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1 Documentation, Compliance and ICD-10 Coding With Mario Fucinari DC, MCS-P, MCS-I Certified Insurance Consultant Certified Medical Compliance Specialist (MCS-P) Sponsored by Foot Levelers The information contained in these notes is for educational purposes and is not intended to be and is not legal advice. NO RECORDING OF ANY TYPE ALLOWED Unauthorized Audiotaping or Videotaping or Distribution of any presentation materials is illegal. LEGAL NOTICE: The information contained in this workbook is for educational purposes and is not intended to be and is not legal advice. Audiotaping and/or videotaping are strictly PROHIBITED during the presentations. The laws, rules and regulations regarding the establishment and operation of a healthcare facility vary greatly from state to state and are constantly changing. Mario Fucinari DC does not engage in providing legal services. If legal services are required, the services of a healthcare attorney should be attained. The information in this class workbook is for educational purposes only and should not be construed as written policy for any federal agency. All clinical examples are based on true stories. The patient names in the clinical examples have been changed to protect the innocent. No part of this workbook covered by the copyright herein may be reproduced, transmitted, transcribed, stored in a retrieval system or translated into any language in any form by any means (graphics, electronic, mechanical, including photocopying, recording, taping or otherwise) without the expressed written permission of Mario Fucinari DC. Making copies of this seminar workbook and distributing for profit or non-profit is ILLEGAL. Mario Fucinari DC assumes no liability for data contained or not contained in this workbook and assumes no responsibility for the consequences attributable to or related to any use or interpretation of any information or views contained in or not contained in this seminar workbook. CPT is a registered trademark of the AMA. The AMA does not directly or indirectly assume any liability for data contained or not contained in this seminar workbook. This seminar workbook provides information in regard to the subject matter covered. Every attempt has been made to make certain that the information in this seminar workbook is 100% accurate, however it is not guaranteed. Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 1

2 About Dr. Mario Fucinari, DC, CCSP, MCS-P, MCS-I Graduate of Palmer College of Chiropractic Currently in Full Time Practice in Decatur, Illinois Certified Chiropractic Sports Physician (CCSP) Logan College of Chiropractic Certified Insurance Consultant - Logan College of Chiropractic Certified Medical Compliance Specialist Physician Medical Compliance Training 2007 Post-graduate Faculty of Logan College of Chiropractic and Palmer College of Chiropractic National Speaker s Bureau for NCMIC and Foot Levelers and many state associations Past President of Illinois Chiropractic Society (ICS) and Current Chairman, ICS Medicare Committee ICS Chiropractor of the Year 2012 Member of ACA and ICS Contributing Author to many State Association Newsletters CERT- Comprehensive Error Rate Testing (CERT) Program The CERT contractor is currently AdvanceMed located in Richmond, Virginia. They are a subcontractor employed by CMS to determine error rates of providers and of the Federal government programs such as Medicare. You must provide information upon request. This does not constitute a HIPAA violation. Chiropractic has consistently ranked number one for errors. The reasons for our errors are ranked as follows: Insufficient documentation Number One! Medically unnecessary services (maintenance care) Incorrect coding Office of Inspector General (OIG) Report (June 2005) Data analyzed was based on information from The report released stated that the OIG determined that 67% of chiropractic claims are in error or fraudulent. As a result of the report, the OIG recommended that a national cap of 24 chiropractic visits be instituted. OIG Report May 2009 It was uncovered that in 2006, Medicare inappropriately paid $178 million (out of $466 million) for chiropractic claims for services that medical reviewers determined to be maintenance therapy ($157 million), miscoded ($11 million), or undocumented ($46 million). Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 2

3 Fraud These claims represent 47 percent of all allowed chiropractic claims that met the study criteria. Knowingly and willfully executing, or attempting to execute, a scheme or act to defraud any health care benefit program or to obtain by means of false or fraudulent pretenses, representations or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program. Abuse Abuse may, directly or indirectly, result in unnecessary costs to a health care benefit program, improper payment, or payment for services that fail to meet professionally recognized standards of care, or that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly or intentionally misrepresented facts to obtain payment. DHHS AND DOJ ISSUE WARNING ON POTENTIAL EHR MISUSE (Thursday, Oct 4, 2012) Reacting to recent news and government reports, the DHHS and DOJ issued a joint letter to five healthcare provider associations warning that EHR fraud would not be tolerated. However, there are troubling indications that some providers are using this technology (EHR) to game the system, possibly to obtain payments to which they are not entitled. False documentation of care is not just bad patient care; it is illegal. These indications include potential cloning of medical records in order to inflate what providers get paid. Provider Signature Requirements (Effective January 1, 2010) For medical review purposes, Medicare requires that the author authenticate services provided/ordered. Medicare denies many claims due to the lack of an appropriate signature. Here are some things to keep in mind on signature requirements: 1. The signature must be that of the provider of service. This means the person providing the service whether that is the physician or a non-physician practitioner (NPP). No one else can sign for the physician; this includes another physician in a group, the senior nurse, etc. 2. The signature must be hand-written or electronic. Medicare does not accept stamped signatures. 3. The Centers for Medicare & Medicaid Services (CMS) 1995 and 1997 Documentation Guidelines (DG) for Evaluation and Management (E/M) services require that the provider's signature be legible. If your signature is not legible, please provide a signature log or authentication statement verifying the information. 4. The signature of the transcriptionist is not the same as the physician signature. While your office may need or require this information, Medicare does not. 5. If you are using electronic medical records, please verify your system and software products protect against modification. Providers using electronic systems should recognize the potential for misuse or abuse with alternate signature methods. Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 3

4 6. If you are splitting or sharing services between yourself and a NPP, then both parties must sign their portion of the service. The NPP cannot sign for the physician. 7. Physician offices should have a protocol in place to have physicians sign their records within a reasonable time, generally 48 to 72 hours after the encounter, but certainly prior to submitting the claim to Medicare. 8. You cannot add a signature to a record later (this does not include the brief time to transcribe the record), instead use an attestation statement. EHR Meaningful Use Meaningful Use of EHR Participation Criteria To participate in the EHR incentive program, providers must: Register at Be enrolled in Medicare Fee For Service or Medicare Advantage Plan Obtain a National Provider Identifier (NPI) Use certified EHR technology Be enrolled in PECOS. (For information on PECOS, visit and click on the link to Enrollment FAQs. ) Three Critical Components: The incentive funds are tied to Medicare claims reimbursements beginning in The incentive payment will be 75% of Medicare paid claims with caps each year. The Eligible Provider must use the EHR in a meaningful way ("meaningful use"). The EHR software being used must be "certified." What does this mean? See below. If physicians do NOT adopt EHR by: reimbursements will be reduced by 1% reimbursements will be reduced by 2% reimbursements will be reduced by 3% reimbursements will be reduced by 4% (less than75% compliance) reimbursements will be reduced by 5% (less than75% compliance) Informed Consent This is STATE controlled. Prior to treating a patient, the doctor must provide adequate information concerning the possible risks, benefits and alternatives to a particular procedure. Doctors must properly and clearly communicate with their patients. If called into question, documentation of the communication is vital. Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 4

5 A general informed consent is recommended. Describe the procedures to be employed. Disclose the risks of treatment Inherent foreseeable risks typically only be listed, unless the state determines otherwise. Answer any questions for the patient The Consultation as Part of the Examination (E/M) Chief Complaint a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient s own words should show PHx, Family Hx, Social Hx Family History specific health related events in the patient s family. Includes information about the health status or cause of death of parents, siblings, and children and the following diseases: Orthopedic (arthritis, scoliosis) neurologic pathology (heart disease, cancer, diabetes) Past Health history Prior Illnesses and injuries Type, date, treatment, current status Prior Interventions Type, date, treatment, outcome Prior Surgery Type, date, reason, results, current status Hospitalizations Prior trauma Type, date, treatment, current status and extent of impairment The most common mistake is not going back far enough when questioning about trauma or injury. Medications Allergies Immunization status Dietary status Social History Marital status Employment history Occupational history Use of drugs, alcohol, tobacco Level of education Sexual history and social factors O,P,Q,R,S,T Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 5

6 Mechanism of Trauma Onset, duration, intensity, frequency, location and radiation Provoking and Palliative Factors Prior interventions, treatments, medications, secondary complaints Quality and character of symptoms/problem Radiation of symptoms Severity Time ICD-10-CM The increased specificity of the ICD-10 codes require more detailed clinical documentation in order to code some diagnoses to the highest level of specificity There are unspecified codes in ICD-10-CM for those instances when the health record documentation is not available to support more specific codes The benefits of ICD-10 cannot be realized if non-specific codes are used rather than taking advantage of the specificity ICD-10 offers The Basics of a S.O.A.P. Note Medicare Subsequent (Daily) Visits SOAP I. History Review of chief complaints (is this in relationship to the initial visit or treatment for the exacerbation) Changes since last visit System review if relevant II. Physical Exam Exam of area of the spine involved in Dx.. Assessment of change in patient condition since last visit Evaluation of treatment effectiveness Subsequent Visits Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 6

7 General Questions Subjective What s going on? Reporting of patient pain, limitations, concerns and problems. Information that cannot be verified or measured during the encounter. You may want to use a quote or summarize what the patient reported. A well-done interview seems like a conversation on the surface. Address their symptoms Any change in palliatives or provoking? Has the quality, intensity or radiation of pain changed? Changes in ADL? Are they compliant with their home care? New injuries or new conditions? Any questions or comments? Objective What did you find? Reporting of all measurable, quantifiable, and observable data obtained during the encounter. Present a picture by reporting anything that the provider used their senses (vision, hearing, smell, touch) Does not depend on patient reporting. Make certain that it is clear that you were not just a passive observer in the visit. Remember that your documentation may be read by those unfamiliar with the shorthand that health professionals use so freely. Use judgment when using abbreviations and keep them standard. Include functional status and the positive and significant negative tests that you performed. Medicare P.A.R.T. P.A.R.T. To demonstrate a subluxation based on physical examination, two of the four criteria mentioned under the above physical examination list are required, one of which must be asymmetry/misalignment or range of motion abnormality. P.A.R.T. (2 of the 4 Required) 1. Pain/Tenderness - location, quality, intensity Pain and tenderness findings may be identified through one or more of the following: observation, percussion, palpation, provocation, etc. Furthermore pain intensity may be assessed using one or more of the following: visual analog scales, algometers, pain questionnaires, etc. Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 7

8 2. Asymmetry/misalignment - sectional or segmental level Asymmetry/misalignment - Asymmetry/misalignment may be identified on a sectional or segmental level through one or more of the following: observation (posture and gait analysis), static palpation for misalignment of vertebral segments, diagnostic imaging, etc. 3. Range of Motion Abnormality Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and Range of motion abnormality - Range of motion abnormalities may be identified through one or more of the following: motion, palpation, observation, stress diagnostic imaging, range of motion measurements, etc. 4. Tissue, tone changes in skin, fascia, muscle, ligament Tissue, tone changes using descriptions pertaining to the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament. Tissue/Tone texture may be identified through one or more of the following procedures: observation, palpation, use of instruments, tests for length and strength etc. Seven Components of the E/M service Key Components History Examination Medical decision making Contributing Components Counseling Coordination of care Nature of presenting problem; and Time Evaluation and Management (E/M) CPT Codes New patient vs. Established patient New patient is a patient never treated in the office or not in the last three years. The same degree of familiarity is applied for a doctor who is on call for you. *New Patient codes: *Established Patient Codes: Review of Systems a series of questions of body systems that is used to clarify the differential diagnosis (Ddx), necessary tests, or for baseline data. Code 99203: 3-8 out of 13 must be present. If NO ROS are present, then it is a code. Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 8

9 ROS must document that you reviewed the systems with the patient. Denies or Complains of should be listed Ophthalmologic, Otolaryngologic, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin, Neurologic, Psychiatric, Endocrine, Hematologic/Lymphatic, Allergic/Immunologic Example: Cardiovascular: Denies: dyspnea, palpitations. Complains of: Hypertension Musculoskeletal: Complains of Foot pain, worse in the morning, lower back pain. Denies: Foot numbness The Examination: On the initial examination or if significant, on subsequent visits, note the following: Inspection Patient build Carriage and gait cycle Patient movement Examine the shoes Scoliosis Antalgia Skin appearance Biomechanical Inspection Life in Balance Vital signs Height Weight Temperature Respiration Pulse bilaterally (rapid?) Blood pressure bilaterally Spinal Manipulation and Cervical Arterial Incidents (NCMIC, Chapter 8, page 48) "In contrast to earlier clinical practice recommendations, auscultation of the neck 108;176;239; and use of functional vascular test variations (e.g., Estridge s, dekleyn s, George s, Hautant s, Houle s, Maigne s, Smith s, Wallenberg s tests, etc.) 4 now are known to have no diagnostic value in identifying patients with cervical vascular susceptibility." Palpation Static Musculature spasm Edema Tenderness on palpation Motion Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 9

10 Segmental motion List any crepitus In summary, the physical exam should include: Orthopedic tests Palpation findings Pinprick sensitivity tests Reflexes Range of Motion - Give plane and degrees so it can be referenced later to show progress. The more specific the degrees, the better. Note pain. Muscle strength Outcome Questionnaires Function Begins from the Ground Up!! Evidence Based Outcomes Assessment Tools Measures Functional Impairment Why Outcomes Assessment? An objective measure of the patient s status Provides objective documentation regarding the patient s condition. Helps the doctor, patient and insurer to make informed decisions A deterrent to malpractice Backed up by refereed journals (JMPT, Spine) Outcomes Assessment Tools Have patient complete on initial exam, on re-exam as clinically indicated and at any exacerbations. These tests quantify the amount of patient deconditioning present. A measure of the patient s functional impairment of activities of daily living. Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 10

11 Outcome Assessment Tests Visual Analog Scale Pain Drawings Revised Oswestry Low Back Pain Disability Questionnaire Roland-Morris Disability Neck Pain Disability Index Questionnaire Headache Disability Index Bournemouth Questionnaire Cervical and Lumbar. Lifestyle illnesses Zung Psychological Assessment Questionnaire Neck Pain Disability Index Score 0-8% = None 10-28% = Mild 30-48% = Moderate 50-68% = Severe >70% = Crippled Revised Oswestry Score: 0-5% = None 6-20% = Mild 20-40% = Moderate 40-60% = Severe 60-80% = Crippled 80%+ Bed Bound *If you compare the original score to the score at re-examination, there must be a minimum of a 30% decrease in score on re-evaluation to be clinically significant. Re-Examination Formal re-examination should be done to determine progress and need for further care Should be done at least every visits or every days. Recheck all positive findings and significant negative findings. A re-examination should include A brief consultation about current condition Repeat of significant orthopedic tests Visual Analog Scale or Borg Scale Outcome measures test repeated After the re-examination, update record with an interim note or report. This will document and explain the clinical significance of why you did the exam (rationale) and the results of the exam. This then leads to your treatment plan and treatment goals. Any change in diagnosis Treatment frequency/schedule Treatment goals Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 11

12 Restrictions Referrals or further tests Exercise/rehabilitation The Medicare Card Participating Physician Par doctor accepts assignment for Medicare claims Agrees to not collect more than the 20% from the Medicare patients Medicare reimburses doctor directly Medigap crossover 5% increase in fees for par doctor Listed in the Medicare Participating Physician Directory (MEDPARD) Non-Participating Physician You may not charge more than the limiting charge (115% of the fee schedule amount) Payment from the patient, who then recovers it from Medicare Not listed in the Directory If you decide not to be a participating physician, as a non-par doctor, you may choose to decide on a claim-by-claim basis whether to accept assignment or not. (Box 12, 13 and 27) However, you are still bound by the rules and regulations of Medicare whether you are a participating doctor or not. Radiology Clinical Indications for Plain Films Indications: Degenerative conditions Inflammatory conditions Fracture Neoplasms Infection Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 12

13 Clinical Indications for MRI or CT Non-responsive, deteriorating or lingering symptoms after 4 weeks Radiology Red Flags X-rays that are outside of the area of chief complaint. Full spine x-ray for trauma case or on everyone. Unbundling of x-rays Repeat studies Repeating films recently taken at another facility. Assessment What do you think? Provider records their professional opinions and judgments as to the patient s diagnosis, their progress and/or their functional limitations. You interpret the data presented in the objective portion of the note. You may also point out inconsistencies, justify your goals, discuss emotional status or indicate progress in therapy. You may also present reasons why certain information was not obtained or deferred. What is Medical Necessity? How is the patient is improved? Why does the patient still need care? Medicare s Definition of Medical Necessity 1. The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services must have a direct therapeutic relationship to the patient s condition. (Medicare does not pay for pain). 2. You must have a reasonable expectation of recovery or improvement of function. 3. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam. A diagnosis of pain is not sufficient for medical necessity Medicare Medical Necessity Acute subluxation - treatment for a new injury, identified by x-ray or physical exam. The treatment is expected to improve, arrest, or retard the patient s condition. Chronic subluxation - A patient's condition is considered chronic when it is not expected to completely resolve (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the functional status has remained stable for a given condition, further manipulative treatment is considered maintenance therapy and is not covered. Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 13

14 Maintenance Therapy Once MMI has been reached, Medicare will NOT pay for maintenance or supportive care. 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. Once the maximum therapeutic benefit has been achieved for a given condition, ongoing maintenance therapy is not considered to be medically necessary under the Medicare program. Name Abbreviation Code Cervical C1-C Thoracic T1-T Lumbar L1-L Sacrum and Coccyx S or SC Ilium/Illi I or SI Writing the Diagnosis Box 21 of the 1500 Health Claim Form is used for reporting the ICD-9-CM diagnosis codes. Numbers are reported on the insurance claim form because you are communicating to a computer. Be sure to use the correct numbers, to the highest specificity. The diagnosis you provide directly relates to the level of care permitted by the third-party payers. There are four diagnostic codes allowed on the 1500 form (Box 21) however, you can list additional diagnostic descriptors in your diagnosis list, in the patients chart. Some providers will also allow you to list the ancillary codes in Box 19 of the 1500 Health Claim form. Hierarchy of the codes: 1. Neurological diagnosis 2. Structural descriptor diagnosis 3. Functional diagnosis 4. Soft tissue, extremity, complicating factors Writing the Diagnosis: Neurological diagnosis include radiculitis and sciatic neuritis Structural diagnosis includes DDD, DJD and spondylolisthesis Functional diagnosis includes restricted range of motion and deconditioning syndrome (useful for rehab) Soft tissue diagnosis may include fibromyalgia Extremity diagnosis includes carpal tunnel syndrome, plantar fascitis or adhesive capsulitis Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 14

15 1500 Health Claim Form 02/12 version of the CMS 1500 claim form on April 1, 2014) Timeline for Implementing the Revised Form for Medicare Claims January 6, 2014: Medicare begins receiving and processing paper claims submitted on the revised CMS 1500 claim form (version 02/12). January 6 through March 31, 2014: Dual use period during which Medicare continues to receive and process paper claims submitted on the old CMS 1500 claim form (version 08/05). April 1, 2014: Medicare receives and processes paper claims submitted only on the revised CMS 1500 claim form (version 02/12). Spinal CMT Coding CMT to one to two regions CMT to three to four regions CMT to five to six regions Extraspinal (not a Medicare benefit) Modifiers Indicates service was modified in some way - 25 E/M and Manipulation same visit - 26 Professional component - 52 Reduced Services - 59 Distinct Procedural Service - 76 Repeat Procedure Medicare Modifiers GY - Used when an item or service is statutorily excluded or does not meet the definition of any Medicare benefit. This modifier must be used when physicians, practitioners, or suppliers want to indicate that the item or service is statutorily non-covered (as defined in the Program Integrity Manual (PIM) or is not a Medicare benefit (as defined in the PIM). The use of this modifier will automatically signal Medicare s software to deny any service that is linked to this modifier. If the service is statutorily non-covered or is not a Medicare benefit, modifier GY may be used if the beneficiary insists on having Medicare billed. GZ - Used when an item or service is expected to be denied as not reasonable and necessary. This modifier must be used when physicians want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an Advance Beneficiary Notification (ABN) signed by the beneficiary. If the beneficiary is not notified in writing that the provider expects that Medicare will deny the item or service, she/he cannot be held liable for the charges. The GZ modifier must be used to indicate that the provider expects that Medicare will deny an item or service as not reasonable and necessary and there had not been an ABN signed by the beneficiary. Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 15

16 GA - This modifier is used to indicate that a waiver of liability statement is on file. If the provider believes a service is likely to be denied by Medicare as not reasonable and necessary, the beneficiary must be so advised, in writing, prior to rendering of the service. The GA modifier must be used to indicate that the provider expects that Medicare will deny the service as not reasonable and necessary and the beneficiary has a signed Advance Beneficiary Notification (ABN) on file. -AT Modifier The AT Modifier will be used with the CMT code in all acute and chronic subluxation (nonmaintenance) spinal CMT cases. If the AT modifier is not listed on the code, the CMT will be considered to be for maintenance. The AT modifier is only to be appended to services that are part of active/corrective treatment. The AT modifier should not be appended to services that are part of maintenance therapy. GX Modifier CPT code modifiers flag a service that is altered in some way from the stated description. The basic service definition of the coded service remains intact. Modifiers convey the nature of the service or procedure. 25 On the same day a procedure or service identified by a CPT code is performed, the patient s condition required a significant, separately identifiable E/M code. example: AT Q6 - Locum Tenens Physician Quality Reporting Initiative (PQRS 2014) The 2006 Tax Relief and Health Care Act (TRHCA) (P.L ) required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals (EPs) who satisfactorily report data on quality measures for covered services furnished to Medicare beneficiaries. Providers do not need to sign-up or pre-register in order to participate in the PQRS program. Submission of the quality data codes for the measures will indicate your intent to participate in the PQRS. However, to qualify for a Physician Quality Reporting incentive payment an eligible professional must meet the criteria for satisfactory reporting specified by CMS. The 2014 results will drive the "payment adjustments" (penalties) in The Centers for Medicare & Medicaid Services (CMS) will impose a 1.5% penalty in 2015 (for 2013) and a 2% penalty for 2016 and after, if you have not met the threshold for the use of the PQRS codes. The PQRS measures will only count if you report the measures on active care patients. Do NOT report PQRS measures on maintenance care claims. Reporting is counted according to the number of claims that have a spinal CMT code (98940/98941/98942). Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 16

17 The database will consider the percentage of claims with a spinal CMT code that also have successfully reported PQRS measure codes. If the number is greater than the threshold (50% for 2014), they will generate a check based on the total allowed services for that year. CMS has indicated that PQRS will serve as the basis for its Value-Based Modifier initiative. In the coming years, CMS intends to move Medicare from the position of passive payer to a purchaser of high-quality, efficient care through a value-based purchasing initiative. The Affordable Care Act of 2010 mandates that by 2014, CMS must begin to apply a value-based modifier under the Medicare Physician Fee Schedule. In other words, cost and quality data will be factored into the calculation of payments for physicians. Starting in 2015, some payments will be affected by the value-based modifier; by 2017, most physician payments will incorporate a quality calculation. Given this fact, participation in PQRS offers doctors a valuable opportunity to prepare for the transition from fee-for-service reimbursements to payments based on quality performance. Starting in 2016, chiropractic payments will be affected by the value-based modifier. In 2016, those doctors that do not report PQRS measures will also be assigned the lowest level of Value-Based Payment Modifier of -1%. Total # of Individual PQRS Measures: There are 288 measures for Most of the Quality Measures do not pertain to chiropractic. Others may pertain indirectly, but are not eligible for a measure, since they are included in other services and are not mutually exclusive. Some measures require only a one time submission. Three of the measures must be reported by chiropractors: 1. Pain Assessment # Functional Outcomes Assessment # Preventive Care and Screening: Screening for High Blood Pressure #317 PQRS # 131 Pain Assessment and Follow-Up: Percentage of visits for patients aged 18 years and older with documentation of a pain assessment through discussion with the patient including the use of a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present Definition: Pain Assessment - A clinical assessment of pain using a standardized tool for the presence and characteristics of pain; characteristics may include location, intensity, quality, and onset/duration. Standardized Tool An assessment tool that has been appropriately normalized and validated for the population in which it is used. Examples of tools for pain assessment, include, but are not limited to: Brief Pain Inventory (BPI), Faces Pain Scale (FPS) (for mentally disabled) McGill Pain Questionnaire (MPQ) Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 17

18 Multidimensional Pain Inventory (MPI) Neuropathic Pain Scale (NPS) Numeric Rating Scale (NRS) Oswestry Disability Index (ODI) Roland Morris Disability Questionnaire (RMDQ) Verbal Descriptor Scale (VDS) Verbal Numeric Rating Scale (VNRS) a.k.a. Borg scale Visual Analog Scale (VAS). Follow-Up Plan Proposed outline of treatment to be conducted as a result of pain assessment. Follow-up must include a planned reassessment of pain and may include documentation of future appointments, education, referrals, pharmacological intervention, or notification of other care providers as applicable. The documented follow-up plan must be related to the presence of pain. Return next visit for re-assessment of pain Associated Follow-up Options: Follow-up appointment, Referral, Notification to another provider, OR indicate the initial treatment plan is still in effect. Not Eligible A patient is not eligible if one or more of the following reasons exist: - Severe mental and/or physical incapacity where the person is unable to express himself/herself in a manner understood by others. For example, cases where pain cannot be accurately assessed through use of nationally recognized standardized pain assessment tools. - Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient s health status. Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 18

19 Pain Assessment Codes to use: Pain assessment documented as positive utilizing a standardized tool AND a follow-up plan is documented OR Pain assessment documented as negative, no follow-up plan required Documentation that patient is not eligible for a pain assessment OR Pain assessment documented, follow-up plan not documented, patient not eligible/appropriate NO documentation of pain assessment, reason not given OR Documentation of positive pain assessment; no documentation of a follow-up plan, reason not given G8730 G8731 G8442 G8939 G8732 G AT G Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 19

20 PQRS # 182 Functional Outcome Assessment: Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies Measure #182, the Functional Outcome Assessment measure, has an additional definition for quality data code G8942, which now is reported to reflect functional outcome assessment documented, no functional deficiencies identified, care plan not required, or functional outcome assessment and care plan documented in the previous 30 days. DESCRIPTION: Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies INSTRUCTIONS: This measure is to be reported each visit indicating the appropriate numerator code; however, the assessment is required to be current as defined for patients seen during the reporting period. This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. Documentation of a current functional outcomes assessment must include identification of the standardized tool used. Clarification: The intent of the measure is for the functional outcome assessment tool to be utilized at a minimum of every 30 days but reporting is required at each visit due to coding limitations. Therefore, for visits occurring within 30 days of a previously documented functional outcome assessment, the numerator quality-data code G8942 should be used for reporting purposes. Definitions: Standardized Tool An assessment tool that has been appropriately normalized and validated for the population in which it is used. Examples of tools for functional outcome assessment include, but are not limited to: Oswestry Disability Index (ODI), Roland Morris Disability/Activity Questionnaire (RM), Neck Disability Index (NDI), and Patient-Reported Outcomes Measurement Information System (PROMIS). The use of a standardized tool assessing pain alone, such as the visual analog scale (VAS), does not meet the criteria of a functional outcome assessment standardized tool. Functional Outcome Assessment Patient completed questionnaires designed to measure a patient's limitations in performing the usual human tasks of living and to directly quantify functional and behavioral symptoms. Current A patient having a documented functional assessment within the previous 30 days. Functional Outcome Deficiencies Impairment or loss of physical function related to Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 20

21 neuromusculoskeletal capacity, may include but are not limited to: restricted flexion, extension and rotation, back pain, neck pain, pain in the joints of the arms or legs, and headaches. Care Plan A care plan is an ordered assembly of expected/planned activities or actionable elements based on identified deficiencies. These may include observations goals, services, appointments and procedures, usually organized in phases or sessions, which have the objective of organizing and managing health care activity for the patient, often focused on one or more of the patient s health care problems. Care plans may also be known as a treatment plan. Not Eligible A patient is not eligible if the following reasons(s) exist: - Patient refuses to participate - Patient unable to complete questionnaire Oswestry Disability Index (ODI) Revised Oswestry Low Back Pain Disability Questionnaire Roland-Morris Disability/Activity Questionnaire (RM) Neck Pain Disability Index Questionnaire (NDI) Physical Mobility Scale (PMS) Functional Assessment Documentation of a functional outcome assessment using a standardized tool AND documentation of a care plan based on identified deficiencies on the date of the functional assessment. OR Documentation of a functional outcome assessment using a standardized tool; no functional deficiencies identified, care plan not required OR Documented functional outcome assessment and care plan within the previous 30 days Documentation that the patient is not eligible for a functional outcome assessment Functional outcome assessment documented, care plan not documented, documentation the patient is not eligible for a care plan Functional outcome assessment using a standardized tool not documented, reason not given OR Documentation of a functional outcome assessment using a standardized tool; care plan not documented, reason not given Code G8539 G8542 G8942 G8540 G9227 G8541 G8543 Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 21

22 Example: AT G PQRS Measure #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated. This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period. Eligible professionals who report the measure must perform the blood pressure screening at the time of a qualifying visit and may not obtain measurements from external sources. The documented follow up plan must be related to the current BP reading as indicated, example: Patient referred to primary care provider for BP management. Blood Pressure Classifications: Normal Pre-Hypertensive First Hypertensive Second Hypertensive Follow-up plan of care Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC) BP screening intervals, lifestyle modifications and interventions based on the current BP reading Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 22

23 Lifestyle Modifications: Weight reduction, Dietary approaches to stop hypertension, Dietary sodium restriction, Increased physical activity, or Moderation in Alcohol consumption Blood Pressure Screening Normal blood pressure reading documented, follow- up not required OR Pre- Hypertensive or Hypertensive blood pressure reading documented, AND the indicated follow- up is documented Blood pressure reading not documented, documentation the patient is not eligible OR Pre- Hypertensive or Hypertensive blood pressure reading documented, indicated follow- up not documented, documentation the patient is not eligible Blood pressure reading not documented, reason not given OR Pre- Hypertensive or Hypertensive blood pressure reading documented, indicated follow- up not documented, reason not given Code G8783 OR G8950 G8784 OR G8951 G8785 OR G AT G Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 23

24 Example: (Circle one of the following) Pain Assessment G8730 Pain Assessed, present G8731 Pain assessed, but no pain G8732 Pain NOT assessed Outcomes Assessment (OATS) G8539 OATS done today G8942 OATS not done today; but within the last 30 days G8542 OATS done today; no deficiency G8541 OATS NOT done in the last 30 days Blood Pressure Screening G8783 Normal BP G8950 HyperBP with follow-up G8785 BP not documented ICD-10 CM Implementation Date is October 1, 2014 ICD-9 Limitations Diagnosis has changed. We know more. Many sections of the codes are full. Uses obsolete technology leading to inaccurate and limited data Need more description. Sprain/Strain Medicine advances; codes can t ICD-10-CM 1993 the 10 th Edition of the International Classification of Disease ICD-10) was issued by the World Health Organization (WHO) WHO is responsible for maintaining the ICD-10 Each country is responsible for adapting the ICD-10 to suit its own country s needs. The Clinical Modifications were developed by the National Center for Health Services (NHHS). This is used currently for morbidity and mortality reporting. ICD-10 has been in use for the reporting of mortality on death certificates as of January 1, Exemption From ICD-10 Worker s Compensation, auto and personal injury insurances are exempt from HIPAA and therefore may not be using ICD-10. Your office may have two sets of diagnostic codes Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 24

25 ICD- 9 Diagnostic Codes 3-5 Characters in length Approximately 14,000 codes First digit may be alpha; 2 nd through 5 th is numeric Limited space for adding new codes Lacks detail Lacks laterality Difficult to analyze data due to non- specific codes Codes are non- specific and do not adequately define diagnoses needed for medical research Does not support interoperability because it is not used by other countries ICD- 10 Diagnostic Codes 3-7 Characters in length Approximately 69,000 available codes Character 1 is alpha; character 2 and 3 are numeric; character 4 through 6 can be either Flexible for adding new codes Very specific Has laterality Specificity improves coding accuracy and quality of data for analysis Detail improves the accuracy of data used for medical research Supports interoperability and the exchange of health data between other countries and the U.S. ICD-10-CM The increased specificity of the ICD-10 codes require more detailed clinical documentation in order to code some diagnoses to the highest level of specificity There are unspecified codes in ICD-10-CM for those instances when the health record documentation is not available to support more specific codes The benefits of ICD-10 cannot be realized if non-specific codes are used rather than taking advantage of the specificity ICD-10 offers ICD-10 Specificity Side of Dominance - Right, Left, or ambidextrous (defaults to the right coding) Laterality - All paired organs or structures Ordinality - Is this the initial or subsequent visit for the complaint? - Are these symptoms the sequela of the initial event? Documentation of diagnoses and procedures Codes must be supported by the patient s health documentation ICD-10-CM codes are more specific Requires more documentation to support codes Expect a 15% increase in documentation time (per AAPC) Revenue Impacts due to specificity Denials Additional Documentation ICD-10 Impact on Health Care Plans Coding more specific and includes severity Changes will be based on new coding, coverage, and reimbursement Difficult to measure what the changes will mean to overall reimbursement Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 25

26 Billing and Eligibility Updated transactions include support for ICD-10 New codes mean more specificity Expect increased rejections, denials, and payment delays as both health plans and providers get used to new codes Planning and Training Yields Success Plan early. Time to contact your vendors Train in stages. Train doctors, coders and staff Measure productivity and retention Retrain when necessary ICD-10 Chapters Chapter 13 Diseases of the Musculoskeletal system and connective tissue (M00-M99) Chapter 15 Pregnancy, childbirth and the puerperium (O00-O99) Chapter 19 Injury, poisoning and certain other consequences of external causes Chapter 20 External causes of morbidity (V00-Y99) Factors influencing health status and contact with health services (Z00-Z99) General Equivalence Mapping (GEMs) The GEMs will act as a translation dictionary to bridge the language gap between the two code sets and can be used to map an ICD-9 code to an ICD-10 code and vice versa. Attempt to include all valid relationships between the codes in the ICD 9 and ICD 10 classifications Coding Examples ICD-9 Cervicalgia ICD-10 Cervicalgia M54.2 Coding Examples ICD Sciatica ICD-10 M54.30 Sciatica unspecified side M54.31 Sciatica Right M54.32 Sciatica Left M54.40 Sciatica with lumbago unspecified M54.41 Sciatica with lumbago right M54.42 Sciatica with lumbago left Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 26

27 Placeholder X character The ICD-10-CM utilizes a placeholder character X The X is used as a 5th and /or 6th character placeholder at certain 6 and/or 7 character codes to allow for future expansion. 7th Characters Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 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. Code First/Use additional code Provides instructions on how to sequence the codes. Signals that that an additional code should be reported to provide a more complete picture of the diagnosis. Code Also Alerts the coder that more than one code may be required to fully describe the condition. The sequencing of the codes depends on the severity and/or the reason for the encounter. Unspecified codes Codes (usually a code with a 4th digit 9 or 5th digit 0 for diagnosis codes) titled unspecified are for use when the information in the medical record is insufficient to assign a more specific code. For those categories for which an unspecified code is not provided, the other specified code may represent both other and unspecified. Basic ICD-10 Coding Guidelines: A initial encounter D Subsequent encounter S - Sequela General ICD-10 Coding Guidelines: 1. ICD-10-CM codes should be listed at their highest level of specificity and characters. a. Use three digit codes only if there are no four digit codes within the coding category. These are the heading of a category of codes. b. Use the 4, 5, 6, or 7 digit code to the greatest degree of specificity available. These provide further detail 2. Codes that describe symptoms and signs are only acceptable if that is the highest level of diagnostic certainty documented by the doctor. No other diagnosis has been established (confirmed) by the provider. 3. Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. 4. Additional signs and symptoms that are not routinely associated with a disease may be reported. 5. Coding for diagnoses that are probable, suspected, likely or questionable are not to be coded, because they indicate uncertainty. Rule out and working diagnosis are not to be coded. Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 27

28 Other documentation related coding guidance involves diagnoses documented as borderline" at the time of discharge. Unless the classification provides a specific entry (e.g., borderline diabetes), borderline diagnoses are coded as confirmed without regard to the care setting (i.e., inpatient versus outpatient). The guidelines clarify that borderline conditions are not considered uncertain diagnoses. As always, coders are encouraged to query the provider for clarification whenever the documentation is unclear regarding the condition. 6. Code all documented conditions that coexist at the time of the visit that REQUIRE OR AFFECT patient care. Do not code conditions that no longer exist. 7. Coding for diagnoses that are probable, suspected, rule out, etc are not allowed for outpatient s. 8. The term first-listed diagnosis is now to be used instead of the term principle diagnosis. 9. The acute condition should always be listed first. 10. Each unique ICD-10 diagnostic code may be reported only once. If you use a left and right code, you only list the diagnosis with these sides once. 11. If the condition is bilateral and there is no bilateral code, t hen you have to list the left and right code separately. 12. If a condition is borderline, then it is listed as confirmed. 13. An unspecified code should be reported only when it is the code that most accurately reflects what is known about the patient s condition at the time of that particular encounter. 14. It is inappropriate to select a specific code that is not supported by the health record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code. Note: There are 21 chapters in the new ICD-10 Classification System. Some of the chapters will never be used by the chiropractor. If you use functional medicine in your practice, I recommend that you take classes that pertain to your area of expertise. ICD-10 Chapter 13: Rules for Diseases of the Musculoskeletal System and Connective Tissue (M00 M99) Specific Guidelines for Musculoskeletal and Connective Tissue System Diagnosis 1. Site and laterality: For some conditions where more than one bone, joint or muscle is usually involved, such as osteoarthritis, there is a multiple sites code. If there is not a multiple sites code, then use multiple codes to indicate the multiple sites involved. 2. Code by site first, then condition. 3. Site represents the involved: a. Bone b. Joint c. Muscle 4. Multiple site codes. If there is no multiple site code, multiple codes should be used 5. Arthritis and osteoarthritis have both site and laterality designations in ICD-10 Documentation, Compliance and ICD- 10 Coding, Mario Fucinari DC, MCS- P Page 28