medicare simplification. why is medicare so complicated? cover 3 services only they pay for...

MEDICARE SIMPLIFICATION

Why is Medicare so complicated?

Cover 3 services only

They pay for episodic care

They cover active treatment of musculo-skeletal conditions related to the spine

They don’t cover maintenance care

Why is Medicare so complicated?

They require an examination to support necessity

They require a treatment plan with functional goals

They require the patient to be discharged

They require records when requested

So why the high error rate?

50% or more of chiropractors fail to document the care provided to this population

MAC A/B

Jurisdiction 6

Illinois, Wisconsin, Minnesota

Who is your CCAC?

Who is your provider relations rep at NGS?

Enrollment

NPPES/PECOS

www.nppes.cms.gov

Individual and Corporate NPI required

CMS Requirement for Coverage and Payment

Active musculo-skeletal condition

CMT directly related to condition

Expectation of functional improvement

Demonstrate presence of subluxation (How)

Acute

New condition or injury…expectation of improvement, arrest or resolution of condition

Chronic

No expectation of full resolution but continued treatment should result in some level of functional improvement

Maintenance

Once functional status remains stable, further care is considered maintenance and is not covered

Beneficiary can then make a reasonable decision about receiving and paying for the service (CMT)

Claim must be filed if the patient chooses

ABN

Only utilized for covered services which will likely be denied payment as maintenance care

Must be on file during the duration of the maintenance care

May revert back to active care when appropriate

Use GA modifier

Patient chooses if claim is to be filed

ABN

Do not have the patient sign an ABN on initial visit or each successive visit

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CMT

98940 1-2 regions (35%)

98941 3-4 regions (55%)

98942 5 regions (<10%)

CMT

Cervical including occiput

Thoracic including post ribs

Lumbar

Sacral including coccyx

Pelvic including SI joints

Extraspinal regions

Head including TMJs

Upper extremity

Lower extremity

Ribs anterior

Abdomen

Medicare Population

Geriatrics…the branch of medicine dealing with problems peculiar to old age and aging

Consider patient based on age and/or physical capacity and realistic expectations

WHO classifications…elderly 65-75; old 76-90 and very old >90

Medicare Population

Successful aging…optimizing health while minizing physiological declines as a result of aging through exercise, smoking cessation, decrease alcohol consumption and social and intellectual stimulation

Usual aging….typical declines in physiological function over time which reflect effects of disease, adverse environmental conditions and poor lifestyle conditions

Geriatric 5 I`s

Intellectual impairment

Incontinence

Immobility

Instability

Iatrogenesis

Geriatric Challenges

Report of good health

2-3 comorbidities ….others uncovered

Atypical symptoms with slow onset or progression

Fractures without trauma

Age bias of provider

Demographic Trends

Life expectancy …1900 47 years; 1990 75 years

Population >65 US and Canada =12%

Projected 2030=20%

American seniors account for 37% of hospitalizations

31% of all prescription meds

36% of all health care expenditures

Utilization Trends

Prevalence of back pain in elderly between 13-49%

NMS impairments most common conditions causing activity limitations

>65 population make up 15-17% of patients utilizing chiropractic while representing 12% of the population

Significant????

New/Renewal Patient Process

Obtain Medicare credentials

Secondary/supplemental coverage

Intake forms including photo ID, demographic information

Chief complaint, review of symptoms, etc.

HIPAA disclosures

History

Date of encounter

Chief complaint (NMS)

History of present illness and date of onset

Mechanism of trauma

Pain description including location, description and intensity (VAS/NRS)

Functional limitations

History

Date of encounter

Chief complaint (NMS)

History of present illness and date of onset

Mechanism of trauma

Pain description including location, description and intensity (VAS/NRS)

Functional limitations

Physical Examination

Medicare beneficiaries should be processed like all other patient populations

Standard of care issues

Neuromuscular and musculoskeletal

Rule out red flags/contraindications to CMT

Physical Examination

Vital signs

Pain/tenderness

Asymmetry

Ranges of motion-spinal

Tone

Orthopedic examination

Neurological examination

Other body/organ systems as indicated

Imaging

May be utilized to demonstrate subluxation

Considered reasonably proximate if 12 months prior or 3 months post initiation of care plan

CT/MRI acceptable

Exception is a permanent condition

Diagnostic Impressions

ICD-9-CM that support medical necessity

Primary diagnosis supports region of subluxation (739)

Secondary diagnosis supports the NMS condition

Three categories of secondary codes based on severity and expected recovery (short, moderate and longer term care)

Care Plan

Recommended level of care including any and all therapeutic interventions

Frequency of care

Expected duration of care

Treatment goals

Objective measures to evaluate effectiveness

Functional Limitations

Medicare requires an expectation of improvement and/or recovery

Assessing the patient for functional deficits is critical for reimbursement

Documenting improvement can be accomplished by use of valid outcome assessment tools

Authentication

Sign all records generated

Subsequent Encounters

CMS does not require the treatment plan be updated on each visit

The records must however include….

Date of onset

History including review of chief complaint, changes since last visit and ROS if relevant

Exam including area of the spine involved, assessment of change and evaluation of treatment effectiveness

Documentation of all interventions

Denial Appeals Process

Redetermination by the carrier or MAC

Reconsideration by a Qualified Independent Contractor (QIC)

Hearing by an Administrative Law Judge

Review by the Medicare Appeals Council within the Departmental Appeals Board

Judicial review in the US District Court

Common Errors

Records not legible

Technical errors…missing signatures, dates

Documentation does not support procedure…spinal levels treated and clinical relevance

Missing treatment plan

CC not clearly identified

Area being treated not clearly identified

Quality Reporting

PQRS

Mandatory in 2013 and non-compliance in 2015 will result in a 1.5% Medicare penalty

2016 the penalty is scheduled for 2%

See handouts

So why is Medicare so complicated?

Cover 3 services only

They pay for episodic care

They cover active treatment of musculo-skeletal conditions related to the spine

They don’t cover maintenance care

So again, why is Medicare so complicated?

They require an examination to support necessity

They require a treatment plan with functional goals

They require the patient to be discharged

They require records when requested

Quiz

What is the difference between Medicare documentation and other entities?

Is PART examination sufficient to demonstrate medical necessity?

Are musculoskeletal conditions and subluxation inter-related clinically?

How do you respond to a request for records?

Does Medicare cover tx of chronic problems?

Is the geriatric population expanding?

Quality Reporting

Pain Assessment

Functional Outcome Assessment

Hypertension Screening

Quality Reporting

Process versus outcome measures

Claims based

Mandatory with all Fee-for service claims

Explanation l

The End