CMS Offers Guidance on ICD-10, Dual Coding and Dual Processing

In a recent news update, the Centers for Medicare & Medicaid Services provided guidance concerning dual coding and dual processing.

As CMS notes, discussions of ICD-9 and ICD-10 often include mention of these terms. Different people use these terms to mean different things, but in general, dual coding or processing refers to the use of ICD-9 and ICD-10 codes at the same time.

When can you expect to use dual coding and processing and when can’t you?

1. Testing to Prepare for ICD-10
Dual coding and dual processing can be useful tools to prepare for ICD-10 by testing whether you are able to prepare, send, receive and process transactions with ICD-10. However, CMS says ICD-10 can be used for testing purposes only before the compliance date; providers and payers cannot use ICD-10 in "live" transactions for dates of service before the ICD-10 compliance date (October 1, 2015).

2. Dual Coding and Dual Processing After the Compliance Date

Following the ICD-10 compliance date, providers and payers must use:

  • ICD-9 in transactions for services provided before the compliance date
  • ICD-10 in transactions for services provided on or after the compliance date

While providers and payers must be able to use both ICD-9 and ICD-10 codes after the compliance date to accommodate backlogs in claims and other transactions, CMS notes they will not be able to choose to use either ICD-9 or ICD-10 for a given transaction. The date of service determines whether ICD-9 or ICD-10 is to be used.

The transition from ICD-9 to ICD-10 could significantly disrupt payments to practices due to the complexity of the new code set. To reduce the negative financial effects of the transition, considering outsourcing your billing to a veteran medical billing service provider such as PGM Billing. With more than 30 years of coding and billing experience, PGM can help ensure you collect what you deserve while eliminating the costs associated with paying for a medical biller's salary, benefits, bonuses, training and the technology needed to do the job.

CMS Issues 2015 Proposed Payment Rule for Ambulatory Surgery Centers

The Centers for Medicare & Medicaid Services (CMS) has released the 2015 proposed payment rule for ambulatory surgery centers (ASCs).

View the 2015 ASC payment proposal (pdf).

As the ASC Association notes, positive news for ASCs from the proposal includes CMS proposing to add 10 new spine procedures to the ASC list of payable procedures. Another piece of positive news is CMS proposing to define ASC device-intensive procedures as procedures assigned to any APC with a device offset percentage greater than 40 percent as based upon the standard Outpatient Prospective Payment System APC rate-setting methodology. The previous threshold was 50 percent.

But the proposed rule also included some discouraging news for ASCs. CMS elected to continue using the Consumer Price Index for All Urban Consumers to update ASC rates while using what the ASC Association describes as the "more appropriate" Hospital Market Basket cost measure to update hospital outpatient department rates. By using these different measures, CMS is proposing an effective payment update of 1.2% for ASCs and an effective payment update of 2.1% for HOPDs.

ASCs facing tightening margins due to reimbursement declines and increasing costs cannot afford to leave any money on the table. To ensure you receive the appropriate reimbursement for the procedures your ASC's physicians perform, consider outsourcing your ASC billing to PGM Billing. PGM is a veteran firm with more than 30 years of coding and billing experience. Its team of certified billers is well versed in billing for ASCs of all sizes and for all ASC specialties.

FAQs About Medicare Coverage of Chiropractic Services

In the Medicare Learning Network booklet on chiropractic services (pdf), CMS addresses more than a dozen of the most frequently asked questions about Medicare coverage of chiropractic services.

These questions — and the responses provided by CMS — are as follows:

Q: Are there any visit caps or limits for chiropractic services?

A: No. There are no caps/limits in Medicare for covered chiropractic care rendered by chiropractors who meet Medicare's licensure and other requirements as specified in the Medicare Benefit Policy Manual, Chapter 15, Section 30.5 (available at There may be review screens (numbers of visits at which the Medicare Carrier or A/B MAC may require a review of documentation), but caps/limits are not allowed.

Q: Do non-participating (non-par) providers of chiropractic services have to bill Medicare for services to Medicare beneficiaries?

A: Yes. Being non-par does not mean the provider doesn't have to bill Medicare. All Medicare covered services must be billed to Medicare, or the provider could face penalties. For more details on participating and non-par providers, see the fact sheet entitled "Medicare Enrollment for Physicians, Non-Physician Practitioners, and Other Health Care Suppliers" at (pdf).

Q: Is it true that non-par providers are not subject to Medicare audits/ reviews?

A: No. The non-par or participating (par) status of the physicians does not affect the possibility of any of their Medicare claims being audited/reviewed. CMS audits/reviews are intended to protect Medicare trust funds and to identify billing errors so providers and their billing staff can be alerted to errors and educated on how to avoid future errors.

Q: Can chiropractors opt out of Medicare?

A: No. Opting out of Medicare is not an option for Doctors of Chiropractic. Being non-participating and opting out are not the same things. Chiropractors may decide to be participating or non-participating with regard to Medicare, but they may not opt out.

For further discussions of the Medicare "opt out" provision, see the Medicare Benefit Policy Manual (Chapter 15, Section 40; Definition of Physician/ Practitioner) at (pdf).

Q: Can chiropractors (specialty 35) ever bill for durable medical equipment, prosthetics, orthotics, and supplies?

A: Yes. If as the supplier, they have a valid supplier number assigned by the National Supplier Clearinghouse and Medicare's rules for ordering the supplies are followed. However, a chiropractor who is a supplier cannot both order and furnish the DME. If a chiropractor orders DME, it will not be reimbursed.

Q: Under what circumstances should the chiropractor get an advance beneficiary notice (ABN) signed by the patient?

A: The decision to deliver an ABN must be based on a genuine reason to expect that Medicare will not pay for a particular service on a specific occasion for that beneficiary due to lack of medical necessity for that service. The beneficiary can then make a reasonable and informed decision about receiving and paying for the service. If the beneficiary decides to receive the service, the chiropractor must submit a claim to Medicare even though it is expected that Medicare will deny the claim and that the beneficiary will pay, unless the beneficiary selects option 2 on the ABN.

Q: What are the covered chiropractic services under Medicare?

A: Spinal manipulation is a covered service under Medicare. Acute, chronic, and maintenance adjustments are all "covered" services, but only acute and chronic services are considered active care and therefore, may be reimbursable. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment moves from corrective to supportive in nature, the treatment is then considered maintenance therapy.

Q: Do non-par providers have the same documentation requirements as par providers?

A: Yes. Chiropractic care has documentation requirements to show medical necessity. The participating status of the provider is not relevant to the documentation requirements.

Q: How does Medicare define subluxation?

A: Subluxation is defined as a motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint services remains intact.

A subluxation may be demonstrated by an x-ray or by a physical examination.

Q: Are maintenance therapy services covered by Medicare?

A: Chiropractic maintenance therapy is not considered to be medically reasonable or necessary under the Medicare program, and is therefore not payable.

Q: How does Medicare define maintenance therapy services?

A: 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.

Q: How should a chiropractor bill for maintenance services?

A: The AT modifier must not be placed on the claim when maintenance therapy has been provided. Claims without the AT modifier will be considered as maintenance therapy and denied.

Q: How can a subluxation be demonstrated?

A: A subluxation may be demonstrated by an x-ray or by physical examination.

Q: Are chiropractors eligible for bonus incentive programs?

A: Doctors of Chiropractic are eligible for the eRx Incentive Program and the Physician Quality Reporting Initiative (PQRI) additional payments. Chiropractors are not eligible for incentive payments for Physician Scarcity Area payments.

Q: What expenses for chiropractic services is the beneficiary responsible for in 2013?

A: In 2013, for approved Part B services, the beneficiary will pay the Part B deductible and then 20% of the Medicare-approved amount. The beneficiary will also pay all costs for any non-covered services. Beneficiary cost-sharing for Part C (Medicare Advantage) services will vary according to plan benefits.

Q: What needs to be done to have a claim considered for Medicare Secondary Payer benefits?

A: For a paper claim to be considered for Medicare Secondary Payer benefits, a copy of the primary payer's explanation of benefits (EOB) notice must be forwarded along with the claim form. (See Medicare Secondary Payer Manual, Chapter 3).

Q: Do I have to submit a claim to Medicare if the beneficiary agrees to pay for the service?

A: Remember that, no matter what the beneficiary is willing to agree to, you have fee restrictions in place and Mandatory Claim Submission still applies. The only exception to this would be if the beneficiary specifically requests that you NOT bill Medicare. In that instance, you would NOT submit a claim, but the fee restrictions would still apply.

Q: Do I have to submit a claim to Medicare, even though I know the service will be denied and the beneficiary has agreed to pay?

A: This is one of the purposes of the ABN. If you have a covered service you feel will be denied, you would present an ABN to the beneficiary. If they choose Option #1, yes, you would still be required to submit a claim. If the beneficiary chooses Option #2, then you would not be able to submit a claim.

Note: The responses provided by CMS were current as of October 2013. Medicare policy changes frequently, so ensure you are properly following Medicare chiropractic billing and coding rules prior to submitting claims.

Have questions about performing proper chiropractic billing and coding? Contact PGM Billing, one of the country's leading chiropractic billing companies, to learn what they can do for your practice.

CMS Assigns Physician Specialty Designation for Interventional Cardiology

The Centers for Medicare & Medicaid Services has granted a new specialty designation for interventional cardiology, according to numerous reports, including a Society for Cardiovascular Angiography and Interventions press release.

The new specialty code will allow CMS to distinguish an interventional cardiologist from a clinical cardiologist when billing Medicare for services. The designation is expected to take effect later this year.

As the American College of Cardiology notes, "Previously, no mechanism existed for CMS to accurately report on this category of physician and some local Medicare carriers have denied claims, citing duplicate billing, when a cardiologist and an interventionalist from the same group practice have billed for patient evaluation services."

ACC continues, "The new code allows for the reporting of the involvement of two specialty physicians providing distinct services to an individual patient."

Cardiologists billing is quite complex. It requires extensive experience and knowledge to ensure proper coding and modifier application. This high level of complexity — coupled with frequent changes to cardiology coding and billing rules and regulations — has resulted in more practices outsourcing their billing to a company like PGM Billing.

With more than 30 years of experience in cardiology billing, PGM and its team of certified medical billing and coding experts can manage all aspects of your cardiology billing. They will work with your practice to get clean claims submitted in a timely fashion and therefore ensure you receive proper compensation for services provided.

Free Chiropractic Billing Resource: American Chiropractic Association's FAQs About Medicare Program

The American Chiropractic Association provides a free, valuable Medicare coding and billing resource you can access regardless of whether you are a member of ACA.

On its website, ACA answers about 20 chiropractic questions about the Medicare program. These questions include the following:

  • Are we allowed to bill Medicare patients directly (i.e., not billing Medicare) as long as we have the patient's consent in writing?
  • I have heard differing answers as to if it is appropriate to bill Medicare care for the use of an Activator type device when performing manipulation. Could you tell me if I am allowed to use an Activator?
  • I do not have the time to do all it takes to appeal every Medicare claim. Is there an easier way?
  • I would like to offer cash discounts to Medicare patients. Is this ok?
  • Can I charge CPT code 97010, Hot/Cold Packs, to a Medicare patient?

To access this free resource, click here. If you are responsible for providing chiropractic coding and/or chiropractic billing services, this is a resource worth reviewing.

If you are struggling with the complexities of chiropractic billing, consider outsourcing to a chiropractor billing business like PGM Billing. PGM has more than 30 years of experience in chiropractic billing, and will closely with your practice to ensure you do not leave money on the table and do not raise red flags with audit programs.


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