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