New Rules & Regulations For Chiropractors Anger 39 Healthcare Associations

If you think the pace of all the new rules and regulations is a little too much like a runaway train, you are not alone!

EHR, HIPAA 5010, ICD-10, OIG Compliance, Medicare PRQI, etc, etc

In fact, 39 different healthcare associations have told the Feds to just slow down and quit interfering with our businesses by giving us new hoops to jump through.

Unfortunately, some of us won’t even know what hit us when these new rules go into effect.  Some pack fines, others will cripple your cash flow. Still others we should delegate or dump altogether.

While I don’t have the space in this blog to go over every potential rule/regulation affecting chiropractors, here’s the Executive Summary of the ones to pay the most attention to:


Issue: ICD-10 codes must be used on all transactions (electronic or paper claim) with dates of service on and after October 1, 2013. Otherwise, your claims may be rejected, and you will need to resubmit them with the ICD-10 codes. This could result in delays and may impact your reimbursements, so it is important to start now to prepare for the changeover to ICD-10 codes.


ICD-10 has been in the works forever.  The dates keep getting delayed mainly because most healthcare associations protest that they are not ready for the transition, which admittedly will be huge.  Every diagnosis code you are currently using will be obsolete.

Recommendation:  2013 is still a ways away.  The info you will need to learn will not likely change, but there are more pressing issues you may want to focus your time and resources on that have sooner due dates. Put this one on the back burner for now.

HIPAA 5010

Issue: On January 1, 2012, standards for electronic health care transactions change from Version 4010/4010A1 to Version 5010.  In other words, if you submit claims electronically, you will have to “convert” to 5010 format before 2012 or you will risk not being paid.

Background:  The 5010 electronic health care transactions include functions like claims, eligibility inquiries, and remittance advices.  Unlike the current Version 4010/4010A1, Version 5010 accommodates the ICD-10 codes, and must be in place first before the changeover to ICD-10. The Version 5010 change occurs well before the ICD-10 implementation date to allow adequate Version 5010 testing and implementation time.

If providers do not conduct electronic health transactions using Version 5010 as of January 1, 2012, delays in claim reimbursement may result. Preparing for 5010 – including potential updated software installation, staff training, changes to business operations and workflows, internal and external testing and more – will take time. Medicare has declared June 15, 2011 National Testing Day for the 5010 conversion – most healthcare entities outside of chiropractic are ready to go, others will take advantage of the June 15 opportunity to make sure that everything works as it should.

While my good friends at ChiroCode are a notable exception (see their recent alert abouyt HIPAA 5010 testing day), unfortunately, it appears that most of the chiropractic profession is still in the dark on this one. DC’s have reported to me that even some State Associations and EMR companies have no clue about this.  While this is disturbing, in the end, it’s your responsibility to make sure your office is ready.

Recommendation:  Prepare your office as soon as possible for the 5010 conversion.  Most payers (insurance companies) are ready now.  Many electronic claims clearinghouses are either ready or will be soon. Some EMR companies are ready, some are clueless.  You need to make sure that your office, your EMR, your clearinghouse will be transitioned in time. You missed my webinar on what steps to take, questions to ask, when to panic (just kidding), but you can still get it on CD: “How to Get Your Chiropractic Practice Ready for HIPAA 5010.” Or get the info somewhere else.  Whatever you do, don’t assume someone else will take care of everything for you only to be disappointed in 2012 when they didn’t!

Medicare PQRI


Issue:  Bonus or incentive payments are now available for chiropractors who report certain codes and track demographic info for Medicare.

Background: The Physicians Quality Reporting Initiative (PQRI)The 2006 Tax Relief and Health Care Act (TRHCA) (P.L. 109-432) required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals who satisfactorily report data on quality measures for covered professional services furnished to Medicare beneficiaries during the second half of 2007 (the 2007 reporting period).

To participate in the 2011 Physician Quality Reporting, individual eligible professionals may choose to report information on individual Physician Quality Reporting quality measures or measures groups: (1) to CMS on their Medicare Part B claims, (2) to a qualified Physician Quality Reporting registry, or (3) to CMS via a qualified electronic health record (EHR) product. Individual eligible professionals who meet the criteria for satisfactory submission of Physician Quality Reporting quality measures data via one of the reporting mechanisms above for services furnished during a 2011 reporting period will qualify to earn a Physician Quality Reporting incentive payment equal to 1.0% of their total estimated Medicare Part B Physician Fee Schedule (PFS) allowed charges for covered professional services furnished during that same reporting period.

Recommendation.  Lots of hype, little payout. For most chiropractors, don’t even bother with PQRI hassles.  You are eligible for up to 1% of your allowed Medicare charges if you utilize the proper codes and report data correctly.  Do the math and most people will choose to dump this.

EHR Incentive Payments


Issue: Up to $44,000 worth of Incentives are available for providers who demonstrate meaningful use of EHR technology.

Background:  Unless you are living under a rock, you probably don’t need this background, but here it is anyway.  The feds have up to a $44K present for you if you use EHR according to their groundrules.  EHR companies hold webinars every 27 minutes to tell you the wonders of this miracle gift from Uncle Sam.

Recommendations: This is my story and I am sticking to it.  Despite my poorly disguised sarcasm, I actually love EHR – but it’s not the $44K incentive that tickles my fancy.  Use HER to improve your documentation, patient care, practice management, billing – whatever.  But don’t buy it because you think it’s going to be free because of the $44K expense offset.  If you are dead set on the incentive idea, there are many tools around that can help you determine if you would meet meaningful use and how much to expect in incentives if you do. The best one is the “Meaningful Use Attestation Calculator” that is published by Medicare so it should be as reliable as Medicare (but at least unbiased). Do your homework and see how much you can earn or weep at the fact that you won’t get back a dime, despite what the salesperson with the shiny white teeth told you.

OIG Compliance


Issue:  For the last 12 years, the Department of Health and Human Services (HHS) Office of Inspector General (OIG) has promoted the voluntary adoption of compliance programs throughout the healthcare industry by the development and promulgation of compliance guidance tailored to specific healthcare industry segments.  As recently as May 18, 2011 the OIG has made announcements that the transition towards mandatory compliance plans will be soon.

Background: The OIG has stated that a compliance plan will become mandatory, but has not given an official date yet.  So, we know it’s coming, we just don’t know when. Given that the vast majority of chiropractors probably have either no compliance plan or one that has been sitting in a binder on a shelf since the day it was made, this represents an area where a little prevention can go a long way.  A well-designed compliance plan can not only help you avoid fines for doing things wrong, but it can also help you set standards for doing things right in terms of billing, collections, HIPAA privacy, etc.

Recommendations:   An effective compliance plan designed to identify and correct potential violations is a tool to help prevent mistakes AND it can be used in your defense if you are charged with alleged fraud.  If you have no compliance plan in place at all or if it was done prior to 2009 (when many rules and changes thanks to the Affordable Care Act and other government regulations), you need to get a simple framework set up to make sure that your office is covering the basics of compliance.

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