Chiropractic Coding & Compliance Alert

Transcription

1 The Coding Institute AVOID AUDITS.IMPROVE REIMBURSEMENT.REDUCE DENIALS.INCREASE REVENUE Also Access Your Alert Online at Chiropractic Coding & Compliance Alert October 2014, Vol. 1, No. 1 (Pages 1-8) In this issue Regulatory Update Use These Strategies to Protect Your Practice From Tough Payer Scrutiny Here s how to survive audits -- and recoup your pay -- with impeccable documentation. Documentation 8 easy ways to keep your claims on track Reimbursement Ethically Upgrade Your Pay With Accurate PQRS Reporting in 2015 Reporting 3 quality measures is all you need. You Be the Coder Coding for the Lumber and Sacral Spine Together Reader Questions Billing Along With Chiropractic Manipulation Is Advance Beneficiary Notice a Way Out for Non-Medicare Services? Chiropractors and the Electronic Health Record (EHR) Incentive Program Billing Medicare for Manual Devices p5 p6 p6 p7 p1 p3 p3 p5 Regulatory Update } Use These Strategies to Protect Your Practice From Tough Payer Scrutiny Here s how to survive audits -- and recoup your pay -- with impeccable documentation. If you ve noticed an increase in the number of payers auditing chiropractic services in the last few years, you re not alone. CMS is paying closer attention to whether Medicare actually covers chiropractic services that are billed and whether they re coded correctly and properly documented. Read on to find out what CMS expects from your next claim. Bone Up on These Regulations Here are a few important guidelines regulating chiropractic services and reimbursement that you ll need to understand and abide by: Sections 1862(a)(1)(A) and 1833(e) of the Social Security Act that defines chiropractors as physicians eligible for Medicare reimbursement require that all services billed to Medicare, including chiropractic manipulations, be medically necessary and supported by documentation. Federal regulations (42 CFR $410.21(b)) limit the Medicare reimbursement to treatment of subluxations that result in a neuromuscular condition for which chiropractic manipulation is the appropriate treatment. Section of the Medicare Carriers Manual details that the provider should document the existence of a subluxation through an X-ray or a physical examination and the services must be provided as part of a written plan that should include specific goals and measures to evaluate effectiveness. The chiropractic treatment must provide a reasonable expectation of recovery or improvement of function, states section of the Manual....Ongoing maintenance therapy is not considered to be medically necessary under the Medicare program. Reality: Practitioners don t seem to be meeting these criteria. Based on the volume of medically unnecessary, undocumented and noncovered services allowed, chiropractic services represent a significant vulnerability for the Medicare program, according to an OIG report from HHS in June 2005 titled Chiropractic services in the Medicare Program: Payment vulnerability Analysis. Silver lining: Medicare s documentation requirements are very specific, but it is possible to seamlessly incorporate these in your daily chart notes. Read on for certain basic tenets to follow for a simple yet effective documentation Call us: The Coding Institute LLC, 2222 Sedwick Drive, Durham, NC 27713

2 The Coding Institute SPECIALTY ALERTS Call us: The Coding Institute LLC, 2222 Sedwick Drive, Durham, NC Documentation Areas You Can t Afford to Miss In order to establish medical necessity, you need to ensure specific documentation of the following three components. Failing to document any one of these may lead to denial on grounds of lack of medical necessity. 1. Demonstrating subluxation: CMS requires the presence of a subluxation as a medical necessity. According to CMS, subluxation is a motion segment in which alignment, movement integrity, and/or physiological function of the spine are altered although contact between joint surfaces remains intact. Medicare requires that this be treated using manual manipulation. Be sure to document that your treatment is specifically directed to the subluxation in the physical examination, initial chart notes, and subsequent notes. Remember to report subluxation as the primary diagnosis in the CMS 1500 form. You often will choose a code from either the 839.xx (Other multiple and ill defined dislocations) or 739.x (Nonallopathic lesions not elsewhere classified) diagnoses series to describe subluxation, based on patient s condition and your carrier s local Medicare review policy. So, what do you look for in the provider s documentation to help you choose the correct code? The 739 code family is specific to the musculoskeletal system, explains Doreen Boivin, CPC, CCA, with Chiro Practice, Inc., in Saco, Maine. These codes relate to segmental and somatic dysfunction. Each one refers to a region of the spine starting with 739.0, cervical region and ending with 739.9, Abdomen and other. The 839 code family falls under the injuries. Check if the patient hurt themselves due to activities of daily living or due to an external cause, Boivin advises. An 839 diagnosis code means the patient has had an accident or injury, external cause. A 739 diagnosis code means the patient has an acute or chronic condition to address. 2. Methods of Documenting subluxation: You may document the presence of subluxation by these two methods-using an X-ray? If you intend to use an X-ray to document the subluxation, ensure that there is not too much of a time lag between the X- ray taken and the initiation of care. It should have been taken within twelve months prior to or three months following the beginning of treatment. The PART system: This system documents a subluxation based on four criteria related to the physical examination: Pain/tenderness (P) Asymmetry/misalignment (A) Range of motion abnormality (R) Tissue, tone changes (T). Providers must document two of the four PART criteria, one of which must be asymmetry/ misalignment or range of motion abnormality. These should be documented well so that we can track the patient s progress from visit to visit. Asymmetry/misalignment can be as simple as observing the patient s posture. Other ways to determine this can be the doctor palpating the spine or taking X- rays. The (A) and (R) help to establish the medical necessity for why the patient came to see the doctor. The (R) is identified in quite the same way. The importance here is establishing the medical necessity and to track the patient progress 3. Penning the initial and subsequent visits: CMS has established specific requirements for documentation of both initial and subsequent visits such as evaluation and documentation of symptoms that make the patient seek treatment, quality and character of the symptoms, any relevant history etc. These should be included in your chart notes. The American Chiropractic Association also offers precise PART documentation guidelines which can be viewed at acatoday.org/content_css.cfm?cid=1217 Pointers Help You Support Medical Necessity Uncomplicated conditions would logically tend to resolve in a short duration with chiropractic treatment. So, remember to be able to justify your medical necessity for a treatment that would typically last longer, such as 24 weeks. Moreover, if there is no improvement, your care runs the risk of falling under non-covered Chiropractic Coding & Compliance Alert is published monthly 12 times per year by The Coding Institute LLC, 2222 Sedwick Drive, Durham, NC The Coding Institute. All rights reserved. Subscription price is $299. Periodicals postage is paid at Durham, NC and additional entry offices. POSTMASTER: Send address changes to Chiropractic Coding & Compliance Alert, 4449 Easton Way, 2nd Floor, Columbus, OH, p2

3 Call us: The Coding Institute LLC, 2222 Sedwick Drive, Durham, NC The Coding Institute SPECIALTY ALERTS maintenance therapy rather than therapeutic. Use code S8990 for Physical or manipulative therapy performed for maintenance rather than restoration. Have Medicare patients sign an ABN (Advanced Beneficiary Notice), advises Boivin. This informs the patient that Medicare may not pay for the service deeming it not medically necessary. The patient then can make an informed decision to accept the care or not knowing they may be responsible for the service provided. Final diagnosis note: We know that Medicare pays for spinal manipulation only and subluxation must be the primary diagnosis. Remember to incorporate the secondary diagnosis, which is the most specific reason for the encounter. While it is acceptable to use as simple a diagnosis as cervical pain 723.1, it is best to differentiate the causation of pain with myalgia 729.1, disc degeneration 722.4, disc displacement 722.0, strain and sprain 847.0, etc., whenever possible, says Samuel A. Collins, expert in chiropractic insurance billing for the H.J. Ross Network, in one of his articles for the website Codes that have greater differentiation and severity clearly will result in a greater allowance of treatment, as the condition coded clearly warrants such. q Documentation } 8 easy ways to keep your claims on track Document the specific level of subluxation and areas of manual therapy on every visit. Ensure that you report objective, measurable functional improvement on every visit. Use functional outcome assessments to further quantify the necessity and progress of the care plan (CMS makes the use of outcome measures mandatory from 2015 under PQRS reporting). Your notes should demonstrate functional improvement and a discharge decision when maximum benefit is accrued. Chronic conditions such as degeneration and displaced discs (the 722 series) require longer care and therefore should be documented whenever you come across one. In keeping with the need for mainstreaming the patient, your plan should also focus on active care and rehabilitation. Keep the notes legible: they will defend your work and claim only if the auditor can read them. Remember to sign all the patient notes. q Reimbursement } Ethically Upgrade Your Pay With Accurate PQRS Reporting in 2015 Reporting 3 quality measures is all you need. Call it good news or bad news: Chiropractors can only use claims-based reporting for quality reporting on Medicare Part B claims, but they also have fewer measures to contend with than their counterparts in other specialties. Read on for the latest on how successfully or unsuccessfully reporting quality measures will soon affect your bottom line. Background: CMS developed the Physician Quality Reporting System (PQRS) as a result of the Tax Relief and Health Care Act of 2006 to give eligible providers a financial incentive to participate in a quality reporting program related to Medicare claims. Participation is still voluntary, but that will change in Starting point: The PQRS is currently tied to the Value Based Modifiers that CMS is implementing over the next few years, says. Dr. Ron Short, DC, MCS- P, CPC, CEO, Heartland Consulting Group, Pittsfield, Ill. Failure to participate in the PQRS will result in the automatic assignment of the lowest level Value Based Modifier which will result in an additional 1% reduction in reimbursement from Medicare. The Value Based Modifiers will be in effect for chiropractors in Participation Determines Incentives and Penalties PQRS applies to all Part B covered services under the Medicare Physician Fee Schedule (PFS). Eligible providers who currently participate in the program by submitting documentation related to certain services (or measures) receive a 0.5 percent bonus payment for all eligible Medicare services rendered during the calendar year. Incentive bonuses usually are paid in November. (Continued on next page) p3

4 The Coding Institute SPECIALTY ALERTS Call us: The Coding Institute LLC, 2222 Sedwick Drive, Durham, NC Adjustments: CMS finalized Calendar Year 2013 as the performance period for the 2015 PQRS penalties. Therefore, if CMS determines that an eligible professional did not successfully and satisfactorily report data on quality measures for covered professional services during last year s PQRS reporting period (Jan. 1 Dec. 31, 2013), those providers will see their Medicare reimbursement decrease by 1.5 percent (98.5% of the fee schedule amount that would otherwise apply to such services) beginning in Important: Calendar Year 2014 is the performance period that will affect a provider s 2016 Medicare reimbursement. If CMS is not satisfied with the PQRS reports of an eligible provider in 2014, he will not qualify for the 0.5% payment incentive and will see a payment decrease of 2 percent applied to his 2016 Medicare reimbursement. Continued failure to successfully participate in PQRS will result in a 2.0% penalty based on performance two years prior. Better late than never: If you have never participated in PQRS, begin immediately. Even though you ll be assessed penalties for not participating in 2013, you can avoid future pay cuts by catching up in It is not necessary to register to participate in the PQRS program, but participants must have a National Provider Identifier (NPI) number in order to participate and must treat Part B beneficiaries. There is a second reporting period, July 1 to December 31. Anyone who reports 50% of their Medicare patients in that time period will qualify, says Short. Know How to Report Chiropractic Services Other medical specialties have a choice regarding how they report their applicable quality measures, but that s not the case for chiropractors. The claims-based reporting method (on your Medicare Part B claims) is the only available method to the chiropractic profession. DCs do not have to report PQRS using the other four methods (registry-based, qualified Electronic Health Record [EHR], Qualified Clinical Data Registry [QCDR] or the Group Practice Reporting Option [GPRO]). Here s why: None of the 51 measures reportable through EHR relate to chiropractors, and there isn t a Qualified Registry that applies to chiropractic. For 2014, CMS increased the number of individual measures a provider must report on from three (3) to nine (9), However; only three measures apply to DC for reporting. Criteria: Other specialties must report on nine individual quality measures in order to meet PQRS guidelines. Only three reporting measures apply to chiropractic, however: Timeline of Incentives/Payment Adjustments Measure #131: Pain Assessment and Follow-Up Measure #182: Functional Outcome Assessment Measure #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented (New for 2014) To qualify for the incentive bonus and avoid the 2016 payment adjustment you must: % incentive bonus given for successful PQRS reporting % incentive bonus available for successful PQRS reporting % payment decrease based on 2013 PQRS reporting % payment decrease based on 2014 PQRS reporting % payment decrease based on 2015 PQRS reporting. Report satisfactorily on all three measures applicable to DCs during the 12-month reporting period in Successfully report PQRS measures on at least 50% of your Medicare patients during the reporting period to avoid the payment adjustment in 2016, advises Short. To report PQRS measures, providers must place the appropriate G codes on the CMS 1500 physician Claim Form used for billing professional services to Medicare. The G codes will correlate to an action that was taken (or not taken) by the provider. Report Measures #131 and #182 on every visit, for every Medicare patient who is at least18 years old and where you have reported a spinal CPT code (98940, 98941, or 98942). In 2014, you must satisfactorily report on both of these measures at least 50 percent of the eligible visits and successfully perform each measure at least once. In addition, report Measure #317 a minimum of once per reporting period (Jan. 1 Dec.31, 2014) for every Medicare patient who is at least 18 years old and where you have reported a spinal chiropractic CPT code. Again, you must satisfactorily report on this measure at least 50 percent of the time and successfully perform the measure at least once to qualify for the incentive. Reporting both measures correctly for at least 50 percent of the eligible Medicare Part B PFS claims means that, during the 12-month reporting period, the provider has satisfactorily reported the measure p4

5 Call us: The Coding Institute LLC, 2222 Sedwick Drive, Durham, NC The Coding Institute SPECIALTY ALERTS for at least 50 percent of the Medicare Part B eligible patients (i.e., where the patient is minimum 18 years old and a spinal CPT code has been billed). Your best option is to report PQRS measures on every visit to increase the chances of meeting the satisfactory reporting requirements for the incentive and to avoid the payment adjustment. A chiropractor need not be driven to PQRS solely because of financial reasons, because the cost a typical office would bear for the additional effort needed to report PQRS would offset the benefit and the cost of penalty for now. However, in the long run, PQRS can help chiropractors: Assess the quality of care they are providing to their patients Quantify how often they are meeting a particular quality parameter. Using the feedback report provided by CMS, one can compare his performance on a given measure with his peers. All Set For The ICD-10 Transition? ICD-10 implementation is only a year away. Find out next month how you can work to ensure the change doesn't affect your staff's productivity levels for any longer than necessary. Nut shell: All three PQRS measures report activities that chiropractors should be performing in their practices already, adds Short. Reporting these measures is simply a matter of inserting the correct G-codes in the CMS 1500 form when billing the services. The more that they delay implementation of PQRS in their practices, the more money they will have adjusted from their payments. Editor s note: Next month, look for tips on how to report the measures and G codes with finesse. q Reader Questions } Billing Along With Chiropractic Manipulation Can we bill along with chiropractic manipulation done on the same date of service and to the same region? Please suggest. Minnesota Subscriber To get paid for (Manual therapy techniques [eg, mobilization/ manipulation, manual lymphatic drainage, manual traction], 1 or more regions, each 15 minutes), the provider should complete the therapy that should be on a different date of service and different region than chiropractic manipulation. Following this guideline allows you to differentiate the manual therapy technique from being considered a part of the chiropractic manipulation. Manual therapy may include services like myofacial release, joint mobilization or manual traction. As the CPT position paper on states, Under certain circumstances, it may be appropriate to additionally report CMT/OMT codes in addition to code For example, a patient has severe injuries from an auto accident with a neck injury that contraindicates CMT in the neck region. Therefore, the provider performs manual therapy techniques as described by code to the neck region and CMT to the lumbar region. As separate body regions are addressed, it would be appropriate in this instance to report both codes and In this example, the modifier -59 should be appended to indicate that a distinct procedural service was provided. Only use modifier -59 (Distinct procedural service) in cases in which a different region of the body received the You Be the Coder Coding for the Lumber and Sacral Spine Together A patient presents with a subluxation of the lumbar and sacral spine with degeneration of disc(s) in the lumbar region, and the chiropractor performs CMT to the lumbar and sacral spine. Which codes do we report? North Carolina Subscriber See page 7. q (Continued on next page) p5

6 The Coding Institute SPECIALTY ALERTS Call us: The Coding Institute LLC, 2222 Sedwick Drive, Durham, NC service. Otherwise, it will result in a refund or deduction from future payments. You can use on an extra spinal body part in the same spinal region if documented as such in the notes (i.e used for a treatment of subluxation of the thoracic spine plus performed on the shoulder for 15 minutes).it is safer to stick to the different regions such as CMT, to Cervical, Lumber, Pelvic, Sacral and done in Thoracic region. Feet, hands etc. can be used. You must document location, technique and time to be paid for q Is Advance Beneficiary Notice a Way Out for Non-Medicare Services? I often get patients who require services other than chiropractic manipulation, which is my only covered service under Medicare. How do I get paid for services that are not covered under Medicare? Arizona Subscriber For services not covered under Medicare, you need not bill to Medicare. The patient usually will have to Specialty coding BookS By The Coding institute experts the coding institute (tci) offers the most economical and practical coding books for specialties. you can quickly check the latest cpt codes with full descriptions, modifiers, RVUs, global days, cci, illustrations and code-specific coding tips so you avoid any confusion. you can also look up up-to-date HcpcS and icd-9-cm codes and get all the reimbursement tools you need on one page! Visit for more details. call or to service@codinginstitute.com for help sedwick road, durham, nc Contact us: bear the costs as well as the liability for those services. The patient can sign an Advance Beneficiary Notice in such cases to acknowledge responsibility for payment. You may then bill the chiropractic code with modifier GA (Waiver of liability statement issued as required by payer policy, individual case). Although Medicare would not pay for this, it will at least recognize the patient s responsibility for the services. Some patients may have a secondary insurance that has a provision for excluded services. Bill such services to Medicare with modifier GY (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-medicare insurers, is not a contract benefit) to indicate patient liability for those services and allow payment from a secondary payer. q Chiropractors and the Electronic Health Record (EHR) Incentive Program Are chiropractors eligible to participate in the Medicare Electronic Health Record (EHR) Incentive Program? Please explain how to go about this. Michigan Subscriber The Medicare Electronic Health Record (EHR) Incentive Program has been instituted for incentive payments to Medicare eligible professionals (EPs) who demonstrate the capacity meaning fully use the EHR technology. This includes the chiropractors too. These professionals meet the criteria for incentive payments for the meaningful use of certified EHR technology, if they meet all the program requirements. This program, however, does not apply to hospitalbased EPs, who are defined as the EP who provides 90 percent or more of his services in a hospital or emergency department. EPs may not receive the EHR incentive payments from both the Medicaid and Medicare EHR Incentive Programs simultaneously within the same year. In case the EP qualifies for the incentive from both the Medicare and Medicaid, he will have to forego the benefits from either one of these. For further details see cms.gov/regulations-and-guidance/legislation/ EHRIncentivePrograms/index.html. q p6

7 Call us: The Coding Institute LLC, 2222 Sedwick Drive, Durham, NC The Coding Institute SPECIALTY ALERTS Billing Medicare for Manual Devices I often use my hand held manual device to provide the manipulative thrust in a precise and controlled manner. How do I bill for the reimbursement for this added service? Mississippi Subscriber The Medicare Carrier Manual refers to manipulation as Chiropractic service specifically limited to treatment by means of manual manipulation, i.e., by use of hands. It goes on to say that some chiropractors do use hand held devices to assist themselves, but Medicare would not permit additional payment for the use of such equipments. It specifically covers manual manipulation performed by chiropractor with his own hands. Although not covered by Medicare, the use of hand held devices is popular as it protects your own joints from a burn out, letting you work longer, and thereby helping you prosper indirectly. q Information for and answers to You Be the Coder and Reader Questions have been reviewed by Doreen Boivin, CPC, CCA, Chiro Practice,Inc, Saco, Maine and Elizabeth Earhart CPC, Godshall Chiropractic, Millersville, PA. We Want to Hear From You Tell us what you think about Chiropractic Coding & Compliance Alert. What do you like? What topics would you like to see us cover? What can we improve on? We d love to hear from you. Please Harshita Sharma at harshitas@codinginstitute.com Thank you in advance for your input! You Be the Coder Coding for the Lumber and Sacral Spine Together You ll report (Nonallopathic lesions of lumbar region, not elsewhere classified) as the primary diagnosis, followed by a secondary diagnosis of (Degeneration of lumbar or lumbosacral intervertebral disc), and a tertiary diagnosis of (Nonallopathic lesions of sacral region, not elsewhere classified). However, you must have a neuromuscular complaint as well to report Medicare previously required chiropractors to have an X-ray that demonstrated the subluxation, but it is not so now. You can use an X ray, but it would not be covered if taken and read by the chiropractor. A chiropractor can view an X ray already taken so long it meets the guidelines that allow it in proximity to the onset of the condition. You can use P.A.R.T in lieu of an X ray, so long you make sure to document all the essential features of your examination of the patient, including the two mandatory aspects of PART and also demonstrate the diagnosis code choice. A similar policy from Noridian Medicare, another Part B MAC, advises chiropractors to enter up to four diagnosis codes in priority order (two primary and two (Question on page 5) secondary conditions). If you need to document more than four diagnosis codes, as will be the case any time there are more than two regions billed, the additional diagnoses must be present in the medical record, the policy states. Looking ahead: When ICD-10 is implemented in Oct. 2015, these diagnosis codes will change. For example, in ICD-9 would map to M99.83 (Other biomechanical lesions of lumbar region) in ICD-10.The category M99 refers to (Biomechanical lesions, not elsewhere classified) The ICD -9 secondary diagnoses of would map into two ICD-10 CM codes: M51.36 (Other intervertebral disc degeneration, lumbar region) and M51.37 (Other intervertebral disc degeneration, lumbosacral region).these come under the category of Other dorsopathies. You cannot include a current injury scenario with these codes. The ICD-9 tertiary diagnosis code would map into ICD-10 CM code M99.84 (Other biomechanical lesions of sacral region). q p7

8 The Coding Institute SPECIALTY ALERTS Call us: The Coding Institute LLC, 2222 Sedwick Drive, Durham, NC AVOID AUDITS.IMPROVE REIMBURSEMENT.REDUCE DENIALS.INCREASE REVENUE Chiropractic Coding & C o m p l i a n c e A l e r t Mary Compton, PhD, CPC maryc@codinginstitute.us Editorial Director and Publisher We would love to hear from you. Please send your comments, questions, tips, cases, and suggestions for articles related to Chiropractic Coding & Compliance Alert to the Editor indicated below. Harshita Sharma harshitas@codinginstitute.com Editor Jennifer Godreau, CPC, CPMA, CPEDC jenniferg@codinginstitute.com Director of Development & Operations Leigh DeLozier, CPC leighd@codinginstitute.com Executive Editor The Coding Institute LLC, 2222 Sedwick Drive, Durham, NC Tel: Fax: service@codinginstitute.com Chiropractic Coding & Compliance Alert is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional services. If legal advice or other expert assistance is required, the services of a competent professional should be sought. CPT codes, descriptions, and material only are copyright 2013 American Medical Association. All rights reserved. No fee schedules, basic units, relative value units, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. Rates: USA: 1 year. $299. Bulk pricing available upon request. Contact Medallion Specialist Team at medallion@codinginstitute.com. All major credit cards accepted. The Coding Institute also publishes the following specialty content both online and in print. Call for a free sample of any or all of the specialties below: Anesthesia Cardiology Dermatology Emergency Medicine Evaluation & Management Family Medicine Gastroenterology Health Information Compliance ICD-10 Coding Internal Medicine Modifiers Neurology & Pain Management Neurosurgery Ob-Gyn Oncology & Hematology Ophthalmology Optometry Coding and Billing Orthopedics Otolaryngology Part B (Multispecialty) Pathology/Lab Pediatrics Physical Medicine & Rehabilitation Podiatry Practice Management Psychiatry Pulmonology Radiology Rehab Report Urology Call us ( ) and mention your customer number for a special price, free trial, or just to find out more about SuperCoder the complete online medical coding solution. Order or Renew Your Subscription! Yes! Start/Renew my one-year subscription (12 issues) to Chiropractic Coding & Compliance Alert Print & Online - $399 Print only - $299 Online only - $199 Name Title Company Address City, State, ZIP Phone Fax * Must provide address if you choose online or both option to receive issue notifications To help us serve you better, please provide all requested information Payment Options Charge my: MasterCard VISA AMEX Discover Card # Exp. Date: / / Signature: Check enclosed (Payable to The Coding Institute) Bill me (please add $15 processing fee for all bill me orders) Chiropractic Coding & Compliance Alert The Coding Institute PO Box Atlanta, GA Call Fax service@codinginstitute.com Promo Code: P94RAA01 Also Access Your Alert Online at p8