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MEDICARE INFO: Cross-Referencing Regions of Complaint, PART Findings, Diagnoses and CPT Codes

By |June 18, 2013|Documentation, ICD-10 Coding, Medicare|

MEDICARE INFO: Cross-Referencing Regions of Complaint, PART Findings, Diagnoses and CPT Codes

The Chiro.Org Blog


SOURCE:   Dynamic Chiropractic ~ June 15, 2013

By K. Jeffrey Miller, DC, DABCO


In 2012 the Centers for Medicare and Medicaid Services and CMS-contracted reviewers performed chiropractic Medicare reviews nationwide. The results of their efforts were not good news for the chiropractic profession.

The reviews pointed to poor record-keeping and billing practices throughout the profession. Claims were also made of inappropriate billing of maintenance care resulting in significant overpayments for chiropractic services. [1] Unfortunately, these findings were consistent with previous CMS chiropractic reviews. [2]

Of the current review findings, the one that is most disappointing is our consistency from one CMS review to the next. It is difficult to respond to our many Medicare problems all at once. It can be overwhelming. However, while we cannot fix everything at once, we can fix something.

There are a specific set of closely related problems that can and should be addressed together. In actuality, the problems are so intertwined that they are really a single concern: matching the number of symptomatic spinal / pelvic regions; the number of spinal /pelvic regions with PART and/or X-ray findings of subluxation; the number of diagnoses, the number of regions adjusted; and the CPT code used to bill for the adjustment.

Volumes have already been written about this concern. Here, I offer a set of questions to help guide doctors in documenting the number of patient complaints, subluxations, diagnoses, regions adjusted and the appropriate billing codes. This series of questions is accompanied by comments and tables to clarify the importance of each question.

Questions to Ask Yourself After Examining a Medicare Patient

  1. How many regions of the spine / pelvis did the patient list as painful or symptomatic? Medicare is not purely subluxation based, despite the original and lasting rule that a subluxation must be documented in any region adjusted. The diagnostic criteria also require a symptom code for each region of subluxation. With this in mind, Medicare assumes the patient to have a complaint in each region treated and that the patient reported these complaints during their history. This is a common expectation for many other carriers as well. Carriers do not feel treatment of a region that is asymptomatic is necessary. “Asymptomatic” for Medicare and many other carriers translates to “no problem or no condition.”

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Medicare Information Page

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Medicare Documentation Requirements: The Hurdle That Continues to Block Our Progress

By |May 2, 2012|Documentation, Medicare|

Medicare Documentation Requirements:
The Hurdle That Continues to Block Our Progress

The Chiro.Org Blog


SOURCE:   Dynamic Chiropractic ~ April 9, 2012

By David Seaman, DC, MS, DABCN,
Albert J. Luce, DC and
Anthony Hamm, DC, FACO, DABFP


At present, the chiropractic profession has difficulty being compliant with Medicare documentation requirements. The 2009 report from the Office of the Inspector General reported the following: “Distinct from the undocumented claims, 83 percent of reviewed chiropractic claims failed to meet one or more of the documentation requirements.

Concerning treatment, file reviewers reported that only 76 percent contained some form of treatment plan, 43 percent lacked treatment goals, 17 percent lacked objective measures, and 15 percent lacked the recommended level of care.” [1]

In January 2011, the California Chiropractic Association reported the following on its Web site: [2] “Palmetto GBA has released the results of its review of chiropractic Medicare claims and found an “unacceptable” error rate of 68 percent for Northern California and 77 percent for Southern California. These results are very troubling, as Congressional leaders have threatened to remove chiropractic from Medicare if the profession [does] not improve its billing practices.”

Perhaps two primary issues may be at work. Either an inaccurate message is being delivered to chiropractors regarding appropriate Medicare documentation requirements and/or chiropractors are misinterpreting the message. Let’s attempt to clear up some of the confusion, outline documentation requirements based on several Medicare publications, and provide a flow chart for easy visualization of the required process.

Refer to MEDICARE DOCUMENTATION SIMPLIFIED Chart

What Does Medicare Want? (more…)

Utilization, Cost, and Effects of Chiropractic Care on Medicare Program Costs

By |August 22, 2011|Medicare|

Utilization, Cost, and Effects of Chiropractic Care on Medicare Program Costs

The Chiro.Org Blog


An older study of Medicare cost data completed in June (2001 or 2002) by the well-known Washington, DC-based firm Muse & Associates helps demonstrate the cost-saving impact that chiropractic care has on the current Federal Medicare program.

The study, titled “Utilization, Costs, and Effects of Chiropractic Care on Medicare Program Costs“, was commissioned by the ACA and is the first study of its type to compare the global, per capita Medicare expenditures of chiropractic patients to those of non-chiropractic patients receiving care in the federal Medicare program. The study utilizes data obtained from Medicare’s Standard Analytical Files for 1999 — the most recent year that cost data was available for analysis.

The study’s executive summary states:

“The results strongly suggest that chiropractic care significantly reduces per beneficiary costs to the Medicare program. The results also suggest that Chiropractic services could play a role in reducing costs of Medicare reform and/or a new prescription drug benefit.”

The study specifically found that:

  • Beneficiaries who received chiropractic care had lower average Medicare payments for all Medicare services than those who did not ($4,426 vs. $8,103);
  • Beneficiaries who received chiropractic care averaged fewer Medicare claims per capita than those who did not; and
  • Beneficiaries who received chiropractic care had lower average Medicare payments per claim than those who did not.

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Postponement of Medicare Pay Cut Is Stripped From The Jobs Bill

By |February 19, 2010|Medicare, News|

Postponement of Medicare Pay Cut Is Stripped From The Jobs Bill

The Chiro.Org Blog


A Chiro.Org Editorial


Physicians continue to hope for a reprieve from the proposed 21.2% Medicare pay cut scheduled to begin on March 1, as another legislative solution to the reimbursement crisis fizzled this week in a hyperpolarized Congress.

A jobs-creation bill, crafted by Senate Democrats and Republicans earlier this week, originally would have delayed the massive cut to October 1, but this provision and many others were stripped out within days as Senate Majority Leader Harry Reid (D-NV) shrank the bill’s cost from $85 billion to an estimated $15 billion.

Now Congress has only 2 weeks to pass legislation that would avert the 21.2% reduction in Medicare reimbursement. Organized medicine warns that if the cuts go through, physicians will turn away new Medicare patients or even drop out of the system instead of going broke on paltry fees. The average physician depends on Medicare for 31% of his or her revenue, according to the Center for Studying Health System Change (HSC).

As in the past, this does not mean that every service will be reduced. In fact, the E&M codes (99201-05 and 99211-15) which medical physicians use to code virtually every visit, has continued to climb in reimbursement by 3-5% yearly, while Chiropractic Spinal Manipulation (SMT) has continued to decline, year after year. (more…)