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Q.- If you change the procedure code from 98941 to 98940 do you have to change Box 14? |
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NO. Box 14 is for a new condition.
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Q.- What is the difference between the ABN and the NEMB? |
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The ABN informs a patient that their service may not be covered and they must choose whether or not they want to receive the service, and then sign the form. The NEMB simply notifies the patient that the service is not covered by Medicare.
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Q.- Does it affect your profile with Medicare if you never file claims that might be denied, and only file for acute care visits? |
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No, this does not affect your profile with Medicare.
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Q.- What forms should be completed by the patient on their first visit? |
A.-
Everything on the Medicare documentation checklist, HIPAA, informed consent, assignment of benefits and any signatures related to a PI or WC case.
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Q.- How often should the ADL information be reviewed with the patient? |
A.-
Review ADL's with the patient on Day One and then continue to manage the list at every visit. In addition, utilize the Quad VAS form.
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Q.- If we have a patient sign a Medicare opt out form when we convert them to wellness, do we still need to have
them sign an ABN form and submit that one visit to Medicare to have them deny it?
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No. If they opt out, there is no need for the ABN.
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Q.- Can you bill 97140 for cervical or lumbar traction 15 minutes in office treatment time?
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A.-
97140 is not traction - 97012 is traction for disc and facet syndrome.
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Q.- Can we offer a gift card to a local restaurant to someone who comes to see us as a patient? If so, is there a dollar limit? |
A.-
According to the Office of the Inspector General, you can offer gifts of no more than $10 per gift, up to five times per year, as long as it is not related to the generation of payment of Federal healthcare dollars. If a gift is offered, it must be offered to everyone - it cannot be a reward for becoming a patient.
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Q.- Is there a way to have a safe harbor "family plan"? |
A.-
If it is truly cash and a family plan, use the S codes.
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Q.- How do you bill Medicare for an office visit that is not covered, so the secondary insurance pays? |
A.-
The billing procedure is no different than with any other service, except the correct modifier must be placed on the CPT code.
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Q.- What form do we use for non-Medicare patients on a maintenance program (for example, the agreement not to use Medicare coverage)? |
A.-
There is usually no form to use unless the carrier mandates such a form. If not, this is already part of the patient's contract and no form is needed.
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Q.- Once you start billing Medicare with A P R of the P A R T, and the asymmetry and ROM remains and the pain goes away, do you have to change it on the bill to A R, or just continue with billing A P R? |
A.-
If the conditions change, you can change the code as you go. But, there is really nothing that should be removed, because you should be choosing the most severe code in the first place. Also, the P A R T diagnosis codes should not be part of the reported codes if there is a more severe code.
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Q.- If Medicare and the secondary insurance do not cover office visits, do you charge the patient, or just do not bill them since they are not covered? |
A.-
The patient should be billed.
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Q.- We are currently billing a patient's insurance and contracted with the company. She wants traction without an adjustment, but doesn't want to use up her visits on just that service. Can we charge her a cash fee for this or should we collect the contracted rate? |
A.-
Services not related to a treatment plan and not related to subluxation/ improvement of a functional deficit would become a cash service.
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Q.- When billing 97140 we use the modifier 59 if we are not performing for the full 15 minutes. Do we use both 59 and 52 modifiers? |
A.-
Yes. For ADL/Functional-based Manual Therapy less than 15 minutes and in a separate and distinct area of the spine non-related to manipulation, use 97140-52-59.
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Q.-
Can we offer a prompt-pay discount?
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A.-
Yes, but the practice is only allowed to discuss the discount opportunity during the following times: after the patient registers for services and the patient pays his or her cost-sharing amount; when the practice sends written statements to a patient by mail; and AFTER the patient has agreed to purchase the services, when financial arrangements are made between the practice and the patient. The discount must be disclosed to third-party payors and the waived amount cannot be claimed as bad debt or otherwise shifted to burden any payor.
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Q.- What is the best way to help patients understand how to complete the QUAD? |
A.-
Explain it one condition at a time. For example, "On a scale of 1-10, what is your pain like at these 4 times?" Then ask for the second condition, same questions. Sometimes the patient gets confused because they don't understand that multiple conditions can go on the same form.
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Q.- How can we explain to patients that their insurance does not cover maintenance care?
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Ask the patient to read the medical necessity portion of their policy. The policy states whether or not they pay for maintenance or wellness care.
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Q.- A patient receives therapy along with an adjustment, and we bill GA for adjustment and GPGY for therapy. Medicare crosses over to secondary and they pay for therapy. Do we bill for the patient at all, or bill only for the adjustment? |
A.-
Call the secondary payor and ask for clarification if they cover the therapies when the adjustment is connected with an ABN. If they have no problem with it, document it and continue as planned.
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Q.- If we have two doctors in our practice, it is best to have one in-network and one out-of network? |
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From a contractual point of view, it is against most insurance contracts to have one doctor in and one doctor out of network.
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Q.- When testing ROM, how important is measuring degrees vs. indicating pain and mild, moderate or severe restrictions? |
A.-
ROM is not as important as ADL's for overall medical necessity, but proves the need for active rehabilitation. ROM is best used when paired with a functional deficit. If the functional deficit is not related to pain, degrees of improvement of ROM would correlate the findings to the functional deficit improvement. (example - can't turn head to drive, but no pain upon restriction). If the functional deficit is related to pain, improvement of restriction due to pain during ROM would correlate the findings to the functional deficit improvement. (example - can't turn head to drive, but has pain upon restriction). This is an important distinction because the painful ROM is going to be a complicating factor that allows for both passive modalities and active rehabilitation at the same time until the painful ROM is at MMI.
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Q.- Can a CA note in the chart that a patient has given informed consent for treatment if the doctor signs the note? Can it be typed as a standard part of a chart and then signed by the doctor? |
A.-
According to malpractice carriers, this works best when the form is signed and the doctor WRITES in the file that "the patient understands the Informed Consent Form" in his own handwriting. It is difficult to defend a patient's claim that the doctor never informed them of the dangers when the doctor didn't do it himself.
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Q.- When is a GA modifier used? |
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The GA modifier is used only if the patient has signed an ABN form. Do not place a GA modifier on charges once the patient has opted out of billing Medicare.
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Q.- If we have a patient on wellness and they get an ultrasound, can we give them a discount on the fee or do we have to charge the full fee? |
A.-
You can give them a discount on the fee.
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Q.- If a patient comes in for a maintenance visit, no acute symptoms, but needs 2-3 adjustments instead of 1, can they still be considered wellness, or do they have to join a cash discount network? |
A.-
If the doctor feels the patient should not be on active care, the wellness codes can be used for that patient. A discount network plan is only needed for Medicare/Medicaid patients for their excluded services of exams, therapies and x-rays.
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Q.- On the Quad VAS, what is the difference between high intensity and low intensity scores? |
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The difference between high and low intensity scores is to be used to correlate the severity of the injury with the complaint, diagnosis and the prognosis.
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Q.- When determining which level exam code to use, does the time just have to be the time the doctor is in with the patient, or can we also consider the time our CA is with the patient, taking detailed history, blood pressure, etc.? |
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Time is not related to the requirements that the CA performs. Coding based on time is for the doctor's face-to-face time with the patient.
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Q.- When we send records to an insurance company, do we sent our worksheet to compile the xray report or can we just send the xray report summary that is typed in the notes? |
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You can send the report summary, as long as it says exactly what is on the worksheet.
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Q.- Can CPT's medical nutrition therapy codes (97802-97804) be used by a physician? |
A.-
For Medicare Part B coverage of Medical Nutrition Therapy (MNT), only a registered dietitian or nutrition professional may provide the services. While these requirements may preclude you from billing Medicare, it may not preclude you from billing commercial carriers for MNT services. Be sure to check individual plans for coverage and provider requirements. For medical nutrition therapy assessment and/or intervention performed by a physician, the physician should submit the appropriate E/M codes (e.g., office visit or preventive medicine services codes).
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Q.- If code 98943 (ext. adjustment) is not covered by BC/BS and they allow $22.00 for this service, do we collect the allowed amount or the full amount? Also if we have to collect the allowed amount, can we discount it since it isn't covered under the policy? |
A.-
If it is not covered by contract, you may use the out of network fee.
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Q.- If we have a paper file for a past patient (including old intake forms, old travel cards, etc.) and now due to documentation requirements, we have new information associated with the patient's new case, do we combine the old and new files, and if so, what are the rules?
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A.-
You can combine them or create a new paper file, until the requirements for EMR are released. This does not apply to PI patients because they are not covered under HIPAA or Medicare.
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Q.-
If I have a Weight Loss Program that I advertise as come to our Free Seminar on Weight Loss or No Charge for our Weight Loss Seminar, is that okay? Also, at the end of my seminar, if I say the normal fee is $125 for a personal hour long consultation, but if you schedule now it is $25 …is that okay? There will be no Chiropractic Adjustments as part of their program and there will be no diagnosis or insurance filed. It will be a cash only program for weight loss. Is that complaint?
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Not an issue as long as the services provided don't end up as billings to an insurance company.
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Q.- I treat a family of 5. Can I offer them a discount on the children?
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A.-
Yes, if there is a financial hardship. Download the form "Financial Hardship" from our website. If no hardship exists, then you may give a prompt pay discount, but no more than 15%.
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Q.- Under the Medicare signature requirement, does the provider have to physically sign the HCFA form in box 31, or can we use the typed name or signature stamp?
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A.-
A typed name or signature stamp is fine for the HCFA form. The provider must physically sign documentation in the patient record.
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Q.-
If a Medicare patient comes in with a non-spinal shoulder injury, is an ABN necessary? Can we charge our regular (higher than Medicare) fees? Are we accountable for Medicare standard notes?
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A.-
Since you are treating for non-spinal, the services are excluded and an ABN is not necessary. You must charge the regular rate for services provided since you will not be billing 98940/1/2. The code for extremity adjusting would be 98943 plus whatever therapies you provide, which are all excluded by contract. You are not held accountable in this instance for Medicare standard notes.
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Q.- We are using the code 98940 and 98941 on a cash patient. Are we regulated under the insurance requirements?
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Q.- If patients are coded wellness S8990, do we need to meet the insurance documentation requirements?
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No requirement for medical necessity. Documentation in SOAP that shows what was done on the patient without the need to show improvement is sufficient.
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Q.- Can you bill for an office visit and an adjustment with therapies on the same visit?
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Yes, for a separate and identifiable service over and above the EM supplied during the adjustment.
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Q.- What is a good diagnosis code to use with electromuscle stim 97014?
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Q.- When verifying a new patient's identification, do we need to have a copy of their driver's license in their file, or can we just make a notation in the file that we verified their identification?
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Make a copy for the record.
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Q.- If when evaluating a patient before adjusting, the doctor finds a cervical subluxation but the patient has no compliants in that area, can the doctor adjust it but not bill it?
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A.-
The doctor can adjust the area if there are no complaints as long as there is documentation and a treatment plan to back up the procedure, e.g., your cervical subluxation findings treated with cervical adjustments. It runs the risk of malpractice to adjust in areas with no diagnosis or plan for treatment. If this area is being treated as wellness or maintenance, then the patient should pay cash for the services rendered. In the treatment plan, the ICD-9 diagnosis of subluxation can be replaced by v70.9 or Unspecified General Medical Examination, which remains an internal code for the office and does not require billing for the service.
As a reminder, if you are billing insurance for this, the documentation for the area must contain a direct therapeutic relationship (DTR) between the complaint, exam, diagnosis and treatment plan set up with regards to recommended frequency and level of care and treatment specific to the diagnosis. Documentation must also include objective measures to evaluate treatment effectiveness and specific treatment goals for established baselines of the patient's functional deficit that ties to the diagnosis. For more information on this, please watch webinar #80 Direct Therapeutic Relationship Training Course to learn how creating a DTR helps prove medical necessity for chiropractic care.
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Q.- If I have an outside company that shreds my medical documents, how do I know if I am being HIPAA compliant?
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A business associate agreement that covers HIPAA compliancy will need to be signed with the shredding company. The Downloads section of our website has an example of a business associate agreement that you can use for your practice.
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Q.- How do you write an appeal letter to a private insurance company when treatment is considered not medically necessary?
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Usually, there is not a specific letter that needs to be filled out and returned to the major medical carriers. Follow these 5 steps. (1) Call the carrier and ask them why the claim was dendied. (2) Fill out an incident report and let us know what the carrier is asking for. (3) Download the Case Summary Binder from our website. (4) Create the crosswalk from the binder to your notes. (5) Send the entire packet to the carrier.
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Q.-
Do I need an ABN for a Medicare patient when involved in a personal injury (PI) case?
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A.-
No need for an ABN. You can do 1 of 3 things:
1. You can file a lien and wait to bill the third party liability carrier.
2. You can file a lien and wait 90 days and then bill Medicare for the adjustments. Once you do, you can only collect the allowed amount for the adjustments.
3. You can bill the carrier right away if you feel the carrier will not settle in a timely manner. Once you do, you can only collect the allowed amount for the adjustments.
The ABN has nothing to do with a PI case for these reasons:
1. Because the 3rd party liability carrier is the primary coverage.
2. It would be active care not wellness care.
3. Ancillary services do not require an ABN form.
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Q.- If I have applied for Medicare credentialing, can I see Medicare patients and charge them as cash patients until I get the provider number?
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You can’t see them for cash. If just waiting for the provider number, you can see patients but must hold the claims until getting the number from CMS. If you keep submitting applications and none of them are accepted for approval, then you can’t see the patients at all until the application is approved and you get a back billing date.
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Q.- Is the treatment plan date the date the patient first comes in and has an exam, or is it the day they have their first adjustment?
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"Treatment plan date" is the day the patient first comes into the office with a complaint, not the date of the first adjustment.
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Q.- Should we record in our notes the beginning and ending time of examinations?
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Time spent is not required documentation, but if you do record it, then it becomes the main factor in the code you choose.
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Q.- Is is OK to bill for the product Biofreeze in a personal injury case?
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Q.- Is foot pronation considered a pre-existing condition, prior to the accident, in a personal injury case?
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A.-
Yes, it would be unless you can show a specific relationship between trauma the and pes planus. Usually, they are denied as related to a pre-existing condtion.
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Q.-
I have the MD check the box for the LSO brace on the PI script form. Should I also have the MD sign the 1) Prescription and Certification of Medical Necessity form or the 2) Medical Necessity for Aspen Summit Brace form? Does it matter which form I use?
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It does not matter which form is used. The MD is responsible for medical necessity as long as you have the proper prescription. The prescription form is all that is needed, but you should get medical necessity form as a backup.
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Q.- We did a promotion accepting donations for Haiti. Some patients had x-rays done, but decided to go elsewhere and want copies of their x-rays. Can we charge for the copies?
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Yes, you can charge for the hard costs of x-ray reproduction plus a small percentage, 1-5%. This would be for cash only.
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Q.- We have a patient who only has Medicare Part A. Do we charge him our regular fee or the Medicare allowables? Does he sign an opt out form, even though he doesn't have Medicare Part B?
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A.-
Part A Medicare does not cover outpatient services. Therefore, the patient is treated as a cash patient. ABN and opt out forms are for patients with traditional Medicare Part B.
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Q.- I know that on the first subluxation diagnosis you have to have the second diagnosis in the same category. On the sample completed treatment plan, I noticed on your third and fourth diagnosis you have just the subluxation. Does this mean that I don't have to have a diagnosis from each of those categories to go with the subluxations?
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There are 5 levels of subluxation and 5 secondary diagnosis codes. We didn’t use a number to report it on the sample treatment plan, but yes, you must have a secondary diagnosis for all areas adjusted.
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Q.- When should the informed consent form be signed, prior to the exam or prior to the first adjustment?
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Q.- Should we charge the Medicare rate or our cash rate for adjustments on Medicare maintenance patients?
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A.-
Charge what you wish as long as it does not exceed the Medicare allowable rate.
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Q.- We use a travel card and have patients rate their symptoms on each visit (0-10 scale).
Should we discontinue getting this each visit and instead use the quadruple visual analog scale every 4-5 weeks?
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A.-
There is no need to discontinue unless you want to. You can add the QVAS if that is easier for you. If you use ADL's on a daily basis, then there is no need for the QVAS on a daily basis.
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Q.- If a patient has 7 procedures on 1 day and their limit on benefits only covers 4, when billing that date of service is it appropriate to include all 7 procedure lines or pick the best 4?
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A.-
If the policy states that everything over the limit is not billable, then charge the carrier for the most expensive services. If the policy allows the patient to be charged, bill the patient for the services not allowed by the carrier.
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Q.- For documentation of assessment of complicating factors (relative and absolute), what types of contraindications
should be noted? Should we also note if there are none?
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A.-
The entire list of contraindications are listed in Section 240 of the Medicare Policy Manual. Also document if the assessment revealed no complicating factors.
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Q.- Is it appropriate to give brief stretching exercise instructions as part of the office visit and not have a separate
charge? Example - for patients who do not choose active therapy as part of their care plan due to expense, or
patient is already on an exercise program and doctor wants to add 1 or 2 specific stretches that do not meet
billing requirements.
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A.-
Yes, that is totally OK. Part of your E/M code during the adjustment is management of the patient's case.
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