Medical Billing and Coding Healthcare Blog

The U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) recently analyzed Medicare paid claims for chiropractic services from 2013.

A major finding: In 2013, $76 million in Medicare payments for chiropractic services were questionable, with Medicare inappropriately paying $21 million for chiropractic services that lacked a primary diagnosis covered by Medicare, according to an OIG report.

The OIG's notes that chiropractic services have the highest rate of improper payments among Part B services, according to the Centers for Medicare & Medicaid Services' (CMS) Comprehensive Error Rate Testing program. Medicare covers chiropractic services to improve function ("active treatment"), but it does not cover "maintenance therapy," which is when further clinical improvement cannot be reasonably expected from ongoing treatment.

While the millions of dollars tied to Medicare documentation deficiencies is significant, what may be just as significant is the fact that almost half of the questionable payments were for claims suggestive of maintenance therapy, and just 2% of chiropractors were responsible for half of the questionable payments.  

According to American Chiropractic Association President Anthony Hamm, DC, in a news release, "Proper documentation is integral to our work moving forward to further integrate the essential services provided by chiropractic physicians in Medicare. Poor documentation is not only a black eye on the profession; more importantly, it reflects poorly on the deliverance of quality-driven care for our patients." 

To reduce questionable payments, OIG made the following recommendations for CMS:

  1. establish a more reliable control for identifying active treatment, which would enable CMS to identify potential maintenance therapy;
  2. develop and use measures to identify questionable payments for chiropractic services;
  3. take appropriate action on the chiropractors with questionable payments;
  4. collect overpayments based on inappropriately paid claims; and
  5. ensure that claims are paid only for Medicare-covered diagnoses.

OIG noted that CMS did not concur with the first recommendation, but concurred with the other recommendations.

Is your practice struggling with chiropractic coding and billing errors? Contact PGM Billing, one of the nation's leading providers of chiropractic billing services. PGM has more than 30 years of chiropractic billing experience, which is why chiropractors from all over the country choose PGM as their billing company.

The American Society for Gastrointestinal Endoscopy (ASGE) has published two new coding sheets in order to assist practices in understanding and implementing GI-specific coding.

As ASGE notes, the purpose of the coding sheet is to "provide a high level overview to support practices as they prepare for 2016."

Coding sheets are available for:

  • Colonoscopy (CPT codes 45378-45398, G0105, G0121). Colonoscopy is a procedure in which a trained specialist uses a long, flexible, narrow tube with a light and tiny camera on one end, called a colonoscope or scope, to look inside your rectum and colon. Colonoscopy can show irritated and swollen tissue, ulcers, polyps, and cancer.
  • Endoscopic retrograde cholangiopancreatography (ERCP) (CPT codes 43260-43278). ERCP is a procedure that combines upper gastrointestinal (GI) endoscopy and x rays to treat problems of the bile and pancreatic ducts. ERCP is also used to diagnose problems, but the availability of non-invasive tests such as magnetic resonance cholangiography has allowed ERCP to be used primarily for cases in which it is expected that treatment will be delivered during the procedure

Each coding sheet explains the procedure, provides an image of it, and then provides the associated CPT code descriptions.

Practices should use these coding sheets to determine the proper CPT code for these procedures.

The mission of ASGE, founded, in 1941, is to advance patient care and digestive health by promoting excellence and innovation in gastrointestinal endoscopy. ASGE, with more than 14,000 members worldwide, promotes the highest standards for endoscopic training and practice, fosters endoscopic research, recognizes distinguished contributions to endoscopy, and is the foremost resource for endoscopic education.

For more assistance with determining the proper CPT, ICD-10 and HCPCS codes, visit the website of PGM Billing, a leading physicians billing service. There you will find many valuable Practice Management Tools, including ones for ICD-10 conversion, looking up HCPCS codes and a CPT codes search app.