Archive for the ‘Medicare’ Category

Random Thoughts Episode #136: Chiropractic Audits, Business Building & Success

by Tom Necela on July 20th, 2010 in Audits, Billing, Business, Chiropractic Audits, Coding, Collections, Documentation, Medicare, chiropractic billing, chiropractic business, chiropractic coding, chiropractic collections, chiropractic documentation, compliance

Reading time: 5 – 8 minutes

I’m on the road for the next couple weeks traveling for a number of on-site consultations with clients so this blog post will be a summary of random thoughts on the most common questions that repeatedly brought to my e-mail inbox.

1)  Chiropractic Audits: a few months ago I received a lovely piece of hate mail to accuse me of trying to disproportionately scare well intentioned, upstanding chiropractors in regards to the possibility of an audit. My latest “tweet” included a post to the most recent findings from Medicare reviews for the states of Nevada and Hawaii.  In those two states, chiropractic documentation failed to meet requirements 60 to 70% of the time.  Similar posts from other review results in the past were even higher than that and OIG reports even higher still.

I might not be the greatest mathematician, but it seems to me that the majority of chiropractors are not scared enough!  If 60%+ of chiropractic documentation is substandard, that means most of you are in trouble or headed down the wrong road. It’s not a great picture for me either.  There are roughly 50,000 chiropractors in the United States, so that it would be physically impossible for me to help roughly 30,000 of you get your documentation in order, teach you proper billing and coding, or come to your assistance in the case of an audit.  I wish that I would live long enough to be able to help, but with those numbers, some of you are just going to have to suffer the consequences.

For those of you who think slightly more highly of me or take the potential of audits more seriously, now is the time to take action. It is obvious to all that audits are a big business for not only cash-starved government entities like Medicare, but also for insurance companies looking to expand profits by taking your money back.  The audit numbers and amounts recovered in post-payment demands are so large that they are virtually beyond comprehension for the average chiropractor.

Since I don’t know most of you personally nor do I care to manipulate the facts to scare you, let me just share a few recent scenarios that came by my desk.

Chiropractic Audit case #1:  Medicare audit, six patient, 94% error rate determined; post-payment demands made for 18 months (legal limit for that state).   Total bill amounts to only a little over $2000.  Big pain in the patootie is that this doc failed a previous audit and now has to submit all claims for “pre-payment review” which means that Medicare doesn’t pay him a dime until they receive and approve all notes and every treatment.

Chiropractic Audit case #2:  Auto insurance carrier, handful of patients who were treated for the last 3 yrs on claim (bad state, no limitations statute).  Total repayment demand is approx $56,000. Legal expenses totalled $8000 so far.  Doctor may also face civil fines.

Chiropractic Audit case #3: Commercial insurance.  Re-payment demands made by insurance company after extrapolation (process of configuring an error rate to apply across the board).  Demand total was close to $95,000.  Insurance in error on reviews in some instances and doctor’s repayment will be significantly less, but she will still have to re-pay. Doctor will likely be kicked off insurance provider list as well. Legal fees approximately $17,000.

Maybe this is all chump change to you and you have a life of leisure that can afford the time and hassle it takes to wrestle with the insurance companies, hire attorneys and formulate your audit defense. The rest of you, take note.

2)  Business Building:  Don’t chase your customers or patients. Find out where they are going and get yourself or your information in front of them.  This simple advice (not mine but I can’t remember who I heard it from) is full of wisdom and potential applications.  For example, people who are sick or hurting often go to the medical doctor.  How can you get the MD to route them toward your office?  Most people work.  Which of your patients has a position in human resources or is the owner of a small business with a fair number of employees?  Rather than try to come up with some fancy high-powered presentation that you will likely work on for the next four years until you’ve whittled it to perfection, why don’t you just approach people who already know and trust you as patients and see if they can help you make inroads into their company?  People surf the Internet. First off, that means you need to have a website too.  While the chances of catching random visitors that become patients are slim, but you can stack the deck and give them a reason to come to your site by writing articles, posting videos, and providing other informative content for your community.

Obviously if you are busy enough, you may not need to employ any or even all of these strategies. But for the rest of you, instead of spending time surfing the net do something tangible to improve your web presence. Rather than whining that referrals are down, take a concrete step towards leveraging your patient relationships to increase your referrals on your patience. Instead of sitting in your office hoping patients will come to you, reach out to where they are and bring them in.

3)  Success.  Keep in mind that your business should be there to serve you and not vice versa. I’ve run into too many chiropractors whose primary purpose seems to be providing jobs for their employees. Worse, I’ve seen too more “successful” chiropractors whose drive to succeed left their spouses, children, health and sanity by the side of the road.  A few fortunate ones can come back and retrieve it. But for many once these items are lost, they are gone forever.  Take a day off and go play while the weather is nice.  Spend the afternoon with your children, the evening with your spouse.  Your bank account may not look immediately better for it, but in the long run it is cheaper to stay married, stay healthy, stay sane and not have to pay for years of therapy for your screwed up kids!

As for me, I intend to practice what I preach both working and playing.  If you have an Audit or business issue to discuss, feel free to drop me an email. That’s the beauty of the internet, it can be checked anywhere.  On the other hand, if you see a bald man not acting his age on a wakeboard at a lake near you, it just might be me :-)

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Still Free? The Word on Co-pays, Coupons & Discounts

by Tom Necela on July 6th, 2010 in Audits, Billing, Business, Chiropractic Audits, Collections, Medicare, chiropractic billing, chiropractic business, chiropractic collections, compliance

Reading time: 1 – 2 minutes

Last year, I posted an article on co-pays, coupons, and discounts –  essentially what to do and what not to do.

This subject remains one of the most popular questions I still get asked.

As we recently have celebrated the freedom of the USA with Independence Day, I thought it fitting to re-visit the “freedoms” (or lack thereof) that we are challenged with inside our chiropractic practices.

Unfortunately, when freedoms are abused, trouble sets in.  Keep your nose clean and re-visit the post

Chiropractic Co-Pays, Coupons and Discounts – When Free Isn’t

(click the link above to see the post)

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Chiropractic Medicare Mess Sort of Fixed (For Now)

by Tom Necela on June 22nd, 2010 in Billing, Medicare, chiropractic billing

Reading time: 3 – 4 minutes

Three important details emerge as the bottom line from the recently passed legislation:

  1. The 21% Proposed Fee Cuts are Delayed Until November 2010
  2. Medicare Claims will begin processing with a 2.2% fee increase from June 1 to November 30, 2010
  3. The House will vote on the finalization of this increase on 6/22/2010

Obviously, this creates some logistical mess in the present and to anticipate in the future regarding exactly what fees one should anticipate being paid.  To access your fee schedule directly, you should go to your Medicare carrier’s website because that is who will ultimately be responsible for processing your claims.  The American Chiropractic Association also has a helpful page with some Q&A’s and additional Resources on this subject matter.

Personally, I am sure I am not alone in saying that I can’t wait for all this mess to be over and done with.  The volume of email confusion hitting my inbox is astounding and, although  I certainly can see the importance of dedicating space and time in this blog to the subject matter, I’d love to move on!

With that, I am going to encourage all my readers to sign up with Twitter and “follow me” so that I may continue to keep you informed of news related and important items such as this.  And so we can use the blog for a format of discussing other topics of your interest apart from the latest rules and regulations thrust upon us by Medicare or other entities.

If you are not familiar with Twitter, you are obviously one of the few citizens who are not following the every move of Ashton Kutcher or Brittany Spears (and this is a good thing).

Twitter is a online “micro-blogging” site that allows users to contribute short (limited to 140 characters) messages to each other.  It’s great for exchanging newsworthy items, reminders and has a host of potential business related applications.  It’s also famous for being used (mis-used?) as a sort of online diary by which a person can literally blog about one’s every move, meal or madness.

For our purposes, I use Twitter exclusively to keep chiropractors updated on the latest newsworthy occurrences, regulatory changes and other pertinent info that you need to know.  I typically give links to the stories or sources where you can find the needed info.  And the best part is, it’s FREE and if you aren’t interested in the days topic, there’s nothing to do or delete.  Since it doesn’t get emailed to your inbox, you are not overwhelmed with…um.. stuff  you don’t need.  Just check your Twitter account on your own time and it doesn’t cost you a dime!

So, sign up and “follow me” today so we can keep you informed of these items and so we can continue to use blog space to dedicate towards the other topics of your interest!

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The Medicare Mess Continues to Affect Chiropractic

by Tom Necela on June 15th, 2010 in Business, Medicare, chiropractic business

Reading time: 6 – 9 minutes

In case you were really hankering for some bad news from Medicare, here’s a couple gems that hit directly at the chiropractic profession.

Perhaps you have been following the trail of the Medicare fee increase or maybe you have better things to do in between adjustments than watch a complete demonstration of Medicare insanity.  Either way, you will be pleased to know that:

“in anticipation of the vote to increase Medicare fees in 2010 by 2.2% and in 2011 by 1% which was in response to the previous defeat of the bill to decrease Medicare fee schedule by 21%, Medicare has reported that they will continue to hold claims through Thursday June 17th.  If Congress has not taken final action by Friday June 18th, claims will be paid with the 21% fee decrease applied.”

And if you can read that quote, you probably either have a law degree or spend too much time reading plot-twisting Tom Clancy novels not actually written by Tom Clancy!

To summarize:  Medicare may not quite know what it’s doing with the fee schedule fiasco yet and they plan to hold your claims until June 17, 2010 — in other words, not pay you anything.  After that point, they may pay based on the 21% fee decrease, IF no further action is taken….

Not surprisingly, I have received many emails full of confusion and conflict over this issue from chiropractors around the country.  I have been repeatedly informed of carriers who have already been processing claims with a small fee decrease since January 1 – not the proposed 21% decrease, nor the 0% “interim” fee increase from the 2009 fee schedule that is supposed to be in effect until Medicare gets its act together and a resolution has been obtained. Others have written in to state that Medicare has been paying exactly as expected. Still other more valiant chiropractic efforts have been reported by offices who have attempted to call their Medicare carrier and ask for an explanation of why, when and how they are to be paid.  The responses have ranged from ridiculous to right on the money.

(Interesting side note: I even have a couple Medicare carriers following ME on my Twitter page. Isn’t that supposed to be the other way around?! Perhaps just everyone is desperate for info on the subject matter, even Mr. Medicare himself.)

Obviously, there is still a lot of confusion over the details of the proposed Medicare fee schedules (from both the payers and the providers) and a lot of anger. Witness the recent move by the MD’s represented by the AMA who turned in their lab coats as a sign of protest over Medicare’s move.

One thing emerges as a clear action step: DC’s really need to watch reimbursements to determine exactly how you are being paid.  Then compare that to how you should be paid.  Hopefully they match. If not, my suspicion is that Medicare will be getting more calls and appeals than usual this year.

More Medicare Mess

In other news, Medicare carrier Palmetto GBA released its Medical Review findings for the 2nd Quarter (yes, I know for most of the world, the 2nd quarter hasn’t finished yet – see they’re not behind on EVERYTHING!).

While these findings are specific to this carrier, I believe that they are indicative of challenges the chiropractic profession faces at large, so I will report them here.  Of the 12 items listed that reflect “the majority of documentation issues discovered during the review process” there are four that affect chiropractic in general, and one is specific to chiropractic services exclusively.

Here are the common errors (with my comments in italics below) that were found so that you can be sure to avoid them in your own practice, as I am certain your carrier is finding similar problems:

Signatures: Documentation missing signature authentication by the author of the electronic medical record or contains an illegible signature.

(This is an easy mistake to fix and too simple to get nailed on.  See Medicare signature requirements so you don’t kick yourself for getting claim denials over your signature.)

Evaluation and Management Services: Services do not meet the minimum documentation requirements.

?  Specific concerns:

  • Use of ‘noncontributory’
  • Documenting ‘labs reviewed’ without further information
  • Referred to documentation that was not included with medical review request
  • Ancillary staff or scribe documentation requirements were not met, and
  • Counseling/coordination of care missing time and/or documentation to support service

(While Medicare doesn’t pay DC’s for E/M codes, other insurance companies do. From my experience looking at chiropractor’s documentation, many of the errors above are routinely made on many regular insurance claims.)

Legibility: We accept transcribed notes in addition to copies of originals.

(In other words, if you are not on EMR and your handwriting is pitiful enough that it cannot be read by the average person with no special eyesight abilities, use a transcription service to type up your chicken scratch so at least someone can read them.)

No response to request for medical records: Often times this is because a provider failed to update his/her address/phone number; therefore we are unable to locate the provider.  Please keep in mind it is the provider’s responsibility to notify Palmetto GBA within 90 days of any changes that occur.  Please follow all instructions provided on any letter requesting documentation.

(These instructions are for Palmetto, but most – if not all – carriers have a similar policy.  From experience, I can tell you that nearly every DC that has ever moved a practice incurs a lag time before Medicare catches up.  In the past, this was just inconvenient.  Presently, if you happen to receive a negative determination or payment demand and fail to respond – due to the fact that you moved or for ANY reason – you need to respond PROMPTLY or you will pay the price…literally.)

Chiropractic Services: Missing treatment plan with specific objective, measurable treatment goals.  Follow thru with these specific objective treatment goals on subsequent visits is often omitted.  The initial visit and subsequent visit often was missing key elements/requirements outlined in the Internet-Only Manual Medicare Claims Processing Manual 100-04, Chapter 12, section 220.  Reminder:  Subluxation may be established by either an x-ray or hands-on examination (P.A.R.T.)

(In other determination and reviews I have seen, the terminology “missing” is actually different than “incomplete.”  While that may sound obvious to you, consider what this carrier is saying:  DC’s are not including ANY treatment plan as a part of their notes. It’s not inadequate, incomplete or subpar – it’s just not there!!  Obviously, if there is no treatment plan, there will be no measurable treatment goals.  Heck no goals at all!)

See you next week – where hopefully there won’t be more bad Medicare news to report!

Tom Necela, DC, CPC, CPMA

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National Legislative Changes (or Non-Changes) Affecting Chiropractors

by Tom Necela on June 1st, 2010 in Business, Collections, Medicare, chiropractic business, compliance

Reading time: 2 – 4 minutes

Changes_next_exit

In case you haven’t heard, two recent legislative changes have been passed that will affect you as a chiropractor:

Because these changes (or non-changes) happen quickly, I typically alert chiropractors of these via my Twitter page. But for a change of pace and because I know 14, 238 of you reading this are NOT following me on Twitter I thought it might be useful here as well.

(BTW: If you are on Twitter, no worries. I won’t send you tweets about what a great lunch I am eating or give you my reaction to the latest celebrity gossip in 140 characters or less.  If you are not on Twitter, it’s a quick way to stay updated on changes in chiropractic that you need to know. Plus, as a special bonus, you can re-tweet them (sort of like an email forward without the bad jokes) to friends and impress them with you ability to stay in the know on current events!)

So, here’s the news:

Medicare Fee Decrease

The long-anticipated (dreaded?) 21% Medicare fee decrease is scheduled to go into effect June 1, 2010.  While hopes have been high for a delay, no final Congressional action has yet been taken.

Medicare recently released a notice indicating that they would hold claims for the first ten business days of June to provide Congress with additional time to consider this issue.

Chiropractors should be aware that this hold will only affect claims with dates of service June 1, 2010, and forward.

Claims paid prior to June 1 should still be paid at the zero percent (0%) fee increase proposed by other recent legislative activity.  Translation: claims paid with dates of service Jan 1 through May 31 will be paid at the same fee schedule as your 2009 rates.

Red Flag Rules Delayed

Again, the Federal Trade Commission (FTC) has delayed implementation of the Red Flags Rule. The next date is set for January 1, 2011.  Although it has been a subject of much debate whether this ruling even applies to chiropractors, no worries – you still have time.  Meanwhile, Congress intends to determine the scope of entities who are covered by the rule. We will just have to wait and see how that turns out.

Hope you had a great holiday weekend!

I will be back next week with my usual fare of musings on all things related to the business of chiropractic.

Tom

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The Best of…Strategic Chiropractor Blog Flashbacks

by Tom Necela on May 10th, 2010 in Audits, Billing, Business, Chiropractic Audits, Coding, Collections, Documentation, HIPAA, Medicare, Medicare ABN, OIG Report, Politics, chiropractic billing, chiropractic business, chiropractic coding, chiropractic collections, chiropractic documentation, chiropractic practice management, compliance

Reading time: 1 – 2 minutes

flashback

In business and in life, it is helpful to go back and review the basics, to take a look at where you’ve been and where you want to go.

Today’s blog post feature’s 3 links to our most popular columns of the past – in case you missed them – or in case you need “a refresher course.”  (pardon the Fletch reference)

Here they are (in no apparent order):

Enjoy!

Tom Necela, DC, CPC, CPMA

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Medicare Releases Chiropractic Medical Review Findings for the 1st Quarter

by Tom Necela on April 6th, 2010 in Audits, Chiropractic Audits, Coding, Documentation, EHR / EMR, Medicare, chiropractic EHR, chiropractic EMR, chiropractic coding, chiropractic documentation

Reading time: 4 – 6 minutes

detective

Recently, a Medicare carrier (Palmetto GBA) released their 1st Quarter results of Medical Reviews they have been conducting.  Even though Palmetto is only one of several carriers who administer claims on behalf of Medicare, their findings are relevant to chiropractors and, in my experience, reflective of trends across the chiropractic profession at large.

The goal of the medical review program is to reduce payment errors by identifying and addressing documentation and billing errors concerning coverage and coding. In their reviews, Palmetto GBA identified ten problem areas for the first quarter of 2010. These areas were as follows:

  1. Split/shared visits
  2. Signatures
  3. Labels/Diagnostic Testing
  4. Hospital & Nursing Facility Discharge Services
  5. Chiropractic Services
  6. Therapy Services
  7. Individual Psychotherapy Services
  8. Evaluation & Management Services
  9. Legibility

10.  Teaching Physician Services.

Please note this is not an all-inclusive list but does reflect the majority of documentation issues discovered during the review process.  Of this list, however, three items have direct application to chiropractic reimbursements in the Medicare program.

So let’s discuss these three “Frequently committed errors”:

  1. Signatures.  Put simply, Medicare requires an “identifier” for services provided or ordered.  That identifier is your signature – either in handwritten or electronic form.  Signature stamps in your documentation are not acceptable per Medicare Signaure Requirements (See section 3.4.1.1 B) Quite frankly, this is so basic that it is ridiculous that it even makes the top ten. Apparently, despite its simplicity, most physicians seem to overlook it.
  1. Chiropractic Services.  As a relatively small profession, we should not even make the top ten hit list.  We did, however, so now it is our responsibility to correct these problems asap as a profession.  Palmetto found chiropractic documentation to be lacking in the area of Treatment Plans.  More precisely, chiropractors were missing treatment plans with specific objective, measurable treatment goals. Follow thru with these specific objective treatment goals on subsequent visits was also often omitted.  Difficult?  Not very.  Documented?  Apparently, not very often.  Can you fix this, doctor?  Definitely!
  1. Legibility.  If this is not the biggest commercial for EMR, I don’t know what is!  Again, there is no reason any physician should be getting dinged for this one.  Alas, I have seen many of your notes and I sadly agree, that they are barely legible, sometimes only to the highly trained eye (yours and that of your longstanding staff) – and sometimes, even you cannot decipher your own notes.  Put simply, if your notes cannot unquestionably be read by a third-party without eliciting a migraine or use of some special telescopic lens, it is high time to get on EMR.  There are plenty of good systems out there.  In fact, ANY system that produces legible documentation is better than marginal handwriting – and I have yet to see an EMR system that fails to product legible documentation!

In summary, we chiropractors need to get our act together pronto – not only for Medicare, but for all third party payers.  The items above are not difficult to fix, but I realize that some of you are overwhelmed by how much work you have to do to bring your documentation, billing and coding up to acceptable standards.  Others may be so consumed with building your business that you literally don’t have time to look up and see the arrow sailing directly at the target on your chest.  And some of you are just plain tired of putting out the fires in all these areas due to a lack of solid systems that both maximize your reimbursements and minimize your audit risk.

The good news is: help is available. And while it is a physical impossibility for me to assist  all of you with these needs let alone answer the truckload of emails I receive per month on chiropractic billing, coding and documentation questions from random chiropractors at large!  But I am willing to offer a FREE, no obligation look under the hood of your practice for those of you willing to invest the time and effort into completing a Practice Analysis Questionnaire.  Download it, complete it, fax it in today and take a concrete step towards improving your practice, your business, your piece of mind and your life.

To Your Success!

Tom Necela, DC, CPC, CPMA

P.S.      Not sure what can be done with YOUR practice?  Take a look at what my clients have to say about the transformations they have achieved in their practice!

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The Impact of Medicare Fee Cuts on Your Chiropractic Practice

by Tom Necela on March 30th, 2010 in Billing, Business, Medicare, chiropractic billing, chiropractic business, chiropractic practice management

Reading time: 3 – 4 minutes

CB027333

Despite the best efforts, lobbying and protests of every major physician association (including the American Chiropractors Association and the International Chiropractors Association), the 21% Medicare fee cuts are still scheduled for April 1, 2010.

For those of you who hope to lessen the blow of this bad news by taking comfort in the fact that a relatively small portion of your practice consists of Medicare patients – think again.  This fee cut (which by the way, is scheduled to be a nice, round 20% reduction for Chiropractic fees) will impact all of your third party reimbursements in time!

This is due to the simple fact that most third party payers use the Medicare fee schedule as a basis to calculate their own reimbursement decisions.  Read the fine print in your contracts and you will find that ABC Insurance pays 150% of the Medicare allowable or XYZ Insurance’s fee schedule is set at 175% of Medicare.

So, yes, at this point, there is no good news to report about this Medicare situation, which will go into effect April 1 or as soon as the carriers can get to the business of revising their reimbursement calculators to ensure that the screws on our Medicare torture chamber are nice and tight.

If you can find your state representatives and senators (you may have to watch some MTV programming or track them down in some tropical paradise, as it is spring break for most), be sure to let them know how disappointed you were in their inability to block this legislation and take 20% out of your already dismal Medicare paychecks.

In the meantime, my other recommendation is to consider this slap in the face a brutal wake up call that it is high time for you to start improving your practice.  Take a look under the hood and see what needs tuning up.  Then, promptly get to work on tweaking for additional performance.

If you need some guidance in the area of what’s going wrong, what to fix or where you stand, fill out my free, no obligation Practice Analysis Questionnaire and I will take a look with you.

Unless we get some sort of last minute reprieve, making no changes in your practice whatsoever will likely result in a 20% loss of your income in the near future if these Medicare fee cuts reach their full impact.  I don’t know about you, but I am not willing to let anyone – whether it is the government, Goliath or any goon bigger than I am – take 20% of my income without a fight and some definite activity on my end to make up for the difference.

Contact your political reps.  Start formulating Plan B.  And let’s get to work on making lemonade out of lemons!

In the meantime, keep these words of Alistair Cooke in mind:

“In the best of times, our days are numbered. And so it would be a crime against nature for any generation to take the world crisis so solemnly that it put off enjoying those things for which we were assigned in the first place: the opportunity to do good work, to fall in love, to enjoy friends, to hit a ball and bounce a baby.”

To Your Success!

Tom Necela, DC

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Medicare Fee Cuts Update for Chiropractors

by Tom Necela on March 2nd, 2010 in Business, Collections, Medicare, chiropractic billing

Reading time: 6 – 9 minutes

file_6

In the usual right up to the wire, last minute fashion common amongst government entities, Medicare (CMS) issued the following statement regarding the proposed Medicare fee cuts that were supposed  to go into effect Monday, March 1, 2010:

“CMS is working with Congress, health care providers, and the beneficiary community to avoid disruption in the delivery of health care services and payment of claims for physicians, non-physician practitioners, and other providers of services paid under the Medicare physician fee schedule (MPFS).  The Department of Defense Appropriations Act of 2010 provided a zero percent (0%) update to the 2010 MPFS effective for dates of service January 1, 2010, through February 28, 2010.

We believe Congress is working to avoid the negative update that will take effect March 1, 2010.  Consequently, CMS has instructed its contractors to hold claims containing services paid under the MPFS for the first 10 business days of March. The holding of MPFS claims will only affect claims with dates of service March 1, 2010, and forward.  This hold should have a minimum impact on provider cash flow because, under current law, clean electronic claims are not paid any sooner than 14 calendar days (29 for paper claims) after the date of receipt.”

In other words, Medicare still doesn’t know whether or not there will be a fee cut.  And in the meantime, they will hold your claims and do nothing.  But, no worries, by law they have 14 calendar days (for electronic) and 29 calendar days (for paper billing) to get their act together and decide what you will be paid.

Presumably, you have nothing better to do than check the Medicare website (or that of your carrier) for the moment when the decision is finalized.

For an organization willing to slap a fine on you for “inducements” of any gift in excess of $10, they are not worried in the slightest on how their financial sloppiness affects our patients.  Sure, Medicare claims their indecisiveness “should have a minimal impact on cash flow” because they have the grandest of intentions of still paying you on time. (The failure of which will likely be the subject of a future statement released by CMS.)    However, notice the conspicuous lack of advice on matters of over-the-counter fee collection whilst we all wait in limbo.

Should we collect based on the 2009 fees, the anticipated fee cut, the negotiated slightly reduced compromise fee cut or anything in between?

In reality, for chiropractors the fee cuts – however large or small – may have a relatively minimal impact on our bottom line, especially when compared to other specialties.  After all, even a 20% reduction on a $35 is $7.   Not pleasant, but not likely to break the bank.

What will add insult to injury is the calculation of the difference between what you are collecting now and what you should have been collecting on March 1 and the time differential that Medicare notifies you about what should have been done, had they informed you on time, along with the positive or negative financial accounting and remuneration that goes along with it.

If you can read and comprehend that sentence (and I am not sure I can, even though I wrote it!) you will likely have no problem with the upcoming changes.  Perhaps you should even go to work for CMS as a translator or policy writer.

For the rest of us, here’s the skinny in plain English and my recommendations:

  • For now, there is no Medicare fee cut (nor any fee raise)
  • Continue operations under your 2009 local carrier fee schedule
  • Collect any co-pays or patient portions with no changes
  • That way WHEN Medicare does release their fee schedule, you can accurately calculate whether you owe the patient or they owe you more.
  • Get ready to support your state and national associations to oppose drastic fee cuts
  • Write to your Senator to oppose the fee cuts and tell them what a ridiculous inconvenience these shenanigans are for you and your patients (their constituents)

(Please note, these are my recommendations, not requirements, as there are no new requirements yet!)

If this frustrates you, hey at least you know you are alive.  It is my understanding that the dead do not experience such emotions.  On the bright side, US Citizens are not the only ones subject to the frustrations of their ruling class.  Other countries do, however, formulate protests with a bit of humor which makes the bad news go down easier.  For example:

  • In response to frustrations with city council, the 1959 election in Sao Paulo Brazil featured Cacareco, a five-year-old female rhinoceros, who ran under the platform “better to elect a rhino than an ass.”  She won by a landslide.
  • In 1967, in anticipation of municipal elections throughout Ecuador, the Pulvapies foot powder company launched an advertising campaign that featured the slogan: “Vote for any candidate, but if you want hygiene, vote for Pulvapies.”  Apparently the hygiene of the area had slipped so badly under the current regime that Puvapies won the election, under protest from actual human candidates.
  • The all-time winner of electoral protest goes to Guinness book of World Record holder, Lord Sutch whose platform was “Vote for insanity — you know it makes sense.” He campaigned in a top hat and leopard-skin tail coat. His proposals included bringing back the village idiot, putting joggers on treadmills to make them generate electricity, breeding fish in wine so they could be harvested ready-pickled, converting coal mines into bungee-jumping centers (and making local politicians be the first to test them), and making all dogs eat phosphorescent food so that their poop could be seen at night.

Stay tuned for more details and in the meantime, keep your nose to the grindstone because Medicare may be paying you less money for more work very soon, (maybe).  Your other option is to follow the advice of the “bang head here” group and hope this resolves quickly, though I am not sure I recommend that route.

Keeping you informed (like it or not!),

Tom Necela, DC

P.S.  For those of you who wish to Work Smarter, Not Harder in spite of the wave of regulations, rules and changes Medicare and any other third party payer throws at you, I have two upcoming seminars in Seattle and Portland on Chiropractic, Billing, Coding, and Documentation Mastery (click link for more details an registration)

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How Medicare’s New Consult Code Policy Affects Chiropractors

by Tom Necela on January 20th, 2010 in Medicare, chiropractic billing, chiropractic coding

Reading time: 3 – 5 minutes

pickpocket-intro

For those of you chiropractors who have been following Medicare’s new consult policy that recently went into affect, you may feel like we are yet again victims of another Medicare scheme to pick our pockets of the few reimbursements we do receive.

Recently Medicare removed reimbursement for Consultation Codes (99241-99245) and the impact is being felt across many health disciplines, including chiropractic.  If you are unfamiliar with using Consult Codes, you have likely been missing out on significant income opportunities by documenting your services accurately.

Chiropractors, for the most part, view the consult as the time when we meet with a New Patient, answer a few of their questions and discuss the benefits of chiropractic care prior to actually performing an examination on the patient.  This does NOT in any way meet the CPT definition of a consult code (99241-99245) and should never be billed as such.

On the other hand, a true consult occurs when a patient arrives in your office at the request of another physician.  In other words, the other doctor (an MD, for example, is common) tells the patient to seek your professional opinion or expertise as a chiropractor.  In this type of situation, with proper documentation and conditions met, you can bill a consult code (99241-99245) in place of your normal E/M code and (here’s the reason for their popularity), these codes will pay significantly better than standard E/M codes.

So, if your office receives MD referrals regularly, you have been missing out on a great opportunity to increase your income that, unfortunately, may now be drying up.  For example, a typical billing of 99203 may be $100, whereas the consult equivalent of 99243 may be $150. I know several clinics who have increased reimbursement by thousands of dollars per year over standard E/M fees because of consult codes.

As of January 1, 2010, Medicare has indicated that it will no longer reimburse consult codes.  For DC’s, we may view this is as no big deal since Medicare does not reimburse us for exams anyway.  Unfortunately, since most third party payers and commercial insurance companies (such as BCBS, Aetna, Cigna, etc) use Medicare as a basis for payment decisions, many other insurance companies have stopped paying for consults as well!  And that can be a big deal for us!

Based on this, I would recommend two action steps for you to take:

  1. Contact your large payers to determine if they are still paying consult codes.  If so, keep (or start) using them until further notice.
  2. Eliminate billing consult codes to payers who have indicated that they are denying the code.
  3. Document the consult for either #1 or #2 as it is still important for the legal record, to indicate that the patient was a consult and that you have performed this services upon request from another provider.  You may not be paid but you are still obligated to report the service as rendered.

While many would agree that Medicare’s policies frequently appear to torture chiropractors, this one has far reaching impact that crosses the line towards other payers as well.  But, as mentioned previously, all payers have not yet adopted this new policy so be sure to utilize these codes while you can.

In the meantime,  if new developments about this occur or if similar, new opportunities comes our way, I will be sure to let you know! And for those of you who are wondering if you are missing out on any other items related to billing, coding or documentation that would help you improve your reimburesements, the answer is likely “YES!”  Take some time to fill out a FREE Practice Analysis Questionnaire and I will be glad to discuss how I may be able to specifically assist your clinic in this area, while also protecting you from unecessary audits due to your billing, coding or documentation mistakes!

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