Medical Billing and Coding Healthcare Blog

The Office of Inspector General (OIG) recently released a 2016 final report on Medicare payments for chiropractic services.

In its review, OIG included chiropractic services for CY 2013 for which Medicare Part B paid approximately $438 million. On the basis of its sample results, OIG estimated that approximately $359 million, or approximately 82 percent, of the $438 million chiropractic billing payments by Medicare for chiropractic services during the 2013 reporting period was unallowable; most payments did not comply with Medicare requirements.

The OIG has attributed the improper part B payments to services that were medically unnecessary, incorrectly coded, insufficiently documented or not documented to support the billed services.

The OIG stated that overpayments occurred because the Centers for Medicare & Medicaid Services' (CMS) controls requiring chiropractors to include the -AT modifier and initial treatment date on claims were not effective in preventing payments for medically unnecessary chiropractic services. OIG claim data analysis and audit results suggest that chiropractors submitted claims with the -AT modifier regardless of whether the services were for active/corrective treatment for subluxation.

Further, chiropractors submitted claims with the initial treatment date, affirming that all required documentation was being maintained on file, even though they did not document the medical necessity of the services as required by Medicare.

Finally, CMS's education of chiropractors on Medicare requirements for chiropractic services may not have been effective in preventing payments for medically unnecessary chiropractic services.

The OIG made the following recommendations to the Centers for Medicare & Medicaid Services:

  • Determine a reasonable number of chiropractic services that are necessary to actively treat spinal subluxation and implement a system edit to identify services for review in excess of that number.
  • Determine whether there should be a limit for the number of chiropractic services that Medicare will reimburse; if so, take appropriate action to put that limit into effect, and implement a system edit to disallow services in excess of that limit.
  • Improve education of chiropractors on Medicare coverage requirements for chiropractic services and the proper use of the AT modifier to ensure that only medically necessary chiropractic services are billed to Medicare.
  • Specifically identify significant obstacles to developing a more reliable control for identifying maintenance therapy and work to establish such a control. (For example, CMS could determine a reasonable length for a chiropractic treatment episode and implement a system edit to identify services for review when the number of days between the date of initial treatment and the date of service exceeds that length.)

CMS concurred with the first and third recommendation, but did not concur with the second recommendation. Regarding the fourth recommendation, CMS stated that it had responded to the same recommendation in a prior OIG report.

After reviewing CMS's comments, OIG refined two of our recommendations. The second recommendation was refined to indicate that CMS should determine whether there should be a limit for the number of chiropractic services that Medicare will reimburse and, if so, should take appropriate action to put that limit into effect. OIG also advised CMS to consider taking other appropriate actions to put such a limit into effect.

OIG also refined its fourth recommendation to specifically address CMS's comments on the recommendation in its prior report.

Resources

Here are some helpful resources for Medicare chiropractor billing compliance:

The Centers for Medicare & Medicaid Services recently released its 2017 ambulatory surgery center (ASC) payment final rule.

There were a few changes worth noting, according to the national ASC Association (ASCA).

1. Payment increase. ASC payment rates will increase by 1.9%, which is larger than the 1.2% identified in the proposed rule.

2. Procedures added. Ten new procedures were added to the ASC list of payable procedures for 2017. They are as follows:

  • 20936 (Sp bone agrft local add-on)
  • 20937 (Sp bone agrft morsel add-on)
  • 20938 (Sp bone agrft struct add-on)
  • 22552 (Addl neck spine fusion)
  • 22840 (Insert spine fixation device)
  • 22842 (Insert spine fixation device)
  • 22851 (Apply spine prosth device)
  • 22853 (Insertion of interbody biomechanical device(s))
  • 22854 (Insertion of intervertebral biomechanical device(s))
  • 22859 (Insertion of intervertebral biomechanical device(s))

Unfortunately, as ASCA notes, "... these codes are add-on codes, and thus will not be separately payable when performed in the ASC."

3. Comments sought on total knee arthroplasty. CMS has requested public comments on whether CPT code 27447 (total knee arthroplasty) should be removed from the inpatient-only list. ASCA noted it has advocated for the code's removal from the inpatient-only list and will continue to do so.

4. Measures added. Seven new measures will be added for 2020 payment determinations. They are as follows:

  • ASC-13: Normothermia Outcome
  • ASC-14: Unplanned Anterior Vitrectomy
  • ASC-15a: OAS CAHPS – About Facilities and Staff
  • ASC- 15b: OAS CAHPS – Communication About Procedure
  • ASC-15c: OAS CAHPS – Preparation for Discharge and Recovery
  • ASC-15d: OAS CAHPS – Overall Rating of Facility
  • ASC-15e: OAS CAHPS – Recommendation of Facility

In December, ASCA will host a webinar on "Understanding Medicare's 2017 Final Payment Rule." For more details, click here.

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