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1 Page1 Office Procedures, Coding and Billing for 2018 Mario Fucinari DC, CCSP, CPCO, MCS-P Certified Professional Compliance Officer (CPCO) Certified Medical Compliance Specialist (MCS-P) Presented by ChiroHealthUSA Disclaimer: The views and opinions expressed in this presentation are solely those of the author. NCMIC and Mario Fucinari DC do not set practice standards. We offer this only to educate and inform. The laws, rules and regulations regarding the establishment and operation of a healthcare facility vary greatly from state to state and are constantly changing. Dr. Mario Fucinari does not engage in providing legal services. If legal services are required, the services of a healthcare attorney should be attained. The information in these seminar slides is for educational purposes only and should not be construed as written policy for any federal agency. NO RECORDING OF ANY TYPE ALLOWED This Material is Copyright Protected 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 or state 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.

2 Page2 About Dr. Mario Fucinari, CCSP, APMP, CPCO, MCS-P Graduate of Palmer College of Chiropractic Currently in Full Time Practice in Decatur, Illinois Certified Chiropractic Sports Physician (CCSP) Logan College of Chiropractic Certified Medical Compliance Specialist Physician (MCS-P) Certified Professional Compliance Officer CPCO (AAPC) Diplomate Academy of Integrative Pain Management (APMP) Post-graduate Faculty of Palmer College of Chiropractic, NYCC, D Youville College, Life West and Western States Chiropractic College National Speaker s Bureau for NCMIC, ChiroHealthUSA and Foot Levelers and many state associations Member Medicare Carrier Advisory Committee Past President of Illinois Chiropractic Society (ICS) Chairman, ICS Medicare Committee ICS Chiropractor of the Year 2012 Member of ACA and ICS New information posted regularly at and Like us THE COMPLIANT OFFICE Step One: Risk Analysis Front Desk Procedures: Revalidation Required with Medicare The Medicare Card

3 Page3 CMS has released images of the newly designed and renamed Medicare Beneficiary Identifier (MBI) card. The new MBI card will be introduced on April 1, The card will go through a transition period from April 1, 2018 through December 31, 2019 as more than 44 million beneficiaries convert to the new card with a new identification number. The Medicare Beneficiary Identifier card will contain a unique, randomly-assigned 11-character identification number that replaces the current Social Security-based number. Each MBI identifier will be randomly generated. An example of the new identifier would be: 1EG4-TE5-MK73 CMS will begin mailing the new cards to people who receive Medicare benefits in April The statutory deadline is to replace all the existing Medicare health insurance cards by December 31, Medicare Part B In 2018 the deductible will be $183 Only covered services are applied to the deductible Co-insurance: 20 percent. It is illegal to waive ANY part of the deductible or coinsurance Filing of Medicare Claims Medicare Processing Manual Time Limitation for Filing Part B Reasonable Charge and Fee Schedule Claims (Rev. 170, ) Medicare law prescribes specific time limits within which claims for benefits may be submitted with respect to physician and other Part B services payable on a reasonable charge or fee schedule basis For these services, the terms of the law require that the claim be filed no later than the end of the calendar year following the year in which the service was furnished Opting out of Medicare is not an option for Doctors of Chiropractic. Note that opting out and being non-participating are not the same things. Chiropractors may decide to be participating or non-participating with regard to Medicare, but they may not opt out. MedLearn Matters SE0479 The Medicare Fee: Did you do PQRS in 2016? If no, subtract 2% Did you do an attestation for Meaningful use in 2016? If no, subtract 3% This is the NEW amount charged to the patient. In 2018, sequestration continues. An additional 2% will be deducted from your payment.

4 Page4 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. YOU CAN NOT OPT OUT OF MEDICARE! (Jan 2004) Medicare Updates! H.R. 2, SECTION 514 Oversight of Medicare Coverage of Manual Manipulation of the Spine to Correct a Subluxation Sequestration EHR Meaningful Use PQRS Penalty Value-Based Modifier Medicare MIPS Program Quality Payment Program (QPP) } Quality 2018 threshold for Medicare QPP < $90,000 AND <200 active Part B Medicare patients Check your status at Payment Program

5 Page5 The Medicare Episode of Care The Episode of Care Model The CMS 1500 Claim Form Box 14: Medicare Commercial Insurance PI/ Work Comp - Box 21 Box 24J Radiology Effective Chest X-Ray codes change: Deleted: 71010, 71015, , 71030, and Replaced by: (Radiologic examination, chest ; single view) (Radiologic examination, chest ; 2 views) (Radiologic examination, chest ; 3 views) (Radiologic examination, chest ; 4 or more views). Effective Abdomen Views Deleted: Radiologic examination, abdomen; single anteroposterior view anteroposterior and additional oblique and cone views complete, including decubitus and/or erect views Replaced by: Radiologic examination, abdomen 1 view views or more views

6 Page6 Orthotics CPT Code Changes: Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes Billed in 15-minute units. NOTE: Checkout for orthotic/prosthetic use is deleted as of Dec. 31, 2017 Comparisons of ICD-9 to ICD-10 ICD-10-CM ICD-9 Diagnostic Codes ICD-10 Diagnostic Codes 3-5 Characters in length 3-7 Characters in length Approximately 17,000 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 Approximately 70,000 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 requires 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

7 Page7 ICD-10 Updates: Example M Spinal stenosis, lumbar region without neurogenic claudication M Spinal stenosis, lumbar region with neurogenic claudication What are your local carriers telling you? ICD-10 Step to UPDATE 1. Gather your last 40 new patient s charts 2. Make a list of the ICD-10 diagnoses 3. You have your Top 40 Playlist 4. Check your EOBs 5. Identify Unspecified Codes and Deleted Codes 6. Convert to 2018 Code Usage 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. Sequencing of ICD-10 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 degree of specificity. This must be supported by the chart documentation. The diagnosis you provide directly relates to the level of care permitted by the third-party payers. Medicare Subluxation Complex Segmental and somatic dysfunction M segmental and somatic dysf.- cervical region M segmental and somatic dysf.- thoracic region M segmental and somatic dysf.- lumbar region M segmental and somatic dysf.- sacral region M segmental and somatic dysf.- pelvic region Diagnosis Pointer for Medicare:

8 Page8 Proper Sequencing of Codes in ICD-10 Optimal sequencing of the codes: Neurological diagnosis Structural descriptor diagnosis Functional diagnosis Soft tissue Extremity Modifiers 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.

9 Page9 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. 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. 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 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 Modifier 59 - Distinct Procedural Service Modifier XE - Separate Encounter: A service that is distinct because it occurred during a separate encounter Modifier XS - Separate Structure: A service that is distinct because it was performed on a separate organ/structure Modifier XP- Separate Practitioner: A service that is distinct because it was performed by a different practitioner Modifier XU - Unusual Non-Overlapping Service: The use of a service that is distinct because it does not overlap usual components of the main service Ensure that you have clinical circumstances to justify the modifiers and please do not append to HCPCS and CPT codes to simply bypass the NCCI edits.

10 Page10 Medicare considers two physicians in the same group with the same specialty performing services on the same day as the same physician OR XS Point properly in 24E The Advanced Beneficiary Notice Form (June 21, 2017) Period of Effectiveness An ABN can remain effective for up to one year. ABNs may describe treatment of up to a year s duration, as long as no other triggering event occurs. If a new triggering event occurs within the 1-year period, a new ABN must be given. See 50.5 Triggering Events. 1. One ABN for maintenance manipulation and one for non-covered services ( voluntary ) 2. Good for up to one year 3. Signed copy to patient 4. Update as needed 5. Personally signed and dated by the patient Red Flags of the ABN: Name: Identification Number: Options: Signature and Date: The CMS 1500 Claim Form Box 14 Box 21 Box 24J Offering Gifts and Other Inducements to Beneficiaries (OIG Advisory Opinion 2002) A person who offers or transfers to a Medicare or Medicaid beneficiary any remuneration that the person knows or should know is likely to influence the beneficiary s selection of a particular provider, practitioner, or supplier of Medicare or Medicaid payable items or services may be liable for civil money penalties (CMPs) of up to $10,000 for each wrongful act. The statute defines remuneration to include, without limitation, waivers of copayments and deductible amounts (or parts thereof) and transfers of items or services for free or for other than fair market value.

11 Page11 The OIG has interpreted the prohibition to permit providers to offer beneficiaries inexpensive gifts (other than cash or cash equivalents) or services without violating the statute. For enforcement purposes, inexpensive gifts or services are those that have a retail value of not more than $10 individually, and no more than $50 in the aggregate annually per patient. Similarly, there is no meaningful statutory basis for a broad exemption based on the financial need of a category of patients. The statute specifically applies the prohibition to the Medicaid program a program that is available only to financially needy persons. The inclusion of Medicaid within the prohibition demonstrates Congress conclusion that categorical financial need is not a sufficient basis for permitting valuable gifts. This conclusion is supported by the statute s specific exception for non-routine waivers of copayments and deductibles based on individual financial need. If Congress intended a broad exception for financially needy persons, it is unlikely that it would have expressly included the Medicaid program within the prohibition and then created such a narrow exception. Why ChiroHealthUSA? As benefits for chiropractic care dwindle, more families are forced to choose between needed chiropractic care and other necessities. Because patients with insurance coverage have the benefit of the carrier negotiating the fees with the doctor, cash-paying patients, or those with non-covered services like Medicare beneficiaries, may have to pay MORE than insured patients. ChiroHealthUSA allows patients to use the membership concept they are already familiar with to access needed care for their immediate family. Doctors are usually required to charge insurance companies and patients the same fees unless they are under a network contract for a lower fee. ChiroHealthUSA is a contracted network that allows doctors to set and accept discounts on their services for our members. When a patient joins ChiroHealthUSA, they are entitled to similar in-network discounts just like the insurance companies. A single $49 annual membership includes everyone in your immediate family. Partially insured patients who have coverage for some services and not others, like Medicare patients, may use their ChiroHealthUSA benefits to complement their existing benefits, specifically for the non-covered services. Patients may use their membership cards at more than 3,900 doctors in the network. Simple. Compliant. Profitable. ChiroHealthUSA is a provider-owned network designed with doctors in mind. Our network model allows you to offer legal, network-based discounts to cash, under-insured and out of network patients who are members. Members covered by Medicare and federal programs are eligible for discounts on non-covered services. The network approach to discounts reduces the risks of compliance and OIG violations related to inducements, improper down-coding, dual fee schedules, and potentially inappropriate time-of-service discounts.

12 Page12 With ChiroHealthUSA, you can choose the level of discounts. The existence of a contract allows you to set, offer, and accept these rates from our members. Our contract eliminates the middle man, and solves a host of legal and regulatory problems for you and your patients. ChiroHealthUSA only makes membership available to individuals, which means there is no potential for silent PPO activity to lower your reimbursements. Patients pay a low annual membership fee that includes them and their legal dependents. This fee is often recovered through discounts received on their first visits. There is no cost to the clinic for this program. Sources: for Free Free Webinars ICD-10 Coding of the Top 100 Conditions for the Chiropractic Office by Dr. Mario Fucinari New information posted regularly at Like us Compliance Program Manual for the Chiropractic Office by Mario Fucinari DC, CPCO, MCS-P Step-by-Step Procedures to compliance www,askmario.com Medicare can now ask for records from up to FIVE years ago. Are you complaint? The OIG stated that a compliance plan (different from HIPAA) is a mitigating factor against fines and/or jail time. If you have a Compliance Plan done in keeping with the OIG Recommendations, it may be your bullet-proof vest! For a professionally created Compliance manual, unique to your office or chart audits contact Mario Fucinari DC, MCS-P, a Certified Medical Compliance Specialist and Instructor for further information. See our list of services at or at doc@askmario.com If you have questions Doc@AskMario.com Thank You!!

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14 Page14 A. Notifier: B. Patient Name: C. Identification Number: Advance Beneficiary Notice of Noncoverage (ABN) NOTE: If Medicare doesn t pay for D. below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D. below. D. E. Reason Medicare May Not Pay: F. Estimated Cost WHAT YOU NEED TO DO NOW: Read this notice, so you can make an informed decision about your care. Ask us any questions that you may have after you finish reading. Choose an option below about whether to receive the D. listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do G. OPTIONS: this. Check only one box. We cannot choose a box for you. OPTION 1. I want the D. listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. OPTION 2. I want the D. listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. OPTION 3. I don t want the D. listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. H. Additional Information: This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call MEDICARE ( /TTY: ). Signing below means that you have received and understand this notice. You also receive a copy. I. Signature: J. Date: CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: MEDICARE or AltFormatRequest@cms.hhs.gov. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland Form CMS-R-131 (Exp. 03/2020) Form Approved OMB No

15 Page15 A. Notifier: B. Patient Name: C. Identification Number: Advance Beneficiary Notice of Noncoverage (ABN) NOTE: If Medicare doesn t pay for D. below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D. below. D. E. Reason Medicare May Not Pay: F. Estimated Cost WHAT YOU NEED TO DO NOW: Read this notice, so you can make an informed decision about your care. Ask us any questions that you may have after you finish reading. Choose an option below about whether to receive the D. listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this. G. OPTIONS: Check only one box. We cannot choose a box for you. OPTION 1. I want the D. listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. OPTION 2. I want the D. listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. OPTION 3. I don t want the D. listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay. H. Additional Information: This supplier doesn t accept payment from Medicare for the item(s) listed in the table above. If I checked Option 1 above, I am responsible for paying the supplier s charge for the item(s) directly to the supplier. If Medicare does pay, Medicare will pay me the Medicare-approved amount for the item(s), and this payment to me may be less than the supplier s charge. This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call MEDICARE ( /TTY: ). Signing below means that you have received and understand this notice. You also receive a copy. I. Signature: J. Date: CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: MEDICARE or AltFormatRequest@cms.hhs.gov. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland Form CMS-R-131 (Exp. 03/2020) Form Approved OMB No