TOP Education s 2018 Synergy Conference Medicare Active to Maintenance 1 CEU Presented By: Mark A. Davini, DC, DABCN
Please scan IN at the start of class Please scan OUT at the end of class You must attend the entire session to earn your credit(s) for this class
Mark A. Davini, DC, DABCN 1981 graduate of Palmer College of Chiropractic 24 years in active practice Diplomate in Chiropractic Neurology Certified Chiropractic Industrial Consultant Past Chairman of the MA Board of Registration of Chiropractors Mass Chiropractic Society, Vice-President of Public Information and Education Mass Chiropractic Society, Chairman of the Ethics Committee Lecturer for various state and national associations continuing education programs to include chiropractors, nurses, dentists, the Council on Licensing, Enforcement and Regulation for the Commonwealth of MA, and 2nd and 3rd year medical students at the University of Massachusetts Medical School. Dr. Davini co-developed and teaches the Chiropractic Assistants Procedures Program (C.A.P.P.) Co-Developer of TOP Education, LLC Active in the defense of chiropractors involved in malpractice litigation. Compliance Auditor/Clinical Monitor as well as a pattern practice analyst Awarded 2 U.S. Patents on the M-Brace for Carpal Tunnel Syndrome Chiropractor of the Year by the Massachusetts Chiropractic Society in 1996. Doctor of the Year by the Worcester County Chiropractic Society in 1987
National Coverage Determination (NCD) Local Coverage Determination (LCD) The NCD and LCDs are Medicare s primary resource for coverage, limitations, documentation requirements, reporting of services and definitions. Every area/state (jurisdiction) has a LCD that further defines the NCD and may differ from other jurisdictions. This is your local rule book.
Par v. Non-Par Participating Provider (PAR) Signed CMS-460 is in place PAR the participant, hereby enters into an agreement with the Medicare program to accept assignment of the Medicare Part B payment for all services for which the participant is eligible to accept assignment under the Medicare law and regulations and which are furnished while this agreement is in effect. Non-Participating Provider (NON-PAR) No CMS-460 in place or has a terminated CMS-460 agreement NON-PAR providers generally do not accept assignment of the Medicare Claims submitted and all payments are processed to the Patient. (Assignment on a case by case basis is allowed with Non-Par) 5
Most Medicare Claims From Chiropractors Improper, HHS Says October 25, 2016 HHS = $359 million, or 82%, of the $439 million that Medicare paid to chiropractors in 2013 was medically unnecessary. The OIG has issued seven other studies on chiropractic services since 2005. Evidence of widespread improper payments prompted Congress to take corrective action in the Medicare Access and CHIP Reauthorization Act (MACRA). The OIG recommended that CMS determine what is a reasonable number of chiropractic services to actively treat spinal subluxations, and that it tweak its software to detect services beyond that number.
How did HHS come to their conclusion: No treatment plan (or vague plans of care), No objective measures, No measurable goals, No documentation of effectiveness The ROM was missing from the exam. No documentation of subluxation or areas treated. The documentation supported maintenance therapy. Hx lacked documentation to support new or active condition. Based on the Hx, difficult to determine where, breaks in Tx. Providers billed a higher level service than number of areas Tx. Failure to provide medical records for the probe review. Think about your records
The Paperwork Patient demographics Health History Medicare Authorization / Medigap Authorization Form Financial Responsibility ABN Non-Covered Service Waiver form Self Pay Policy / Time of Service Discount Plan Verification of Benefits (Medicare, Secondary, Tertiary) CMS-1500 (02-12) Claim Form Informed Consent Outcome Assessment Tools
ABN Advanced Beneficiary Notice Only for Active Treatment of Spinal Chiropractic Manipulative Therapy (CMT) 98940, 98941, 98942
ABN When to use the ABN with patients? CMT services fall under maintenance care as defined in the NCD & your LCD If you believe the spinal CMT service may be denied for frequency and/or duration Take a moment to think about this!
Form CMS-R-131 (Exp. 03/2020) Form Approved OMB No. 0938-0566 A. Notifier: Legal Office Name Address and phone # B. Patient Name: C. Identification Number: NOT HIC # Advance Beneficiary Notice of Noncoverage (ABN) Chiropractic Manipulative Therapy(CMT) 98940 98941 or 98942 service service NOTE: If Medicare doesn t pay for D. below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D. below. Medicare does not pay for chiropractic maintenance services as defined in the current Local Coverage Determination Regular maintenance chiropractic care. service D. E. Reason Medicare May Not Pay: F. Estimated Cost Enter your FEE here WHAT YOU NEED TO DO NOW: Read this notice, so you can make an informed decision about your care. Ask us any questions that you may have after you finish reading. Choose an option below about whether to receive the D. service listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this. G. OPTIONS: Check only one box. We cannot choose a box for you. OPTION 1. I want the D. listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. OPTION 2. I want the D. service listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. OPTION 3. I don t want the D. service listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. H. Additional Information: This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy. I. Signature: J. Date: CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
NON COVERED SERVICE WAIVER FORM As of January 2014 a SIGNED ABN form should not be used as a Non-Covered Service Waiver Form Non-Covered Service Waiver Forms are used for all Statutorily no covered services. That means; Anything and everything EXCEPT the spinal CMT services 98940, 98941 or 98942
National Coverage Determination (NCD) Local Coverage Determinations (LCD) A. Maintenance Therapy Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3A) 15
Patient Encounter Sequence Active Treatment (AT) Initial phone call: Determine if New or Established patient: Ask: when was the last time you were in to see the doctor? Determine if Medicare.
Patient Encounter Sequence Active Treatment (AT) Once Determined they are Medicare: If Established Patient and is less than 3 years, use Established Patient E/M codes If over 3 years or never seen, use New Patient E/M codes Ask-do they have a Medicare Replacement Plan Ask-do they have Medigap Insurance Review requirement for exam Review fees, non-covered and covered services Schedule appointment Next Go to Medicare Patient Encounter
Medicare Patient Encounter: ROF: Remember appropriate E/M code Review procedures for the day Complete intake forms to include Non-Covered Services Waiver form and Outcome Assessment Tools Complete consult with Hx-Systems Review-Chief Complaints Perform Ex mindful of P.A.R.T. for each CC Plan of Care, Tx, Short & Long Term Goals etc. Sign Informed Consent Render treatment Bill with -AT modifier and appropriate G Codes Next Continue with Active Treatment.
Active Treatment: Treat as indicated Document being mindful of P.A.R.T. for each CC As long as FUNCTIONAL progress is demonstrated continue with updated Plan of Care Bill with AT modifier and appropriate G-Codes Repeat every 30 days or less: Repeat above until resolution/or maximum functional improvement Once resolution or maximum functional improvement has been met Next Continue care until Discharge/Release.
Discharge/Release: Complete OATs Complete documentation Discharge/Release from Active Treatment (AT) Once discharged patient has 2 choices: 1.Patient may choose to be released. 2.Patient may choose to go to maintenance. If patient chooses maintenance go to Maintenance Protocol. Either way explain to patient, new conditions or flare ups require a new Ex at the time and they must pay for it.
Maintenance Protocol: Maximum Functional Improvement has been achieved Patient chooses to continue maintenance care at their own cost Patient fills out ABN as previously described One ABN is signed for that treatment plan and is good for the remainder of the calendar year Patient checks OPTION 1 -You must bill: Bill without AT modifier Bill with GA modifier and G-CODE Patient checks OPTION 2 -You do not bill: If the patient is coming in visit by visit and there is no documented maintenance plan they will need to sign a new ABN with box 2 each visit.
Continue with maintenance having the patient sign a new ABN yearly
Please scan OUT as you leave If you are staying in this classroom for the next session you must have your badge scanned OUT for this session and scanned IN for the next session Thank you! Mark & Paul
Some of our Synergy teachers are making their presentations and other materials available for download at the conclusion of the weekend. www.toolsofpractice.com/ppts
TOP Education, the instructors teaching on behalf of TOP Education are here this weekend to educate. They are not representatives nor speak on the behalf of any particular government entity, insurance company or TOP Education, LLC. Any specific discussions are for example purposes only. All specific policy or procedure questions should be directed to the entity that authors those policies