ACA Demo e-Alert

Meant only for providers and billing staff in the areas of the Medicare chiropractic demonstration project.

Compiled by ACA Staff in conjunction with Dr. Ritch Miller, ACA Medicare Committee Chairman, and Susan McClelland, ACA Medicare Advisor.

To learn more about the demonstration project, please visit http://www.acatoday.com/demo.
If you have further questions, please email demo@acatoday.com.

Issue 3 August 1, 2005

1. “INCIDENT TO” REQUIREMENTS BACK IN EFFECT AS OF MON, JULY 25, 2005
2. REIMBURSEMENT AN ISSUE: ACA WORKING DAILY TO RESOLVE ISSUES
3. CHECK ALL OF YOUR CARRIER LCDs (THERAPY, RADIOLOGY, ETC.) TO ENSURE COMPLIANCE (AND REIMBURSEMENT)

1. “INCIDENT TO” REQUIREMENTS BACK IN EFFECT AS OF MON, JULY 25, 2005

Some of you may have or will receive an email and/or fax from the ACA about the “incident to” requirements. This very important announcement outlines the following:

“URGENT!!

“INCIDENT TO” RULES BACK IN EFFECT
AS OF MONDAY, JULY 25, 2005!

ADVISORY: Unfortunately, the National Association of Athletic Trainers (NATA) was not successful in their lawsuit against HHS and the case has been dismissed. Therefore, effective July 25, 2005, doctors participating in the demonstration project must now abide by the “incident to” regs that were previously put on hold. Participating doctors should now bill for therapy services as they would have prior to the injunction.

This means that doctors of chiropractic in the demonstration areas WILL NOT be reimbursed for therapy services provided by a chiropractic assistant or other non-qualified personnel.

REMINDER: According to the CMS Manual, therapy services are only reimbursable when performed “incident to” a physician by an individual whom has: “graduated from a physical therapy curriculum approved by (1) the American Physical Therapy Association, or by (2) the Committee on Allied Health Education and Accreditation of the American Medical Association, or (3) Council on Medical Education of the American Medical Association, and the American Physical Therapy Association. Typically, these individuals have been (1) admitted to membership by the American Physical Therapy Association, or (2) were admitted to registration by the American Registry of Physical Therapists, or (3) have graduated from a physical therapy curriculum in a 4-year college or university approved by a state departme of education.” For more information: http://www.acatoday.com/maillist_ent_252/redirect.cfm?ID=1831&MID=151&LID=14&EID=340319

(PLEASE NOTE: This regulation is for services rendered “incident to” a physician. The physicians, on the other hand, are always permitted to perform the services themselves.)

For more information on the NATA case and the demonstration project: http://www.acatoday.com/demo.

Please call 1-800-986-4636 if you have any questions”

This means that any claims filed for the date Mon, July 25, 2005, must take into account these rules.

ACA has objected to these “incident to” rules since October of 2003 (http://www.acatoday.com/government/medicare/regulatory/incident_to.shtml) and continues to voice our objections to CMS and other parties.

2. REIMBURSEMENT AN ISSUE: ACA WORKING DAILY TO RESOLVE ISSUES

We have reports that many doctors participating in the demo project are having reimbursement problems. This can vary, depending on the locale. ACA and CMS are working actively with the individual carriers in these states to assess the reasons for high denial rates. We encourage any individuals having these issues to contact ACA and let us know what you are experiencing; this will allow us to be specific with CMS about which issues need to be addressed. (Email us at demo@acatoday.com.) We also encourage you to consult the ACA Documentation Manual and the ACA Chiropractic Coding Solutions Manual 2005 for help with filing claims properly.

3. CHECK ALL OF YOUR CARRIER LCDs (THERAPY, RADIOLOGY, ETC.) TO ENSURE COMPLIANCE (AND REIMBURSEMENT)

ACA encourages all doctors and billing staff in these areas to make sure they check corresponding local coverage determinations (LCDs) on any of the expanded services allowed under the demonstration project. Doctors must follow the local policy as outlined in these pieces in order to be reimbursed for these services. Please check your carrier’s website for complete information. We have provided some links here that take you to some of your state’s local coverage determinations:

· Maine: http://www.cms.hhs.gov/mcd/results_index.asp?from='lmrpcontractor'&contractor=30&name=National+Heritage+Insurance+Company++(31142,+Carrier)&letter_range=4
· Illinois: http://www.wpsic.com/medicare/policies/illinois/index.shtml
· Iowa: http://www.noridianmedicare.com/provider/pubs/med_b/policy.html
· Virginia: http://www.trailblazerhealth.com/lmrp.asp?lmrptype=va
· New Mexico: http://www.oknmmedicare.com/provider/medpolb/polmanindex1.asp

Checking on these policies can mean the difference between payment and non-payment. For example, if you are submitting a therapy service claim with one of the diagnosis (ICD9) codes listed by Medicare as one of the codes for usage in the demonstration project, you could still be denied if your diagnosis code does not determine medical necessity as outlined in your local LCD for therapy services.

As an illustration, this inquiry recently came through Illinois Chiropractic Society:
“On two different patients Medicare has rejected our claims for diagnosis 724.8-Facet Syndrome. The EOB reads “CO 50 These are non-covered services because this is not deemed a “medical necessity” by the payer. The ICD 9 code 724.8 is however given on the list of allowed diagnosis by Medicare for the Demonstration Project. The rest of the claim is correctly filled out.”

Examining the Wisconsin Physicians’ Service (WPS) LCD for Physical Medicine and Rehabilitation reflects that for code 97032 (electrical stimulation), the “ICD-9 Codes that Support Medical Necessity” section does not include 724.8., which is why this claim is coming back with an EOB which states that the services are non-covered because they are not medically necessary. To see this LCD, click here: http://www.wpsic.com/medicare/policies/illinois/physmed09.shtml.

Essentially, make sure that your claim is not only in line with national policy, but is also appropriate where your local policy is concerned.

We need you! If you aren’t a member of the ACA, please consider joining todaby calling 1(800)986-INFO or visiting http://www.acatoday.com/pdf/MembershipApp2005.pdf. We do have a membership category for chiropractic assistants!

For additional information on the Medicare chiropractic demonstration project, please visit http://www.acatoday.com/demo.

The ACA Demo e-Alert is a online newsletter designed for doctors and billing staff practicing in the areas of the Medicare chiropractic demonstration project. This e-Alert will go out periodically to help individuals in these areas understand the regulations and billing procedures, as well as communicate the latest news from Centers for Medicare & Medicaid Services (CMS). ACA discusses details of the demonstration project regularly with CMS and other entities, and wants to ensure that the people on the frontline of this important initiative have access to all the information they need.