The NYSCA Fall Convention in September promises to have something for everyone. It will once again be on Long Island, September 19 through September 21.

Our convention committee has put together a diverse and timely program. We have a wide variety of topics with quality speakers. Continuing education credits will of course be available, and it is a great time to be on Long Island. Try to stay some extra time to enjoy some of the attractions. We even have availability for Yankee tickets on Thursday for a discount to NYSCA members.

On Friday we will have some solid basic practice update information for Workers’ Compensation and Auto No-Fault Insurance. Saturday morning features Dr. David Seaman, the nationally well-respected nutrition author and speaker. Dr. Seaman's presentation with give you a perspective from which to observe the affects of diet and nutrition on neurological processes with regards to acute-to-chronic pain.

Dr. Christina Acampora of Aligned Methods will be speaking on Saturday afternoon with the topic “Communication with Medical Doctors”. This will be followed by Dr. Steven Weiniger of BodyZone, presenting on the subject of Strengthening Posture, Balance, & Motion.

Sunday's session will feature Medicare documentation, which as you know is currently being reviewed in the downstate area by NGS. We have the honor of hosting Susan McClelland, the ACA Medicare advisor and one of the foremost experts in Medicare for chiropractic. This program alone will be a great asset to your practice.

I hope you can join us for a weekend of education and fun. If you have any questions or concerns, please feel free to call me.

Sincerely,
Louis Lupinacci, DC
NYSCA President

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

The NYSCA would like to express our deepest gratitude to the American Chiropractic Association and New York Chiropractic College for their support and advocacy regarding a proposal from the New York State Workers' Compensation Board to limit DCs' workers' compensation reimbursement.

In their recent letter, the ACA urged the Board to reconsider their proposal. Citing numerous cost effectiveness studies related to the services provided by DCs, ACA stated that such a proposal "detracts from the aims of New York's workers' compensation reforms, which include patient-centered, evidence informed and cost-effective care." ACA opposes the establishment of any system which unfairly limits one profession compared to other authorized providers and vows to voice this view strongly whenever and wherever necessary.

As always, the NYSCA and Council, through the Joint Legislative Task Force, continue to work for protecting practice rights and the services provided under New York State Workers’ Compensation. We will also keep you, our membership, informed as updates occur.

Abstract (provisional)

---

Background

Low back pain is among the most common and costly chronic health care conditions. Recent research has highlighted the common occurrence of non-specific low back pain in adolescents, with prevalence estimates similar to adults. While multiple clinical trials have examined the effectiveness of commonly used therapies for the management of low back pain in adults, few trials have addressed the condition in adolescents. The purpose of this paper is to describe the methodology of a randomized clinical trial examining the effectiveness of exercise with and without spinal manipulative therapy for chronic or recurrent low back pain in adolescents.

Methods

This study is a randomized controlled trial comparing twelve weeks of exercise therapy combined with spinal manipulation to exercise therapy alone. Beginning in March 2010, a total of 184 participants, ages 12 to 18, with chronic or recurrent low back pain are enrolled across two sites. The primary outcome is self-reported low back pain intensity. Other outcomes include disability, quality of life, improvement, satisfaction, activity level, low back strength, endurance, and motion. Qualitative interviews are conducted to evaluate participants' perceptions of treatment.

Discussion

This is the first randomized clinical trial assessing the effectiveness of combining spinal manipulative therapy with exercise for adolescents with low back pain. The results of this study will provide important evidence on the role of these conservative treatments for the management of low back pain in adolescents.

Abstract (provisional)

---

Background

Upright examination procedures like radiology, thermography, manual muscle testing, and spinal motion palpation may lead to spinal interventions with the patient prone. The reliability and accuracy of mapping upright examination findings to the prone position is unknown. This study had 2 primary goals: (1) investigate how erroneous spine-scapular landmark associations may lead to errors in treating and charting spine levels; and (2) study the interexaminer reliability of a novel method for mapping upright spinal sites to the prone position.

Methods

Experiment 1 was a thought experiment exploring the consequences of depending on the erroneous landmark association of the inferior scapular tip with the T7 spinous process upright and T6 spinous process prone (relatively recent studies suggest these levels are T8 and T9, respectively). This allowed deduction of targeting and charting errors. In experiment 2, 10 examiners (2 experienced, 8 novice) used an index finger to maintain contact with a mid-thoracic spinous process as each of 2 participants slowly moved from the upright to the prone position. Interexaminer reliability was assessed by computing Intraclass Correlation Coefficient, standard error of the mean, root mean squared error, and the absolute value of the mean difference for each examiner from the 10 examiner mean for each of the 2 participants.

Results

The thought experiment suggesting that using the (inaccurate) scapular tip landmark rule would result in a 3 level targeting and charting error when radiological findings are mapped to the prone position. Physical upright exam procedures like motion palpation would result in a 2 level targeting error for intervention, and a 3 level error for charting. The reliability experiment showed examiners accurately maintained contact with the same thoracic spinous process as the participant went from upright to prone, ICC (2,1) = 0.83.

Conclusions

As manual therapists, the authors have emphasized how targeting errors may impact upon manual care of the spine. Practitioners in other fields that need to accurately locate spinal levels, such as acupuncture and anesthesiology, would also be expected to draw important conclusions from these findings.

Abstract (provisional)

---

Background

Lumbar spinal stenosis is the most common reason for spinal surgery in older adults. Previous studies have shown that surgery is effective for severe cases of stenosis, but many patients with mild to moderate symptoms are not surgical candidates. These patients and their providers are seeking effective non-surgical treatment methods to manage their symptoms; yet there is a paucity of comparative effectiveness research in this area. This knowledge gap has hindered the development of clinical practice guidelines for non-surgical treatment approaches for lumbar spinal stenosis.

Methods

This study is a prospective randomized controlled clinical trial that will be conducted from November 2013 through October 2016. The sample will consist of 180 older adults (>60 years) who have both an anatomic diagnosis of stenosis confirmed by diagnostic imaging, and signs/symptoms consistent with a clinical diagnosis of lumbar spinal stenosis confirmed by clinical examination. Eligible subjects will be randomized into one of three pragmatic treatment groups: 1) usual medical care; 2) individualized manual therapy and rehabilitative exercise; or 3) community-based group exercise. All subjects will be treated for a 6-week course of care. The primary subjective outcome is the Swiss Spinal Stenosis Questionnaire, a self-reported measure of pain/function. The primary objective outcome is the Self-Paced Walking Test, a measure of walking capacity. The secondary objective outcome will be a measurement of physical activity during activities of daily living, using the SenseWear Armband, a portable device to be worn on the upper arm for one week. The primary analysis will use linear mixed models to compare the main effects of each treatment group on the changes in each outcome measure. Secondary analyses will include a responder analysis by group and an exploratory analysis of potential baseline predictors of treatment outcome.

Discussion

Our study should provide evidence that helps to inform patients and providers about the clinical benefits of three non-surgical approaches to the management of lumbar spinal stenosis symptoms.

Trial registration: ClinicalTrials.gov identifier: NCT01943435

Abstract (provisional)

---

Background

Several studies showed the effect of osteopathic manipulative treatment on neonatal care in reducing length of stay in hospital, gastrointestinal problems, clubfoot complications and improving cranial asymmetry of infants affected by plagiocephaly. Despite several results obtained, there is still a lack of standardized osteopathic evaluation and treatment procedures for newborns recovered in neonatal intensive care unit (NICU). The aim of this paper is to suggest a protocol on osteopathic approach (NE-O model) in treating hospitalized newborns.

Methods

The NE-O model is composed by specific evaluation tests and treatments to tailor osteopathic method according to preterm and term infants' needs, NICU environment, medical and paramedical assistance. This model was developed to maximize the effectiveness and the clinical use of osteopathy into NICU.

Results

The NE-O model was adopted in 2006 to evaluate the efficacy of OMT in neonatology. Results from research showed the effectiveness of this osteopathic model in reducing preterms' length of stay and hospital costs. Additionally the present model was demonstrated to be safe.

Conclusion

The present paper defines the key steps for a rigorous and effective osteopathic approach into NICU setting, providing a scientific and methodological example of integrated medicine and complex intervention.

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.

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

New York Chiropractic College will host the Spring 2014 Commencement Ceremony on Saturday, August 2, 2014 at 9:30 a.m. for Doctor of Chiropractic & 2014 Masters graduates. The ceremony will be held in the NYCC Athletic Center and doors are open to the public at 8:30 a.m.

There will be a reception for graduates, guests, faculty, and staff immediately following the ceremony.

Congratulations to all of our Graduates!

To the Editor:

Doctors of chiropractic (DCs) were troubled after reading the latest ill-informed attack on the chiropractic profession by Steven Salzberg, PhD. His latest Forbes blog post “New Medicare Data Reveal Startling $496 Million Wasted On Chiropractors” is sensationalism at its finest, as chiropractic has historically made up less than 1% of all Medicare claims.

It’s evident to anyone who is truly interested in fixing the problems facing the U.S. health care system that chiropractic physicians, with their conservative approach to pain relief and health promotion, are an important part of the solution. DCs are the highest rated healthcare practitioners for low-back pain treatments—treating nearly 27 million Americans annually—above physical therapists, specialist physicians/MDs (i.e., neurosurgeons, neurologists, orthopedic surgeons) and primary care physicians/MDs (i.e., family or internal medicine). This is not surprising when you consider that injured workers are 28 times less likely to undergo spinal surgery if their first point of contact is a DC rather than a surgeon (MD), and that treatment for low back pain initiated by a chiropractic physician costs up to 20% less than treatment started by a MD.

If the blog contributor were truly interested in facts, he would have mentioned that chiropractic consistently outperforms all other back pain treatments, including prescription medication, deep-tissue massage, yoga, Pilates, and over-the-counter medication therapies according to a leading consumer survey. He also might have mentioned that unnecessary spinal fusion surgery (a procedure that has seen a 500% increase in the last decade) has resulted in an estimated $200 million in improper billing to Medicare in 2011 alone. It is noteworthy that Medicare deemed the surgeries medically unnecessary because more conservative treatment hadn’t been tried first.

What makes this viewpoint so short-sighted is also that the need for providers who offer a conservative approach to pain management has never been greater. The Centers for Disease Control and Prevention recently classified prescription drug abuse in the United States as epidemic. The U.S. is home to six percent of the world’s population, yet consumes 80% of its pain medication.

DCs are designated as physician-level providers in the vast majority of states and the federal Medicare program. The services provided by DCs are also available in federal health delivery systems, including those administered by Medicaid, the U.S. Departments of Veterans Affairs and Defense, Federal Employees Health Benefits Program, Federal Workers' Compensation, and all state workers' compensation programs. DCs complete nationally accredited, four-year doctoral graduate school programs with a curriculum that includes a minimum of 4,200 hours of classroom, laboratory and clinical internship, with the average DC program equivalent in classroom hours to medical and osteopathic schools.

Chiropractic services are one of the safest and most effective treatments for back pain, neck pain and headaches, and can help patients avoid riskier treatments, more expensive care and get well sooner. If Forbes.com is interested in presenting more balanced information on improving patient care and cutting excessive health care spending, DCs would encourage the editors to choose articles without the steeped misinformation and blatant personal bias shown in this commentary.

Thank you,
Anthony W. Hamm, DC
President, American Chiropractic Association

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.

Create a campaign and show people how to take their annual posture picture

From text-neck to the computer slump, people know their posture is a problem. It‟s up to you to help them do something about it and create an action plan towards improvement that includes regular chiropractic care. A Posture Month campaign is a great way to build awareness with education and annual posture pictures. Plus, engaged patients will often share their awareness by taking pictures of their friends‟ posture, building your authority as the Posture Expert.

The first step in improving posture is seeing and benchmarking what someone‟s posture looks like. A camera and a regular background create digital documentation so you can make an objective assessment. Hold the camera level with the ground and photograph the subject from the front, back and side. (NOTE: A posture picture is protected health information under HIPAA, so keep pictures digitally secure with a dedicated camera or just download pictures to their EHR).

Grids are great for more precise measurement, but a standard six panel door or anything showing a vertical reference works as a benchmark to compare future images. Have them stand a few inches from the wall or door with what feels like “standing tall good posture.” If they stand rigidly "at attention," tell them to relax (and notice how many people are actually a bit uncertain of what standing tall actually feels like).

People are usually amazed to see their first Posture Picture, which helps them take the first step in becoming Posture Conscious. This awareness and the intentionality of taking a posture picture is the key to teaching patients to take pictures of others. When you review the clinical correlation of their posture and problem, suggest they can take a similar photo of others. Having them download a free posture assessment app (whether or not it‟s the one you use) can be helpful to encourage them to do so, but is not necessary to engage patients to take pictures of those they care about.

A cell phone camera or tablet is an essential tool for any neuro-musculo-skeletal professional. Back pain isn't going away, Boomers are getting older, and posture is an acknowledged marker of general health¹. It's not just kids with backpacks or cane-carrying seniors – studies show poor posture is a major cause of back and neck pain for all ages, and over time often contributes to digestive and cardio-pulmonary problems. The good news: there are easy things people can do to strengthen posture, including care to restore spinal health with an adjustment.

Repositioning the pain patient towards an awareness of their postural and motion deficits provides a logical and intuitively true bio-mechanical link between perceived pain and observable motion dysfunction. Restoring lost segmental motion is among the most agreed upon benefits of an adjustment, and often correlates with pain relief. Chiropractors can then empower patients for pain management, rehab and wellness as well as align with the cultural and scientific perceived value of strengthening core stabilizing muscles by adding posture, balance and alignment exercises to their protocols.

In addition to training healthy joints to move in full-range symmetry, strengthening posture can have potential positive effects on psychological and/or emotional issues by improving posture and body consciousness. Also, posture pictures taken during an initial exam set the stage to build posture awareness and support the benefits of care when patients see tangible posture improvements after treatment.

A posture practice can target the opportunity today by building real relationships, regardless of insurance, to help people with the problem they present with, and then build value. The patient's desire to move well, optimize health and avoid a recurrence of their initial complaint becomes the center of a practice model with three elements: Posture Consciousness, Concepts and Control. In other words, build a cycle: connect their problem with posture, create awareness with a digital posture picture and then empower them with StrongPosture® exercises². Be aware of the benefits of standing taller and moving well.

Dr. Weiniger literally wrote the book on improving posture, Stand Taller ~ Live Longer: An Anti-Aging Strategy, and is managing partner of BodyZone. He's trained thousands of DCs to help their patients move well with the StrongPosture® exercise protocols and promote posture awareness with the free PostureZone iPhone app and online referral directories. Dr Weiniger work on posture has been featured in mainstream media including ABC, NBC and FOX News, Oprah‟s Oxygen network, Scripps, Natural Health, Prevention, Bottom Line and Golf Digest. For professionals his team hosts PostureZone.com for practice tools and PosturePractice.com for training as a CPEP(Certified Posture Exercise Professional).

---

¹ McEvoy MP, Grimmer K. Reliability of upright posture measurements in primary school children. BMC Musculoske-let Disord 2005;29:6-35
² Stand Taller~Live Longer: An Anti- Aging Strategy, S. Weiniger, BodyZone Press, 2008