PQRS

Railroad Medicare Update

2014 Medicare Deductible

Proper Use of an ABN Form

CERT Reviews

CMS announces major savings for Medicare beneficiaries

Part B premiums will see zero growth; billions of dollars saved in donut hole

Background

• Connecticut (implemented in January 2012),
• Downstate region of New York (implemented in April 2012),
• NY Queens County (implemented in August 2011), and
• Upstate region of New York (implemented in December 2011).

Findings

• 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 (P=pain, A=asymmetry, R=range of motion, T=temp, tone, tonicity) exam, the documentation requirement must be fully met per policy. Policy requires documentation of two of the our criteria, one of which must be asymmetry/misalignment or range of motion abnormality.
• Lack of area(s) of 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.

• 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.
• 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.

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 LCD and SIA for Chiropractic Services (L27350). The LCD and SIA can be accessed from the Medical Policy Center on the National Government Services Web site. Enter L27350 in the CMS Identifier Number search field and select Go to initiate an LCD search in the CMS Medicare Coverage Database.

• 253 - Sequestration - Reduction in Federal Spending

As the deadline for implementation of the April 1, 2013 regulation looms, and not having heard from the Department of Financial Services relative to the Association’s February 20, 2013 inquiry above, I telephoned the Department of Financial Services and spoke directly to someone in the Insurance Bureau that works on No-Fault issues. After explaining the foregoing ambiguity again, the DFS representative explained that he believed the issue had been addressed in the State Administrative Procedure Act (SAPA) run-up to the regulation and that the Regulatory Impact Statement clearly states that ONLY the portion of a provider’s fee that exceeds the fee schedule will be denied, not the entire fee.

Not content to take the Department’s word, I looked up the Regulatory Impact Statement (RIS) directly and it seems to concur with the DFS statement. Under the rubric: “Preventing Billing in Excess of Mandated Fee Schedule or for Services Not Rendered,” the RIS states as follows:

• Use of false and misleading Explanations of Benefits relating to chiropractic claims (required under ERISA for informing subscribers of how their claims have been processed), which interferes with the doctor-patient relationship
• Manipulating charge and payment data, allowing ASHN and CIGNA to pass on excessive costs to subscribers, while distorting the amounts providers actually receive in benefit payments
• ASHN's restrictions of care via the pre-authorization process and provider contract provisions that prevent patients from having access to the full breadth of their benefits and in contradiction to their certificates of coverage--a violation of ERISA
• ASHN and CIGNA's imposition of excessive co-pay requirements on subscribers, another ERISA violation
• CIGNA's improper prevention of doctors of chiropractic (DCs) from providing services that fall within their scope of practice, in violation of state provider non-discrimination laws
• ASHN and CIGNA's violation of various state prompt payment laws