The Chiropractic Reimbursement and Compliance Experts - … · 2015-07-31 · ICD:10 It’s a Marathon, Not a Sprint Master Documentation to Master ICD-10 Kathy Mills Chang, MCS-P,

www.KMCUniversity.com 5/29/2015

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ICD:10 It’s a Marathon, Not a Sprint

Master Documentation to Master ICD-10

Kathy Mills Chang, MCS-P, CCPC

The KMCU Way

•Documentation systems based on lots of audits and findings

•Basics are often the most missing items

•Training is the foundation

•Same as 1983----Not!!!

•What are we up against?

Ch-Ch-Ch-Ch-Changes

•Healthcare has been changing for a while

•The changes are getting more rapid and are hitting closer to home

•This event is about awareness

Chiropractic and the OIG

•For the first time since May 2010, the Office of Inspector General, of the Dept. of Health and Human Services, has published a report specifically about chiropractic...or rather, one chiropractor in particular.

OIG Report Facts

•This fellow chiropractor’s dire situation represents the current state of risk that most chiropractors are not even aware they face on a daily basis.

•Is this you?

Getting Started with OIG Compliance


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Reduce Your Risk

•Scrutiny and accountability in healthcare are up

•Affordable Care Act and other state-level documentation and compliance rulings make it more critical than ever to decrease your practice risks.

Learn the Basics to Reduce Your Risk

•Many DCs don’t knowwhat they don’t know, when it comes to compliance in healthcare today!

•OIG Compliance is that rule book that many don’t know they must follow

Who is the OIG?

•Office of Inspector General's (OIG) mission is to protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries.

Government’s Healthcare Oversight

•HHS OIG is the largest inspector general's office in the Federal Government, with approximately 1,600 dedicated to combating fraud, waste and abuse and to improving the efficiency of HHS programs.

•A majority of OIG's resources goes toward the oversight of Medicare and Medicaid — programs that represent a significant part of the Federal budget and that affect this country's most vulnerable citizens.

OIG Strategic Plan 2014-2018

The OIG has a clear an narrow focus for success:

•Goal One: Fight Fraud, Waste, and Abuse

•Goal Two: Promote Quality, Safety, and Value

•Goal Three: Secure the Future

•Goal Four: Advance Excellence and Innovation

Goal One: Fight Fraud, Waste, and Abuse

•Critical to OIG’s mission is fighting fraud, waste, and abuse. We will continue to employ a multi-faceted approach of prevention, detection, and deterrence.• Identify, investigate, and take action when needed•Hold wrongdoers accountable and maximize recovery of

public funds•Prevent and deter fraud, waste, and abuse


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March 2015

3 issued aimed at chiropractic the last several years…the impact has been significant

Work Plan Focus #1-Identify Biggest Issues

Work Plan Focus #1-Identify Biggest Issues

Work Plan Focus #2-Proactive Reviews Work Plan Focus #2-Proactive Reviews


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Work Plan Focus #3-Identify and Address Trends

Work Plan Focus #3-Identify and Address Trends

OIG Compliance vs. HIPAA Compliance

•OIG Compliance relates to fraud and abuse•Documentation, coding, billing and patient financial inconsistencies•Medical necessity and erroneous payment demands•Federal programs with extension through Office of Audit Services

•HIPAA requires covered entities to have contingency plans that establish policies and procedures regarding protected health information•HIPAA also administered by HHS•Office of Civil Rights

OIG Report Facts

•The OIG is not “out to get us all”

•There is enough “low hanging fruit” to take care of the federal budget deficit

•Be aware of the specific errors pointed out in the reports like this

A Warning the Should be Heeded Another Recent Decision


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How This Training Will Protect You!

•Documentation of Case Management

•ICD-10 Awareness

•Risk Management and Risk Avoidance

•Compliance Concerns

Why Is Documentation So Important?

•Ensures quality patient care•Meets licensure

requirements to protect the public•Guards against malpractice

action•Secures appropriate

reimbursement•Because…if it wasn’t

written down, it didn’t happen!

Know your Audience

•Another health care provider

•Your board

•A malpractice attorney

•Third party payer's medical necessity auditor

•Each has different, but necessary requirements of your documentation

What Dr. Diep Didn’t Know That He Didn’t Know!

•The $708,000 recoupment finding to Medicare:• Ignorance of the rules

• Upcoding charges

• Billing Medicare inappropriately

• Poor documentation

• No Policies and SOP

• Ignored help when notified of OIG concerns

OIG Report Facts

•The OIG is not “out to get us all”

•There is enough “low hanging fruit” to take care of the federal budget deficit

•Be aware of the specific errors pointed out in the report


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Problem #1: Stick Out Like a Sore Thumb! Size Matters

•This doctor was in the top 5 in the entire country for volume of CMT codes billed. Top 5!!!!

•He billed an outrageous percentage of 98942, all 5 spinal regions!

So? I’m a Full Spine Adjuster!

•Medical necessity definition dictates that you must prioritize each area of complaint•Every visit:•S + O (P + ART) for every

region treated•2 DX codes for each

region•Treatment plan for

each/short and long term goals

Why It LOOKS Fishy…

The Guideline and Expectation

“The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patients condition and provide reasonable expectation of recovery or improvement of function.”

Problem #2: Did Not Understand The Definitions of Maintenance Care


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Understand the Rules

•He ONLY billed AT modifier, never ever moving a patient to maintenance care.

•Even in the details of the rebuttal from his attorney, he also argued that he "never delivered care that was not AT Modifier worthy".

Is All Care Medically Necessary?

Clinically Appropriate Care

• Life enhancing

•Symptom relieving

•Wellness care

•Supportive care

•Maintenance care

Medically Necessary Care

•Yields a significant improvement in clinical findings and patient functionality.

Maintenance

CMS defines Maintenance Therapy as: "Chiropractic maintenance therapy is not considered to be medically reasonable or necessary under the Medicare program, and is therefore not payable. Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to 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."

GA Modifier

What’s Wrong with this Picture?


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Voluntary Use = “MAY I?” ABN for Voluntary Use

Problem #3: Evidently Didn’t Understand Episodic Care

Definition of Case Management

Episodes of Care

•The foundation for an episode is contained in the beginning four steps of documentation.

•There was confusion about what an episode of care is

•Therefore, the documentation necessary was NOT present

Blatant Disregard

•Medicare documentation requirements are published. •We, as doctors, must know how to diagnose, treat in episodes of care and dismiss patients from active treatment.•Have written policies and procedures.


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Any Patients in Your Office in this Circumstance?

Problem #4: Didn’t Understand Requirements and How to Use Software to

Meet Them

Is it Mandatory?

•Came out of the sentencing guidelines•Affordable Care Act: Mandatory Compliance Plans Coming Soon •CMS has NOT finalized the requirements •CMS will advance specific proposals at some point in the future

Just Do it! Compliance Program!

•The truth is, we've been being told that since 2001.

•Get your policies and procedures and OIG compliance plan in place.

• It's too easy to do, and if you don't know how, ask us! We teach this every weekend!! Don't delay.

Risk #1 Risk #2


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Risk #3 Risk #4

Opportunity #1 Opportunity #2

Opportunity #3 Opportunity #4


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What Do I Need to Know?

•What is ICD-10?

•How is it different from ICD-9?

•How will I know which codes to use?

•What steps do I take along the way?

ICD-10 Delay Haven’t We Been Here Before?

Per CMS Acting Administrator, Marilyn Tavenner

•Feb. 6, 2013: “We will not abandon ICD-10”•Too much work has already been done to turn back now•The old system won’t work with new technologies•That would penalize innovators• It is necessary for health care reform

Start Here: What’s ICD-10?


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ICD-9 to ICD-10 Awareness

•What are the codes?

•How are they different?

•What does all of this mean?

•How do we make the transition?

Why in the World Do We Have to Change?

•WHO says so!

•US is the only civilized country NOT on ICD-10

•Too much complaining about costs and time

What’s Wrong with ICD-9?

• ICD-9 is 30 years old

• ICD-9 lacks specificity

• ICD-9 does not reflect new services

• ICD-9 doe not compare costs and outcomes

• ICD-9 is limited (13,000 codes)

What Can I Expect with ICD-10?

• ICD-10 will encompass more precise documentation

• ICD-10 will allow for more accuracy when determining medical necessity for the services rendered

• ICD-10 will allow providers to code more accurately which will contribute to the health care quality improvement initiatives

How Does it Work? How are ICD-9 and ICD-10 Different?ICD-10

ICD-9


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ICD-10 Coding and Documentation

•Site

•Laterality • 5th or 6th digit - Sciatica• Left – M54.31• Right – M54.32

•Episodes of care• 7th digit• A D S

•Injuries

The 7th Character

•A – Initial encounter, while patient is receiving active treatment such as surgery, ER, or evaluation and treatment by a new physician.•D – Subsequent encounter, routine care during the healing or recovery phase, such a cast change, medication adjustment, aftercare and follow up.•S – Sequelae, complications or conditions that arise as a direct result of a condition, such as a degenerative disc disease a year after a neck sprain. Sequelae code (i.e. DDD) is first, then the injury code.

Placeholder “x” character

Placeholder character “x” in positions 4, 5, and/or 6 in certain codes to allow for future expansion.

7th CharactersThe 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder “x” must be used to fill in the empty characters

For Example

ICD-10-CM code for chronic gout due to renal impairment, left shoulder, without tophus.

So What is “Excludes 1” or “Excludes 2”?

•Similar to Correct Coding Initiative Edits for CPT Codes

•Dictates when certain codes can be used together and when not

•The explanation will be helpful in the long run

Remember the CCI Edits?

Excludes 1 - is used when two conditions cannot occur together or “NOT CODED HERE!” Mutually exclusive codes; two conditions that cannot be reported together(A condition may be acquired OR congenital but not both!)


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Remember the CCI Edits?

Excludes 2 – Indicates “NOT INCLUDED HERE.” Although the excluded condition is not part of condition, it is excluded from, a patient may have both conditions at the same time. The excluded code and the code above the excludes can be used together if the documentation supports them.

Read the Instructions!

Read the Instructions! CMS-1500 Claim Form

• Revision 02/12• Changed to match the

electronic format (5010) and ICD-10 codes

• Adds space for eight more diagnosis codes in box 21

• Jan 6th, 2014 – Health plans and clearing houses must accept the form.

• April 1st, 2014 –Providers must use the new form

Find Your Way to the Codes How do I Find the ICD-10 Code?


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Chapter 6: Nervous SystemChapter 13: Musculoskeletal/Connective

Tissue

Site Specifics in Certain Codes Can We Just Crosswalk from ICD-9?

•General Equivalence Mappings (GEMs)

•Some pointing based on the initial set up

•Three possible ways to define subluxation: M99.01, M99.11, or S13.11

•Time will tell

ChiroCode ICD-10

Three Methods using the ChiroCode ICD-10 book:

1. Commonly used code list

2. GEMs code map3. Alphabetic index4. Always confirm

the code using the Tabular list


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Commonly Used Codes List

Cervical Diagnosis in ICD-10

GEMS Code Map


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Best Mapping Tool for Reference GEMs Examples

GEMs Example GEMs Example

Headaches

• In ICD-9, the codes might be:• 339.21 Acute post-traumatic headache

•GEMs suggest:•G44.319 Acute post-traumatic headache, not intractable

NOTE: in the index, G44.319 is next to G44.311 which is the intractable version of this condition.

Intractable means “hard to control or deal with”This must be documented in order to select the correct code


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Conversion Tools Conversion Tools

Medicare’s GEM Guide GEMS FAQ

Alphabetic Index


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But Wait! There’s More!

Confirm with Tabular List!

Confirmation Required One-to-one Mapping

723.1 Cervicalgia

M54.2 Cervicalgia

One-to-Five Mapping

•724.4 Thoracic or lumbosacral neuritis (radicular syndrome of the lower limbs)

• ICD-10 – M54.14, M54.15, M54.16, M54.17, M54.18 Radiculopathy

Combination Mapping

• 724.3 Sciatica

• M54.30 Sciatica, unspecified side• M54.31 Sciatica, right side

• M54.32 Sciatica, left side

OR

• M54.40 Sciatica with lumbago, unspecified • M54.41 Sciatica with lumbago,

right side

• M54.42 Sciatica with lumbago, left side


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Talk About Detail!

•Take 847.0 Cervical Sprain• Could be S13.4xxA• Could be S13.8xxA

•Much more detail is possible in ICD-10

• Item one: sprain of ligaments of the cervical spine

• Item two: sprain of joints and ligaments of other parts of the neck

Coding Whiplash

•Sprain VS. Strain• 847.0: Sprain of Neck

(Includes strain of joint capsule, ligament, muscle, tendon)

•S13.4 _ _ _ Sprain of ligaments of the cervical spine

•S16.1xxA STRAIN of muscle, fascia and tendon at neck level, initial encounter

Sprain Vs. Strain“Exam findings are consistent with the strain and sprain of the ligaments and muscles of the cervical spine and acute traumatic headache, which does not respond to over the counter medications. Patient was the driver of a vehicle that collided with another motor vehicle on the interstate. He was not treated at the scene.”

• S13.4xxA Sprain of ligaments of the cervical spine, initial encounter• S16.1xxA Strain of muscles, fascia and tendon at neck level,

initial encounter•G44.311 Acute post-traumatic headache, intractable•V49.40xA Driver injured in collision with unspecified motor

vehicle, traffic accident, initial encounter• Y92.411 Interstate as place of occurrence external cause

Migraines: 44 ChoicesDocumentation must

include:• With or without aura

• Intractable or not intractable

• With or without status migrainosus

• Persistent or chronic

• With or without vomiting

• With or without opthalmoplegic, menstrual, etc.

• Induced by ICD-10 training

Vital Definitions

With Aura: Feelings and symptoms noticed shortly before the headache begins…aka “prodrome”• Blind spots• Seeing zigzags• Flashing lights• Prickling Skin•Weakness (paresthesia)


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Status Migrainosus

•Chronic migraines that last more than 72 hours•The codes DCs usually use are very vague•If that DX comes through, doctors may need help with exact diagnosis

Unspecific Codes are Problematic

Remember 728.85? V – Y Codes

Chapter 20: Guidelines for external causes of morbidity (V00-Y99)•Never sequenced first• Provide data about the cause, intent, place, activity, or

status of the accident or patient•No national requirement to use these codes, but voluntary

reporting is encouraged

Y92 Place of occurrence should be listed after other codes, used only once an initial encounter, in conjunction with Y93

Y93 Activity code should be used only once, at initial encounter


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V, W, X, Y CodesFor Fun

•Bus Occupant V79.9(collision with) Animal in traffic being ridden

•Bus Occupant V70.3(collision with) animal, non-traffic

•Bus Occupant V70.4(collision with) animal, while boarding or alighting

E Codes in ICD-9 Expanded

•External Cause Codes•Do you use them?

E844.8•Sucked up into a jet without damage to the airplane; ground crew

ICD-10-CM Increased Specificity

Updated Code V97.33Sucked into a jet without damage to the airplane

Chapter 6: Nervous System

Site Specifics in Certain Codes


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Z63.1--Problems in relationship with in-laws

This Just In!

Say What??

•G44.82 Headache associated with sexual activity

•W22.01xD Walked into wall, subsequent encounter

•Y34 Unspecified event, undetermined intent

•R45.2 Unhappiness


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Case Example

•While playing tennis in a tournament at the Clay Court Country Club, a male player sprained his right wrist and was treated by his Chiropractor close to the courts.•S63.501A Unspecified sprain of right wrist, initial

encounter•Y93.73 Activity, racquet and hand sports•Y92.312 Tennis Court (place of occurrence for

external cause)

Case 1 Answers and Rationale

• S33.6xxA Sprain of the SI joint•M47.819 Spondylosis without myelopathy or radiculopathy,

site unspecified –• Rationale: We don’t know from the notes that it is Lumbar

(M47.816) or Lumbosacral (M47.817)•M62.50 Muscle wasting and atrophy, NEC, Unspecified site

• Rationale: We don’t know from the notes where it is so we can’t use M62.58 Muscle wasting and atrophy, NEC, other site OR M62.59 Muscle wasting and atrophy, NEC, multiple sites

•M99.05 Segmental and somatic dysfunction of pelvic region•W00.0xxA Fall on same level due to ice and snow, initial

encounter• Y92.007 Garden or yard in unspecified residence as place of

occurrence

Case 2-Answers and Rationale

•M50.12 Cervical Disc Disorder with radiculopathy, mid cervical region •G54.2 Cervical Root disorder, NEC not used because of

Excludes1 noted

•S13.8xxA Sprain of joints and ligaments of other parts of neck•M62.838 Muscle Spasm, other•We are unsure about whether or not “back” = “neck” and

hope to seek further clarification..i.e.-M62.830 may have applied as well

•Y93.B3 Activity, free weights•Y92.39 Other specified sports and athletic area as the

place of occurrence of the external cause (gymnasium)


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•G43.019 Migraine Without Aura, Intractable, Without Status Migrainosus

•M50.31 Other Cervical Disc Degeneration, High Cervical Region

•G43.A1 Cyclical vomiting, intractable

Case 4 Answers and Rationale

•M51.15 Intervertebral Disc Disorder with radiculopathy, Thoracolumbar Region •Would not use M54.15 Radiculopathy, Thoracolumbar

Region because of the Excludes1)

•R26.2 Difficulty walking, not otherwise classified

•Y93.H2 Activity, gardening and landscaping


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•M51.16 Intervertebral Disc Disorder with radiculopathy, Lumbar Region• Would not use M54.32 Sciatica, left side because of the

Excludes1

•M62.830 Muscle Spasm of the Back

What to Do Now: Forge Ahead What Should I Do Now?

•Concentrate on perfecting documentation•Learn the subtle nuances in your current diagnosis protocols•Begin to discern what each means to you


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Brainstorm Operational Impact

•Computers, software, memory, other IT concerns•Upgrades to software

and testing for billing-both paper and electronic•Super Bills, Diagnosis

Sheets, Existing SOP and Training Materials

Super CAs will Contribute at a High Level

Brainstorm Operational Impact

Know the IT Impact You’ll Face

• What changes will need to be made?

• Do they have available upgrades?

• When will the upgrades be available?

• Upgrade and your maintenance agreement

• Will they continue to provide support?

• Parallel coding?

• How long will my system be down?

ICD-10 Organization

•Address and prioritize tasks•Date software vendors

will be compatible•Upgrade schedules•Readiness and testing

schedules •Training schedules for

• Physicians• Office Staff


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Managed Care Contracts

•Identify all your payers

•Review the policies related to ICD-9

•Reimbursements tied to diagnosis

•Modify agreements

•Determine their timelines for testing

Managed Care Contracts

•Payer policy changes = Payment impact•Review new payment

policies• Improve coding and

documentation•Communicate changes

to staff•Dual coding•Know important dates

ICD-10 in My Practice

•Medicare: Free training•Chirocode.com: free

email alerts and webinars, more training, memberships, chart audits, and coding tools• FindACode.com:

Crosswalks and other advanced tools• ICD10Moinitor.com: Free

Articles•AAPC.com and

AHIMA.org

Recommended Tools

FindACode.com

www.findacode.com

http://www.findacode.com/


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The Finish Line Looks Good From Here!


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Need [email protected]

Documents

The Chiropractic Reimbursement and Compliance Experts - … · 2015-07-31 · ICD:10 It’s a Marathon, Not a Sprint Master Documentation to Master ICD-10 Kathy Mills Chang, MCS-P,