If you have received a letter from Medicare stating that you will have your fee reduced due to failure to certify with meaningful use through Electronic Health Records you can visit http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/paymentadj_hardship.html.

• Eligible Professional Payment Adjustment Reconsideration Instructions
• Eligible Professional Payment Adjustment Reconsideration Application

Although the categories may not fit your situation, there is a tab for other where you can explain your reason for not meeting the EHR/Meaningful use requirement. As many of us have small practices that this may pose a financial hardship for it is worth a try. The application is simple to fill out and can be emailed. This is only for those doctors who have received the payment adjustment letter for meaningful use. The deadline is February 28, 2015.

The new Non-Acute Pain Medical Treatment Guidelines (NAP MTG), as well as the revisions to the existing Medical Treatment Guidelines (MTGs), went into effect on December 15, 2014.

The Chair began the formal adoption process in June 2014, with the publication of a proposed regulation in the New York State Register. The process amends 12 NYCRR 324.2 to incorporate the Non-Acute Pain MTG as well as revisions to the third editions of the Mid and Low Back, Neck, Shoulder, and Knee MTGs and the second edition of the Carpal Tunnel Syndrome MTG. Additionally, Intrathecal Drug Delivery (Pain Pumps) have been added to the list of procedures requiring prior authorization. For your review, complete copies of the new NAP MTG, revised MTGs and the Amendment of 12 NYCRR 324.2 are available on the Board’s website.

The new NAP MTG presents a comprehensive approach to the management of patients with chronic pain, including best practice recommendations for the appropriate use of narcotics. This is a particularly important topic in light of the opioid epidemic facing the nation, including New York’s injured workers.

As was announced last month, e-learning training programs have been developed to facilitate compliance with both the new NAP MTG and revised MTGs recommendations. The training consists of medical courses that enable providers to earn CME credits, as well as courses for non-medical professionals. These programs are free and have been available on the Board’s website since November 12, 2014. In addition, the Non-Acute Pain Medical Treatment Guidelines training is available with free CME credits on MSSNY’s website. Please take advantage of the training, if you have not already done so. The Board will make an official announcement when the training is available for physical therapists and chiropractors.

If you have any questions concerning the Guidelines, please contact the Board’s Medical Director’s Office at (800) 781-2362.

Robert E. Beloten
Chair

The New York State Assembly Insurance and Labor Committees will be holding a joint hearing in late December to examine the proposed Worker’s Compensation fee schedule. As you are aware, we have been working diligently on the changes that the Worker’s Compensation Board has been promulgating since 2007, and we have met several times with the Workers’ Compensation Board specifically on the fee schedule issue. We will be presenting testimony at the hearing. We are in the process of preparing testimony for submission. In addition, we will be testifying in person, in conjunction with the New York Chiropractic Council, at this hearing.

Arlington, Va. – The American Chiropractic Association (ACA), the New York State Chiropractic Association (NYSCA), and National Government Services, Inc., the Jurisdiction K Medicare Administrative Contractor (MAC), jointly presented a special Medicare documentation seminar in Queens, N.Y. The event provided in-depth instruction on how to properly bill and document chiropractic services under the Medicare program.

Recent government reports show a need for the chiropractic profession to improve its documentation skills. A bill introduced this month in the U.S. House of Representatives calls for HHS to develop a training program for doctors of chiropractic (DCs) whose claim error rates are higher than the profession’s national average. DCs who avail themselves to ACA-sponsored programs will avoid pre-authorization requirements that non-compliant providers could eventually face.

The program presented in New York featured ACA Medicare Committee representatives Michael Jacklitch, DC, Steven Conway, DC, as well as National Government Services representatives Kathy Dunphy, Laurence Clark, MD, and Greg McKinney, MD. Organizers viewed it as a possible template for the future national education program that HHS seeks to establish.

Of particular focus during the training is how DCs should document ongoing treatments and maintenance therapy. Government reports show that a high percentage of chiropractic Medicare documentation does not meet regulatory requirements. “ACA is on record supporting quality documentation tenets, ensuring a much lower error rate with Medicare claims,” said ACA President Anthony Hamm, DC. “Proper documentation will ensure that our claims data is accurate and complete.”

“The format of this presentation allowed for an open dialogue between attendees, National Government Services leaders, and the ACA Medicare Committee to determine how processes may be improved for all concerned. NYSCA looks forward to working with the ACA and National Government Services not only to provide additional meetings but in implementing improvements,” said NYSCA past president and New York Carrier Advisory Committee representative, Mariangela Penna, DC.

Dunphy, National Government Services director of congressional affairs, added, “We appreciate the ACA’s willingness to work proactively toward improving billing practices and look forward to continuing to work with the organization and its members to reduce error rates on chiropractic claims billed to Medicare.”

ACA plans to conduct additional seminars with National Government Services in the Northeast, and is open to working with other MACs that wish to hold similar programs in other jurisdictions.

---
The American Chiropractic Association (ACA), based in Arlington, VA, is the largest professional association in the United States advocating for more than 130,000 doctors of chiropractic (DCs), chiropractic assistants (CAs) and chiropractic students. ACA promotes the highest standards of ethics and patient care, contributing to the health and well-being of millions of chiropractic patients. Visit us at www.acatoday.org.

As referenced in the 2014 third quarter Optum newsletter, effective in the fourth quarter of 2014, Optum Physical Health (Optum^TM) will include reporting of the STarT Back Screening Tool (SBST) as part of the electronic clinical submissions for those providers who are required to submit.

For your information, I have attached the letter that has been sent to Optum providers detailing the inclusion of the SBST in the “Patient Completes this Section” of the electronic Patient Summary Form (PSF). The PSF incorporates a version of the SBST that should be used for most adult patients with musculoskeletal disorders.

There will be a slight delay in the deployment of this tool. The SBST will be visible to providers logging on to the portal on December 7, 2014 rather than the November 23, 2014 date noted in the letter.

If your members have questions, please direct them to Optum’s Member Provider Services (MPS) at (800) 873-4575 or their support clinician.

Arlington, Va. -- The American Chiropractic Association (ACA) has released a 2nd edition ICD-10 Toolkit to prepare doctors of chiropractic for a seamless transition to ICD-10 coding beginning Oct. 1, 2015.

Beginning Oct. 1, 2015, the ICD-9 codes currently used to describe diagnoses and treatment plans can no longer be used by HIPAA covered entities. The conversion to ICD-10 will enable U.S. health care providers to report greater specificity and clinical information. The new coding system includes updated health care terminology and provides higher quality data for processing claims and making clinical decisions. It may also enhance the ability to provide data that proves the effectiveness and positive outcomes achieved by chiropractic services.

To ensure that the chiropractic profession is prepared for and understands ICD-10, ACA has updated its online ICD-10 resources, featuring a 2nd edition ICD-10 Toolkit with a Mapping Tool that simplifies the conversion of diagnosis codes from ICD-9 to ICD-10. If you have previously purchased the Toolkit or the Mapping Tool, you will now receive both as part of this update. Check lists, printable worksheets and an introductory training webinar are available to ACA members. An intermediate training webinar will soon be available for purchase.

"ACA will work to ensure that the chiropractic profession is well-prepared for the ICD-10 transition," says ACA President Anthony Hamm, DC. "Beginning Oct. 1, 2015, all claims submitted to HIPAA covered entities will be rejected unless they contain the proper ICD-10 code. With this in mind, ACA will continue to provide the needed resources for DCs to efficiently and confidently transition to ICD-10 compliance."

ACA will provide the chiropractic profession with up-to-date information and resources in its publications and online at www.acatoday.org/ICD-10. Visit the FAQs page for more information or call the ACA at 703-276-8800.



About ACA

The American Chiropractic Association (ACA), based in Arlington, Va., is the largest professional association in the United States advocating for more than 130,000 doctors of chiropractic (DCs), chiropractic assistants (CAs) and chiropractic doctoral students. ACA promotes the highest standards of ethics and patient care, contributing to the health and well-being of millions of chiropractic patients. Visit us at www.acatoday.org.

Science is hard; good science is more difficult.

When I entered this profession in the late 1970s my naive belief was that since chiropractors were obviously getting people better, all we needed for our ac-ceptance to skyrocket was research showing that chiropractic works.

Flash forward to today. Despite many practice challenges, chiropractic is now far better accepted socially, as well as by other healthcare professionals. It’s been quite a while since I've been called a quack. Last week I went to dinner with six DCs and six MDs- neurosurgeons, neurologists and other NMS docs. The topic of mutual referral underlies many of the conversations, but these collaborations would never have occurred 20 years ago. Plus demand is up, as there’s been a tremendous increase in the problem back pain during the 21st century – a good thing for those treating back pain.

But are chiropractors’ social popularity and success skyrocketing?

Insurance companies continue to tighten the economics of practice as we enter the grand PPACA healthcare system experiment, better known as ObamaCare. Time will tell whether it was bold or foolish, but no one is claiming it is going to fix the growing problem of back pain in an aging, slumped over society.

It seems as though just as physicians and other providers accept us more, the individual practitioner has less ability to steer patients to DCs, because now the MD has become an employee. Medical Homes and other entities with acronyms like ACOs and PCMHs are ascendant, with protocols written by committees of administrators and accountants (as well as some clinicians) who look at the ―scientific evidence.”

And research does show the value of spinal manipulation, but often in less glowing terms than myself and our researchers hoped.

The problem of quantifying back pain

The problem—science is hard. My friends who are scientists continually repeat that the plural of anecdote is not data. They require the use of dimly recalled things from Statistics 101 like chi-square and T tests to determine “statistical significance.” To scientifically and statistically prove something requires showing there is less than one chance in 20 that whatever you are studying happened by chance. Also known as P= <.05, reaching this probability means controlling for all other possible variables.

For back pain, there’s an amazing variance of flavors of patients and their com-plaints. Patient history and the specifics of the problem onset and character is one. Does the pain radiate into the SI joint in the low back only, both SI joints, or going into the buttocks? A really important but often neglected factor is bio-psycho-social, where intertwining of the person's psychological involvement with their pain creates psychological and personal benefits (think more attention or a bigger settlement) and creates a spiral of negative behavior.

The multifactorial nature of back pain is probably the one thing on which all the low back pain research agrees. Regarding spinal manipulation, unfortunately the 200 plus studies currently in the journals don’t fully agree, but new exciting studies are coming out which demonstrate the effectiveness of chiropractic, as well as pointing to a role for the DC in the health delivery system.

Meta-studies draw improved conclusions

A big trend in science is doing a study to look at a number of other studies in a meta-study, which is essentially pooling data to see what works best.

A 2013 study published in SPINE by Goertz looked at eight of these systematic reviews and reported that, indeed, chiropractic manipulative therapy can moderately reduce low back pain and disability.

The study: “Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: Results of a pragmatic randomized comparative effectiveness study.”

The results: “Chiropractic manipulative therapy in conjunction with standard medical care offers a significant advantage for decreasing pain and improving physical functioning when compared with only standard care, for men and women between 18 and 35 years of age with acute LBP” care.¹

In other words, chiropractic makes medical care better.

A possible suggestion for these researchers’ next study: Compare chiropractic plus medical care to chiropractic care alone. Another even more exciting study was just published in the Annals of Internal Medicine. “Spinal Manipulation and Home Exercise With Advice for Subacute and Chronic Back-Related Leg Pain” looked at what happens when you add chiroprac-tic to an exercise and posture advice program already shown to improve low back pain.

Bradford’s team at Northwestern University of Health Science Advice taught ge-neric awareness such as, “Patients were also instructed in methods for developing spine posture awareness related to their activities of daily living, such as lifting, pushing and pulling, sitting, and getting out of bed.”

The study’s result: Adding chiropractic gave even better results than the exercise and advice alone.² In both of these studies, researchers controlled for a multifactorial problem by adding chiropractic to something whose effectiveness was already measured. Both studies’ results counter the arguments that back pain is psychological, or that some improvements occur when you teach people exercises and give them postural advice. In other words, posture training helps and placebo effects may be real…but so are the positive changes seen with chiropractic manipulative therapy.

Chiropractic really does help back pain, as does exercise, as does postural advice. And, when it’s all combined, patients do even better!

But practice is not a research environment. In Bronfort’s study, home exercise and advice were delivered in four 1-hour, one-on-one visits during a 12-week intervention. The main program goals were to provide patients with the tools to “manage existing pain, prevent pain recurrences, and facilitate engagement in daily activities.” And while research is fantastic, in the real world chiropractic practice economics defines what can be done. Especially in these days of third party reimbursements, it’s smart to effectively fit programs into sequenced 8-15 minute encounters, program care to be systematically individualized and progressive, and be able to have different staff reliably and reproducibly teach the exercises and posture awareness.

This is why the StrongPosture® exercise protocols and PostureZone® framework is a great way to systematically teach exercise and also communicate with patients, the public and other professionals.

The PosturePractice Model

By first engaging people with a picture from an app (see above image), and then communicating concepts of PostureZone© biomechanics, the message can apply to spine care, as well as people with other neuromuscular skeletal issues including extremity concerns, hip to foot and shoulder to hand. Plus, Baby Boomers concerned about hunching over and athletes seeking performance also value posture. And while not clinical, for many a significant appeal of the PostureZone© framework is vanity’s appeal— people who stand tall with strong posture simply look better.

Once people are interested and engaged with posture awareness, the StrongPosture® exercises use the PostureZone© cueing in an actionable framework to systematically strengthen functional postural balance, alignment and motion in a daily posture exercise habit, individualized to for the patient and applicable to multiple demographics.

These posture concepts are receiving increasing coverage in national and local media. Dynamic Chiropractic’s October 1st front page article covered how posture is the DC-MD bridge, and on the general public side the November 2014 issues of SHAPE as well as RealSimple magazines talked about the benefits of improving posture.

Through the trends of both clinical research and media, it has become clear that people are interested in chiropractic care and how our services can help them to live longer, healthier lives. As we venture into a new era of healthcare practices, it makes sense to position the chiropractic profession into a place of value, both in the eyes of other wellness profes-sionals as well as those of the consumer.

About the Author

---

1—Goertz, C. M., Long, C. R., Hondras, M. A., Petri, R., Delgado, R., Lawrence, D. J., . . . Meeker, W. C. (2013). Adding chiropractic manipulative therapy to standard medical care for patients with acute low back pain: Results of a pragmatic randomized comparative effectiveness study. Spine, 38(8), 627-34. doi:10.1097/BRS.0b013e31827733e

2—Bronfort, G., Hondras, M. A., Schulz, C. A., Evans, R. L., Long, C. R., & Grimm, R. (2014). Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: A trial with adaptive allocation. Annals of Internal Medicine, 161(6), 381-91. doi:10.7326/M14-000

Dr. Terence Murphy, a chiropractor in Westchester, is running for the NY State Senate. His election would be very significant for the chiropractic profession as a voice in the NYS Senate. Please consider giving him your support.

You can get more information at www.VoteforMurphy.com

---

About Dr. Murphy

Dr. Terrence Murphy’s family originally moved to Yorktown 52 years ago when Yorktown’s mascot, the Cornhusker, was still a common and public sight. Growing up next to Wilken’s Fruit Farm, Terrence enjoyed an incredible childhood which included apple picking and skating on Mill Pond. As the youngest of six children, Dr. Murphy learned at a young age how to stick up for himself. His father Jack, a blue-collar, union man and labor advocate who worked for Con Edison for over fifty years taught him the importance of hard work, dedication, and commitment to community.

Remembering his father’s teachings of the importance of community Dr. Murphy was always willing to help others in need. It was of little surprise to his family when he decided to study chiropractic following his graduation from Yorktown High School in 1984. Terrence’s time away from Yorktown was a blessing in disguise. It allowed him to become an independent individual, traveling the world as a member of a world class rugby team, while reinforcing his love and passion for his home town.

In 1999, Dr. Murphy made his first official mark on Yorktown by opening the Yorktown Health and Wellness Center on Commerce Street. Standing in the same storefront today as then Dr. Murphy has exhibited his father’s lessons of hard work, dedication, and commitment to his community.

Following the passing of his father, Dr. Murphy, opened Murphy’s Restaurant in Yorktown in 2006, with his Mom Deneyse, and older siblings, Colleen, Erin, Sean, Denis, and Pat. As a tribute to their father, Murphy’s stands as one of Yorktown’s largest and most successful businesses and has been recognized twice for providing employment opportunities for the mentally challenged.

Dr. Murphy’s commitment to the Yorktown community does not stop there. For fifteen years he volunteered for the Yorktown High School Athletic Department caring for our young athletes as an on-field medical professional. Terrence served for nearly ten years as a New York State certified EMT and started the watchdog organization Keeping Westchester Safe.

Today, Dr. Murphy continues his chiropractic practice while assist in managing his family’s restaurant. Always keeping family first, Dr. Murphy’s favorite time spent is with this wife Caroline, and children McKayla, Jack, and Kian.

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)