Premera s definition of Medical Necessity is written in your PREMERAFirst Provider Contract Part 1.08.

Transcription

1 Premera and the Washington State Chiropractic Association (WSCA) worked closely to release the following positions focused on several issues centered on the practice of chiropractic care in the state of Washington in an effort to strengthen the relationship between Premera and its Chiropractic providers. Medical Necessity Premera s definition of Medical Necessity is written in your PREMERAFirst Provider Contract Part Medical Necessity shall mean health care services that a Provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: A. in accordance with generally accepted standards of medical practice; B. clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury or disease; and C. not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease. The fact that services were furnished, prescribed, or approved by a physician or other qualified provider does not in itself mean that services were Medically Necessary. A service may be Medically Necessary, but not be a covered service because it is a contract exclusion, investigational or experimental. For example, a chiropractor may determine that maintenance therapy is medically necessary in certain cases, but maintenance therapy is a contract exclusion. Another example would be if a chiropractor determines that vertebral axial decompression therapy is medically necessary in certain cases, but under Premera s Medical Policy this service is investigational and is therefore not a covered service. Premera makes benefit determinations and payment decisions based on the specific plan s benefit design. This means there may be differences between plans and between fully insured and self insured plans as to what is a covered service. 1 of 5

2 Documentation The need for chiropractic care is determined by the chiropractor and based on their training and application of chiropractic principles and philosophy. When a chiropractor contracts with Premera and is treating one of its members it becomes the contracted provider s obligation to identify services that are covered under the relevant plan and the Chiropractic Services and Physical Medicine & Rehabilitation/Physical Therapy Corporate Medical Policies, document and bill the services accordingly. Determination of medical necessity is made by review of the documentation produced contemporaneously with the visit that shows the patient s condition warranted care and that the care that was provided was medically necessary. Documentation should reflect that a given service was provided, the provider s thinking and rationale in the treatment plan as to why the service was provided and treatment plan. The required elements for documentation are found in the Chiropractic Services and Physical Therapy Corporate Medical Policies. The need to document the services provided is to describe the patient s condition, then report findings, signs and symptoms of changes in their condition and to reflect the provider s thought process regarding the need for treatment and future care. Chiropractic Services Corporate Medical Policy Physical Therapy Corporate Medical Policy 2 of 5

3 Evaluation and Management Evaluation and Management services (CPT ) are defined and described by the AMA CPT committee. When an E&M service is charged, the chart notes must document a separate and identifiable service that includes the history, examination, medical decision making and counseling/coordination of care of that visit consistent with the patient s condition for that encounter. Some examples of when E&M services would be appropriate: A new patient visit. An established patient not seen in the prior 60 days with a new complaint or flare up of a condition. A new complaint or a current complaint that needs to be re-evaluated based on the need to change the treatment plan or to manage the uncertainty of the case due to unforeseen changes in patient s status. When counseling and/or coordination of care is greater than 50% of the total E/M component time may become the overriding factor in code selection. When this is the case, the counseling/coordination of care must be documented to show the need. Counseling has seven components as defined by CPT reporting diagnostic results, impressions, and/or recommended diagnostic studies, prognosis, risks and benefits of management (treatment) options, instructions for treatment and/or follow up, importance of compliance with chosen management, risk factor reduction, or patient/family education. There are situations in which charging for an E&M is not consistent with the AMA CPT descriptions, some examples are: o Describing chiropractic care and educating the patient on health, wellness. o Perfunctory E&M that occur on a routine time interval or frequency of visits regardless of the patients presenting condition. o Release and discharge examinations part of the pre/post service component of CMT unless it is an on the job injury, auto accident, or liability case. o Consultations if requested as appropriate by a qualified 3rd party, with appropriate services rendered and a response is sent to the requesting party are billed using the Consultation codes 9924x. 3 of 5

4 Multiple Copayments When will patients have to pay multiple copays on the same date of service? Premera is aware of concerns raised by some practices about their patients being charged multiple co-pays for services received at one visit. We would like to clarify the circumstance under which this can occur. There is a copay charge for each contracted provider a member sees, even when the services are provided on the same date of service. For example, if a member sees a chiropractor, massage therapist and a naturopath in one clinic, three copays should be collected from the member. When a member sees a dual or triple licensed provider and receives multiple services from the same provider on one date of service, one claim per provider license needs to be submitted and only one copay should be collected. If your patient is charged two copays under these circumstances, you may contact Customer Service to have the claim reprocessed correctly. If you have any questions regarding how much copay to collect from the member, please call the Customer Service number on the back of the member s ID card. 4 of 5

5 Delegation of Duties Eligibility for Reimbursement for delegated Physical Medicine and Rehabilitation (PM&R) Delegated services are only eligible for reimbursement when performed, as described below, by auxiliary staff or qualified personnel who are under direct supervision. Direct Supervision means the supervising provider must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. No more than two (2) people can be under direct supervision at one time. Auxiliary staff are personnel who are trained on the job, and includes physical therapy aides. Qualified personnel include: A licensed Assistant Physical Therapist with a valid current WA state license. A licensed Athletic Trainer with a valid current WA state license Chiropractic postgraduate trainees who are not licensed, but have successfully completed a Council on Chiropractic Education (CCE) approved DC program within the prior two years and students who have attained 3 rd year status and who are actively enrolled in the program. Naturopathic postgraduate trainees who are not licensed, but have successfully completed a Council on Naturopathic Medical Education (CNME) approved ND program within the prior two years and students who have attained 3 rd year status and who are actively enrolled in the program. Physical Therapy postgraduate trainees who are not licensed, but have successfully completed their program of study within the prior year and students who are who are actively enrolled in a Commission on Accreditation in Physical Therapy Education (CAPTE) accredited program. PM&R services that can be delegated to auxiliary staff are modalities ( ). PM&R services that can be delegated to qualified personnel are procedures ( ). A written treatment plan with daily notes which documents each visit and meet the requirements of the Corporate Medical Policy on PM&R/PT must be made and initialed, showing who performed the service. A log of the full name of the person providing the service, with a sample of the initials they use in the record and their status in their educational program must be maintained or the person will be deemed to be Auxiliary staff. Reimbursement for delegation of examination procedures, exposing, interpreting or analyzing radiographs as described in WAC will be made as incident to the licensed provider. 5 of 5