare Part B FFS patients.

Want more information about PQRS?
Please visit the CMS PQRS website: http://www.cms.gov/PQRS.

If an initial claim determination results in a denial, providers, participating physicians, and other suppliers have the right to appeal the decision. National Government Services has seen an increase in the number of claims submitted to Medicare Part B Appeals for review and may cause a delay in receiving your decision. We are processing appeal and reopening requests in an efficient manner and working diligently to resolve these issues expeditiously. Our goal is to minimize disruption to the provider/supplier and beneficiary community. You will receive a decision as soon as possible; we appreciate your patience during this period.

Important Information

• Do not submit a duplicate appeal.
• If you are a current NGSConnex user, you can check the status of your appeal at http://www.NGSConnex.com. Please note: do not resubmit the appeal when using NGSConnex.
• The appeals process, levels of appeal, documentation, and recommended forms can be found on our Web site under Review Process > Appeals.
• A local coverage determination (LCD) is a decision a Medicare contractor will make to cover a particular item or service. A majority of appeal requests are the result of the initial claim not following the LCD. It is important to become familiar with LCDs and national coverage determinations (NCDs).
• LCDs contain information to indicate medically reasonable and necessary documentation and should be used as an administrative and educational tool to assist with submitting correct claims for payment. LCDs are located on our Web site in the Medical Policy Center.
• The Centers for Medicare & Medicaid Services Internet-Only Manual Publication 100-03, Medicare National Coverage Determinations (NCD) Manual describes whether specific medical items, services, treatment procedures, or technologies can be paid for under Medicare. All decisions that items, services, etc. are not covered are based on Section 1862(a)(1) of the Act unless otherwise specifically noted. More information on NCDs can be found on the Medicare Coverage Determination Process page on the CMS Web site.
• Not all covered Medicare services are subject to either an LCD or NCD.

Below is a list of LCDs causing the increased number of appeals to National Government Services. Please use the links to become familiar with the policy and avoid future appeals.

• LCD for Noncovered Services (L32456)
• LCD for Routine Foot Care and Debridement of Nails (L26426)
• LCD for Chiropractic Services (L27350)
• LCD for Removal of Benign Skin Lesions (L27362)
• LCD for Noninvasive Vascular Studies (L27355)
• LCD for Drugs and Biologicals, Coverage of, for Label and Off-Label Uses (L25820)
• LCD for Vitamin D Assay Testing (L29510)
• Article for Tetanus Immunization - Medical Policy Article (A49710)
• LCD for Pain Management (L28529)
• LCD for Transthoracic Echocardiography (TTE) (L27360)

Are you an eligible professional practicing in multiple locations? Review the new Multiple Locations Tipsheet for information on how to successfully demonstrate meaningful use in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs. The tipsheet includes guidance on determining if a location is equipped with certified EHR technology, calculating patient encounters, and what to do when different menu objectives and clinical quality measures (CQMs) are chosen across locations.

Guidance for Multiple Locations
Here are some key points to keep in mind if you are practicing in multiple locations:

• To demonstrate meaningful use, 50 percent of patient encounters must take place at locations with certified EHR technology during the reporting period. 
• A location is equipped with certified EHR technology if you have access to the certified EHR at the beginning of the EHR reporting period. 
• You can add numerators and denominators from each certified EHR system for an accurate total. 
• You should report on menu objectives and CQMs from the location with the most patient encounters if different locations chose different measures.

For More Information
Visit the CMS EHR Incentive Programs website for more resources to help you successfully participate.