Fall 2014

Transcription

Fall 2014

Fall 2014
Publication of the Association of New Jersey Chiropractors
www.anjc.info
Volume 10 Number 4
ANJC’S NEW PUBLIC
WEBSITE IS NOW LIVE!
L
ooking to increase your patient base? Do you want timely, informative articles
and videos to share with your patients? ANJC is here to help!
With the recent launch of the NEW AND IMPROVED website for the public,
www.njchiropractors.com, this site contains healthy tips and advice, a weekly blog,
videos and more in an effort to educate the public on the benefits of chiropractic.
As an ANJC member, you can sign up via email to receive our weekly blog, which you
can share and post on YOUR OWN Facebook and Twitter pages! If you communicate to
your patients via email, you can share all of this valuable information with them as well.
Continued on Page 15
Don’t Play It Again, Sam
By K. Jeffrey Miller, DC, DABCO
Chiropractic and the Paleo Diet, Part 2
I
f you have not implemented an electronic healthcare records (EHR) system by now, you have missed out on one of
the most frustrating yet rewarding experiences of your chiropractic career. The initial implementation is a little stressful but
once the transition is over the benefits multiply rapidly.
The primary reason for frustration is finding the right fit. It is
hard to find a chiropractic EHR system that is a perfect fit right
out of the box. This is especially true for the recordkeeping
Trust,
but Verify
By Dr. Ray Foxworth, FICC, MCS-P
I
was speaking with a doctor recently who was
venting her frustration about not knowing who to
believe or trust as an authority when it comes to
being in practice today. She goes to different seminars
Association of New Jersey Chiropractors
3121 Route 22 East Suite 302
Branchburg, NJ 08876 • U.S.A.
PRSRT STD
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Inside:
Dr. Michael Acanfora & Dr. Noah De Koyer —
page 3
Their Problem Isn’t Your Problem
William D. Esteb — page 10
The Nutritional Implications of the
Chiropractic Adjustment, Part II
Dr. Steven Lavitan — page 17
How to Get Paid for Physical Performance
Tests on the Same Day as CMT
Dr. Marty Kotlar — page 19
ANJC Submits Comments Defending the
Provider Non-Discrimination Clause of
Obamacare
— page 23
How to Determine Who Is a Business
Associate and What to Do?
2014 FALL
Wiks Moffat — page 26
INSURANCE
UPDATE
PPACA Sec. 2706, the NonDiscrimination Clause—in Jeopardy?
Matt Minnella — page 27
Featured Articles
By Matt Minnella - ANJC Insurance Director
O
ptum/98943: We are pleased to report that as of July 16, 2014 United
Healthcare and its affiliates, including
Optum, have been properly reimbursing code
98943 at 100% of its fee schedule amount.
They had been denying the code if submitted
without the -51 modifier and paying the code
at only 50% of the fee schedule amount
with the modifier. Hence, since this change
the reimbursement from United/Optum for
98943 has essentially doubled!
Continued on Page 6
Insurance................. 4, 20, 24
Q & A Legal...................... 10
Q & A Medicare................ 11
Q & A Insurance............... 11
ChiroAssist................... 12-15
Foot Loose....................... 16
ANJC NEC.................... 18-19
Malpractice...................... 20
Research Updates.............. 21
Legal Ease........................ 22
For Those Who Live on Their Feet
The all new Premium Comfort orthotic
see inside for more info
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Fall 2014 www.anjc.info
www.njchiropractors.com
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Chiropractic and the Paleo Diet, Part 2:
How to Run a Successful 30 Day Paleo Challenge in Your Office
OVER
By Dr. Michael Acanfora & Dr. Noah De Koyer
20,000
I
n the second part of this three
part series, we will be outlining a
step by step guide on how to run
a successful 30 Day Paleo Challenge
in your chiropractic office.
As we explained in the first part of
this article, the paleo diet or template
is a diet rich in vegetables, tubers,
fruit, nuts, seeds, eggs, meat, fish,
and poultry. It excludes dairy, all
grains, legumes, refined sugars, moderate salt, vegetable oils, high fructose corn syrup, and packaged and
processed foods.
After personal successes and seeing our patients increasingly struggle
with weight, and obesity in many
cases, we wanted to create a program to help our patients lose weight
sustainably in a healthy way. At the
same time we wanted to feature chiropractic as a key component to the
challenge. This is what we developed.
Step #1: Walk the walk and talk
the talk! In his book Outliers, Malcolm
Gladwell states that an expert puts
in 10,000 hours of work and study
before they can truly be recognized
as an expert. We have read countless books, listened to thousands of
podcasts, read hundreds of blogs and
articles, and participated in dozens of
web based programs all regarding the
paleo lifestyle. But most importantly
we both have followed the paleo lifestyle for several years. It is our opinion
that this is the first crucial step to run
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With trial and error approach we
found that it is crucial to have patients sign a terms of agreement for
the challenge. This is not a legal
document, per se, but it outlines
what the participant can expect
from us and what we expect from
them. Some points that are included
in this are the dates that the challenge will run, the days they will be
scanned and weighed throughout the
challenge, the last day to opt out
and transfer their entry fee to the
next challenge, and other important
dates in a neat one page sheet. If
you would like to see the one we created please e-mail us at ndekoyer@
hotmail.com or [email protected].
Step #5: Weigh-ins and nervous
system scans should be performed
three times during the challenge. This
is a perfect place to describe the
scans we use and why we use
them. We use the Insight Subluxation
Station from the Chiropractic Leadership Alliance. It is our opinion that this
system is the easiest to use, most efficient, and most reliable spinal scanning unit. The three scans that are
completed for each patient are:
1. Thermography Scan
2. Surface EMG
3. Heart Rate Variability (HRV)
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deal of excitement right after your presentation. Be sure to get everyone’s
contact information including names,
numbers, and email addresses of those
who are interested before the end of
the evening. Begin your marketing for
the challenge the following day. Once
again we use weekly emails, Facebook
posts and event pages, flyers, large
poster in the waiting room, and an ad
in the paper. We charge a fair fee for
our challenge. We have found that if
participants don’t have some skin in
the game their motivation wanes. The
winner gets 50% of the money collected, while the second place finisher
gets their money back. The remaining
is used for our expenses. We print out
the appropriate number of Balanced
Bites Nutrition Guide, which is used as
a guidepost. We also set up a Facebook forum to answer questions for
the participants and offer recipes and
other advice throughout the challenge.
Finally, we offer grassfed whey protein
concentrate from mercola.com (as an
easy breakfast option) and a 15% discount on all our super foods we carry
in the office, to help them through the
challenge and to stimulate secondary
sales. The super foods we carry are
from Navitas Naturals and they include
hemp seeds, goji berries, chia seeds,
power snacks, cashews, and coconut
oil to name a few. Step #4: Create a terms of agreement that the participant signs.
NCMIC’s Examiner Provides Strategies
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consistent, successful 30 Day Paleo
Challenges. Who can anchor to an unanchored mind and in this instance an
unanchored body?
Step #2: Set a date for an Advanced Health Care Lecture on the
paleo diet. It should be one month
prior to the start of the challenge.
You have to set the foundation for
your patients. They need to know
the benefits, the why, and the how
of an ancestral lifestyle. Our lectures are on a Wednesday night at
7:00PM. They go for about one hour
with interaction during the presentation and time for questions at the
end. We finish with a detailed explanation of how the 30 Day Paleo
Challenge will work, how much it
costs, when we will begin, what they
get as participants, and what they
can expect from us. Our marketing
strategy is multilayered. We strongly
encourage our presentation to our
patient base through weekly emails,
a Facebook Event Page, regular Facebook posts, YouTube videos, small
flyers, and a large poster in our waiting room. We market to the public
through an ad in the local paper and
once again use Facebook. More recently we also have added a webinar
into the mix with great success.
Step #3: Set the date for the 30
Day Paleo Challenge. The challenge
is usually set for two weeks after the
presentation. You will have a great
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4
Back to Basics: Insurance
Claims Tracking
By Dr. Michael W. Goione – ANJC Insurance Consultant
I
n the modern chiropractic office,
insurance verification, claims submission, and payment processing
take a great deal of time and office
staff hours. Without a claims tracking
system in place, much of the work
performed by staff is either wasted
or duplicated. As with any office
procedure, there are many ways to
track claims. This article will discuss
the foundation of how to develop and
implement a basic claims tracking
system.
Claims tracking is a system in the
office that allows the staff to monitor the progress of all claims that are
submitted. With this system the staff
member would be able to quickly
reference whether a submitted claim
has been paid, processed, or is still
outstanding. The system should also
be able to track whether a claim was
paid and processed correctly.
There are many ways to develop
a tracking system and depending on
the technological ability of the staff,
they can be extremely sophisticated
or basic.
One of the simplest ways to develop a tracking system is to use the
batch reports from the electronic
claims clearinghouse. Most offices
are submitting claims electronically
in 2014. Usually claims are submitted in a bulk batch once per week.
Submitting claims daily does move
claims through the system more readily. However, sending claims daily will
increase the number of claims to be
processed. In effect possibly costing
more money due to increased staff
time processing multiple claims.
Claims sent less than once per week
may slow processing time and having
claims sitting unbilled in the system
can be wasteful.
After claims are submitted, the
clearinghouse will produce a report
back to the office detailing the
batch. This batch report will most
likely contain patient name, dates
of service, dollar amount, and insurance company. Placing this report in
a binder or folder is the first step in
tracking claims.
The second step is developing a
coding system to delineate the status
of the claim. For example, highlight
the correctly paid claim in green. A
claim processed but not complete
could be highlighted in yellow. A claim
resubmitted could be yellow. A corrected and properly paid claim could
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then be re-highlighted in green. In a
matter of weeks, a clear pattern of
claims will develop. An obvious problem would stand out if a claim had
no color coding. That claim would
need immediate attention. What
also happens with a system like this
is staff members will get a feel for
how long different carriers take to
process claims. As claim processing
patterns develop, staff time might be
saved by making unnecessary calls
to carriers. The staff can also place
notes on the claim line to reference
back to in the future.
There are still some carriers, PIP
for example, that still require paper
claims. Claims submitted to a secondary carrier often require paper
submission with the primary explanation of benefits. A similar system can
either be developed by paper or on an
Excel spreadsheet. It’s important to
remember that, unlike health insurance carriers, PIP carriers have a 60
day window to make payment. In our
office we contact the PIP carrier in
14 days to confirm their receipt of
the claim. Too many times office staff
wait the 60 days only to find out the
carrier never received the claim. So
it would be wise to create a column
in the system listing claim receipt
confirmation.
Healthcare has evolved into a
complicated and work intensive profession that requires a great deal of
staff hours to process claims in the
office. A claims tracking system is a
simple but highly efficient method of
monitoring all the work that went into
producing those claims.
15.5 mm
Before
4 mm
–––––––
Dr. Michael W. Goione currently practices in Red Bank, NJ. He is the Official
Team Chiropractor to the Monmouth
University Hawks and the Georgian
Court University Lions. Dr. Goione is
also an insurance consultant to the
ANJC and he sits on the Optum Health
Chiropractic Physician Advisory Panel.
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spine. Functional orthotics can help to restore balance and relieve this postural stress & strain.
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Donald DeFabio, DC, taught a free seminar
for ANJC members on September 11, 2014,
at the Cherry Hill Holiday Inn. As Chair of
ANJC’s Council on Rehabilitation and Physical Performance, Dr. DeFabio presented
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Start Here for
Daily Nutrition
2014 Fall Insurance Update
Continued from page 1
We have no reports yet heard
of any members not receiving the
proper payment on claims submitted
after July 16. There were some erroneous denials of 98943 prior to the
policy change even when the 98943
was properly appended with the -51
modifier per the policy at that time.
Unfortunately, these claims need
to be resubmitted without the -51
modifier to be paid properly. We have
heard of some cases where even
when a claim that was resubmitted
without the -51 modifier as requested was denied as a duplicate. This
is an error on their part. If you tried
to resubmit a bill with 98943 and
it was denied as a duplicate please
contact Matt Minnella at ANJC headquarters at [email protected].
Aetna/97140: As previously
reported, the ANJC filed a Declaratory Judgment action against Aetna
contesting their practice of uniformly
denying 97140 when billed with any
CMT (98940-98943) despite application of the 25 or 59 modifiers. Aetna, the ANJC, and our consultants have continued working on a potential multi-phase settlement agreement. Progress is still being made,
but the final product and agreements
are not finalized to date. This process
is taking a significant amount of
time. We are dedicating that time and
great resources to this matter as it is
one of great importance. We will continue to update membership as we
can. Information will remain limited
due to the confidential nature of the
legal proceedings.
Medicaid: The state of New Jersey
will soon be launching a three-year
Medicaid ACO (Accountable Care
Organization) Demonstration Project.
This pilot program is intended to explore new systems of care management, care coordination, evaluation,
and payment. The ACO’s are to be
organized by non-profit community
health outreach organizations that
serve large Medicaid populations.
Applications from these types of organizations were accepted through
this summer. Eight applications
have been received from the cities
of Camden, Newark, Trenton, New
Brunswick, the counties of Gloucester, Cumberland, Passaic, and the
Coastal Healthcare Coalition.
There is not tremendous participation in Medicaid as the fee schedule
only allows $6 for chiropractic services. However, as managed care
has come to be the main way Medicaid is delivered, the reimbursements
have actually gone up. They vary
from plan to plan and are still generally below Medicare rates though
they are notably higher than the $6
original fee schedule.
With the Medicaid expansion
under Obamacare, enrollment has
increased this year by approximately
300,000 over last year in the NJ
Medicaid program. This could be an
area of expanded patient base and
a new revenue stream for chiropractors. Also, this type of pilot program
could be the foundations of future,
broader government health programs. Either way, the ANJC intends
Department of Postgraduate Education
The New York Chiropractic College Department
of Postgraduate Education is proud to be affiliated
with the Association of New Jersey Chiropractors
as an educational sponsor.
to further explore the program and
make efforts to ensure chiropractic
inclusion.
Amerihealth: We had previously
reported that the ANJC made a
complaint to NJ DOBI in regards to
Amerihealth charging a $50 copayment for chiropractic services on
fully funded plans, which we believed
to be in violation of NJ law. Our understanding was that co-payments
were not to exceed 50% of the allowed amount for services rendered.
In many cases, these Amerihealth
co-payments did just that.
We received NJ DOBI’s official response and a greater understanding
of how DOBI determines a carriers’
compliance with these rules. DOBI
advised that the carrier’s obligation
is that “a network co-payment shall
be set so that the carrier insures
50% or more of the aggregate risk
for the services or supply to which
the co-payment is applied.” DOBI
further clarified to us how they calculate the aggregate risk. The calculation is not as simple as the allowed
amount is X and the co-pay is Y; is Y
less than 50% of X for this particular
bill? Instead, to determine whether a
co-payment is complaint, DOBI takes
all allowed amounts from all visits
paid by a carrier for a particular medical provider type and divides it by
the total number of visits billed under that provider type to determine
the aggregate (i.e., average) allowed
amount per visit. If the co-payment
is less than 50% of that average allowed amount per visit, then it is al-
lowable under the state regulations.
It is important to note that when
they are adding up the total allowed
amount this includes all services
rendered by that provider type, such
as E/M codes. Only diagnostics,
such as x-rays, are excluded.
In this particular case of a $50 copayment being applied to chiropractic services by Amerihealth, DOBI
obtained claims data from Amerihealth. They performed the formula
described above and determined
that the aggregate risk for these services (i.e., average allowed amount
per visit) was $100.89. Hence, the
$50 co-payment is less than 50%
and is allowable.
We expressed to DOBI that we
felt this number was erroneous, and
was higher than the actual average
allowed amount for chiropractic visits. They responded that this is what
the numbers showed but also noted
that when calculating this average
it was not only chiropractic claims
that were included. Other physical
medicine providers were included in
calculating this aggregate number.
DOBI advised they felt the other
provider types actually brought the
average down rather than up. At this
time we are investigating whether
average reimbursements for this
particular carrier, Amerihealth, are
higher for DCs vs. other physical
medicine providers and whether it is
appropriate for different providers,
even within physical medicine, to be
grouped together for these regulatory analyses.
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8
ANJC PLATINUM
SPONSORS DIRECTORY
9
ANJC PLATINUM SPONSORS DIRECTORY
SILVER SPONSORSHIP
ANJC Platinum Sponsors are trusted business partners who have supported ANJC for
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and their patients. These business partners meet the highest standards regarding quality of
products and services, and they are sensitive and responsive to the personal needs of our
members. ANJC Platinum Sponsors have a proven track record in assisting NJ chiropractors
with reaching their individual practice goals and in staying on the cutting edge of the health
and wellness revolution in their communities. For all they do for ANJC members, you owe it
to them to first take a look at their products and services before going elsewhere. Many offer substantial discounts and value-added services to ANJC members. Remember — when
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Billing/Coding & Collections
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offers consulting, training and a full range of
Billing/Collections services, which are tailored to
your needs. Also, we offer a verifications department which assists your office in obtaining maximum reimbursement, & handling contracts.
✦ MD On-Line • Tom Schweizer
888.499.5465 • www.mdon-line.com
[email protected]
Description: Provide clearinghouse services to
facilitate the electronic transfer of healthcare
transactions and information between providers
and payers.
✦ NJ PIP Pay Associates • Lori Blair
www.njpippay.com
Description: Our company bills and collects exclusively for Personal Injury Claims. Our costs are
extremely competitive and are based upon our
recovery.
X-Ray, Diagnostic Imaging Services & Equipment
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Description: LiteCure is a medical device company
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Dr. Bill Puglisi • 908.687.2552
[email protected]
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[email protected]
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✦ Upright MRI of Cherry Hill • Marge Beck
856.486.9000 • www.uprightmriofcherryhill.com
[email protected]
Description: At Upright MRI of Cherry Hill, patients
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bending or lying down to permit the best visualization
possible of their problem. Key Products: MRI Scans
Business/Financial Services
✦ C&A Financial Group • Robert Pendergist V.P.
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Description: A full service financial firm focused
on cash flow and quality of life. Key products and
services: Business succession planning, disability
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We also provide exit strategies in and around business ownership.
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Description: We are focused on developing and
delivering the exact combination of financial tools
that Chiropractors require for today’s comprehensive practice and their particular situation.
✦ Guardian Life Insurance Company
Anthony Campanile • 609.709.0041
[email protected]
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Description: Guardian Life Insurance Company
has been providing doctors with disability and life
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✦ M&T Bank• Jerome Baier
732-476-6078 • www.mtb.com
[email protected]
Description: We understand the importance of
building long-term relationships and community
involvement. It’s what we’ve been doing for over
155 years. When your practice succeeds, we all
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Donna Scallo • 732.922.6300 X 167
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Lesley Weiner • 973.890.0800 x 329
[email protected]
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✦ The Omar Group, CPA • Salim Omar, CPA
732.566.3660 • www.omargroupcpa.com
[email protected]
Description: Specializing in providing accounting
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Chiropractic Equipment/Supplies & Patient Education
✦ Back App • Todd D. Comer, DC
1.855.748.9355 • www.backapp.com
[email protected]
Description: We would like to introduce a new
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office work space. The chair was invented out of
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Description: Performance Health is the maker of
market-leading Biofreeze and Thera-Band products,
as well as other vital clinical brands. Key Products: Biofreeze and Thera-Band.
✦ ChiroMatic Sleep Systems • Debbie Carlitz
800.526.5116 • www.chiromatic.com
[email protected]
Description: Developed with help of chiropractors,
ChiroMatic mattresses provide ultra premium support and comfort.
✦ Chiropractic Leadership Alliance (CLA)
Sabrina Pelech • 800.285.2001 ext.130
www.subluxation.com • [email protected]
Description: CLA is focused on equipping chiropractors around the world with the profession’s best
selling technology, the Insight Subluxation Station
for patient assessment and education.
Description: Since 1997 Elite medical Specializes in
Providing Chiropractors and Surgeons with quality
spinal bracing, traction, electrotherapy products
assisting their patients on the road to recovery.
✦ Erchonia • Melissa Morningstar
214.544.2227 • www.erchonia.com
[email protected]
Description: Erchonia is the global leader in low
level laser healthcare applications. All Erchonia
lasers are proven safe and effective through independent clinical trials. Key product and service:
Low level laser therapy.
✦ Excellence Shock Wave Therapy
Denise Ashcraft • 856.769.8270
www.eswtusa.com • [email protected]
Description: Excellence Shock Wave Therapy
provides full service in-office ESWT, certification
training, and technician services. Offer ESWT with
no cost to your office.
✦ Foot Levelers • Kent Greenawalt
800.553.4860 • www.footlevelers.com
[email protected]
Description: Exclusive provider of custom-made Spinal Pelvic Stabilizers and other healthcare products.
✦ Harlan Health Products, Inc. • Harlan Pyes
800.345.1124 • www.harlanhealth.com
[email protected]
Description: We provide leading edge modalities
as well as the training and support so our customers attain the very best clinical outcomes. We
also provide tables, rehab equipment, and all the
supplies you need. Key products: Laser therapy,
Electric Stimulators, Full line of supplies.
✦ Haven Innovation • Sharon Swain
616.935.1040 • www.coxtable.com
[email protected]
Description: Haven Innovation is the manufacturer
of the Cox Table. The best just got better; introducing the Cox Model 8, the latest generation Cox
Table and the ultimate instrument for the hands on
professional. The re-engineered Model 8 is extremely robust and features enhancements for better caudal and cervical section balance, improved
tactile performance, expanded software and control options, and general aesthetic upgrades.
✦ Human Scale • Paul Levy
212.725.4749 • www.humanscale.com
[email protected]
Description: The premier designer and manufacturer of award-winning ergonomic products, including
seating, monitor arms, keyboard supports, heightadjustable tables and more.
✦ Levinson Medical Specialties • Charles Levinson
732.928.4600 • www.charleslevinson.com
[email protected]
Description: Suppliers of physical therapy equipment, supplies, chiropractic tables, service, serving the profession for nearly 50 years. Key Products: Physical therapy equipment, Chiropractic
tables and service.
✦ Mally Enterprises • PJ Cook
www.fromthedeskofdrmitchmally.com
Description: Mally Enterprises founded by Dr.
Mitch Mally supports informational and diagnostic extremity manipulation techniques, case and
practice management, biomechanics, radiology,
physiotherapy and rehabilitation programs with
state-of-the-art DVD’s and books plus hands on
seminars!
✦ ROCKTAPE • Alyson Evans
1.408.213.9550 • [email protected]
www.rocktape.com
Description: Stronger, stretchier and stickierRocktape helps your patients “go stronger, longer”
using hi-tech textiles, aerospace adhesives and
taping applications based on improving movement.
Kinesiology tape and training - redefined. Check
out the fastest growing kinesiology taping company in the world.
✦ ScripHessco • Kevin Baltzer
www.scriphessco.com
Description: ScripHessco has been a trusted
resource to health care practitioners for over 40
years. ScripHessco features over 10,000 products
and is the largest distributor of reconditioned
tables. Key Products include: Electrotherapy Equipment, new and used adjusting tables and traction,
and chiropractic supplies.
✦ Troluna • Christina Troha
www.troluna.com
Description: TrolunaMedical has the superior edge
when it comes to the latest, high quality chiropractic products and proven practice marketing
techniques. “MOVING YOU FORWARD.”
Nutrition & Wellness
✦ Anabolic Laboratories • Bob Rosenberg
Clinical Consultant • 609.239.0358
www.anaboliclabs.com • [email protected]
Description: Anabolic Laboratories, founded in 1924,
is an active pharmaceutical manufacturer that
specializes in the standardization and concentration
of natural ingredients to assist with patient management, healing and pain relief. Available exclusively
through healthcare professionals. Key Products:
Nutritional Supplements for Pain and Inflammation,
Nutritional Supplements for general wellness, and
condition specific Nutritional Supplements.
✦ Biotics Research • Debra Fish
1.800.231.5777 Ex 140 • www.bioticsresearch.com
[email protected]
Description: Biotics Research Corporation was
formed in 1975 and from day one the foundation
has been “Innovation and Quality.” Our goals remain unchanged - innovative ideas, carefully researched concepts, and product development with
advanced analytical and manufacturing techniques
to develop and produce nutritional products of
superior quality and effectiveness available exclusively to healthcare professionals.
✦ Health Centers of the Future
Warren Philips Practice Building
www.healthcentersofthefuture.com
Description: Our events infuse cutting edge testing
and support protocols for common conditions. The
systems you learn can be applied in your office the
next day.
✦ Nordic Naturals
Judi Jones – Senior Sales Consultant
P: 800.662.2544 x30 • M: 610.780.5706
www.nordicnaturals.com
[email protected]
Description: Omega oils have become an essential
component of every health protocol. Because they
are in high demand, many professional brands have
added omega-3 fish oil products as a line extension.
That’s where Nordic Naturals differs. Since 1995,
omega-3 nutrition has remained the passion and
focus of Nordic Naturals. As a brand that specializes
in one thing, we are uniquely positioned to partner
with you in sharing the power of omega-3s with your
patients and community.
✦ Nutritional Frontiers • Jamie Dorley
412.922.2566 • www.nutrionalfrontiers.com
[email protected]
Description: Our Mission is to create, develop and
provide safe, effective therapeutic natural solutions
and educational programs to chiropractors and their
patients with excellent quality, integrity and service.
✦ Prevention Pharmaceuticals • Terrence Tormey
267-247-5448 • www.omax3.com
[email protected]
Description: The makers of OMAX3®, which delivers more than 91% pure Omega-3. Formulated to
achieve a balance of EPA:DHA (4:1) for a proper
inflammatory response.
✦ Prezacor®, Inc. • James Pachence
www.prezacor.com & www.energeze.com
Description: Prezacor®, Inc. is a medical products
company focused on developing and marketing an
innovative pain management technology. The initial
Prezacor Energeze® product is a simple to use extended wear pain relief patch.
✦ Standard Process Inc.® • Bruce Poritzky
www.standardprocess.com
Description: For more than 80 years, Standard
Process, headquartered in Palmyra, Wis., has provided health care professionals with high-quality,
nutritional whole food supplements. Standard Process offers more than 300 products through three
product lines: Standard Process whole food supplements, Standard Process Veterinary Formulas™,
and MediHerb® herbal supplements. The products
are available only through health care professionals.
✦ Take Shape for Life • John Dowling, DC
www.createwellbeing.com
Description: The #1 Doctor recommended, clinically
proven and effective optimal health program in the
country for fast, permanent weight loss and medication use reduction.
✦ XYMOGEN • Richard Malkin
Senior Functional Medicine Consultant
www.xymogen.com • 1.800.647.6100
Description: Wellness and Nutrition Integration
Programs-Clinical Research, Education and Product
Development- 22 Years Proudly Serving New Jersey
Practitioners
Laboratory Services
✦ Healthlink Diagnostic Laboratories
Mike Toader • 609.508.2010
[email protected] • www.hldlabs.com
Description: Healthlink Diagnostic Laboratories is a
state of the art CLIA certified diagnostic laboratory
offering a broad spectrum of lab tests. HLD utilizes
the most advanced technologies to help healthcare
providers and patients detect hormonal and nutritional imbalances, cardiometabolic risks, vitamin D
deficiency, fertility and thyroid disorders through accurate, convenient and innovative laboratory testing.
HLD is a preferred ANJC platinum sponsor offering
very competitive prices.
✦ Parkway Clinical Laboratories Inc.
Carolyn Bonner • 800.327.2764
[email protected]
www.parkwayclinical.com
Description: Parkway Clinical Laboratories (PCL) is
an emerging national CLIA-certified clinical reference laboratory performing routine and esoteric
diagnostic testing, with a focus on supporting
anti-aging and wellness providers in the initial diagnosis and ongoing care of patients suffering from
complex chronic diseases, nutritional deficiencies
and advanced cardiovascular risk. PCL is proud to
be the preferred reference lab and platinum sponsor
of ANJC. Through our broad menu of services, we
provide personalized and customized solutions to
ANJC members, including around the clock ambulatory specimen collection, home draw service and a
discounted fee schedule.
Consultants/Practice Management
✦ Beshert • Michelle Simon
844.237.4378 • www.beshert.net
[email protected]
Description: Beshert is a unique case management company that caters to patients involved in
no-fault, worker’s compensation, and slip-and-fall
accidents as well as patients with sport’s injuries,
out-of-network insurances, and lien/cash cases.
Beshert is a scheduling service that is equivalent
to a medical concierge for patients, attorneys and
doctors. Beshert’s motto: your network is your net
worth.
✦ Breakthrough Coaching • Debbie Olinger
303.451.9123 • www.mybreakthrough.com
[email protected]
Description: Chiropractic Consulting services.
✦ ChiroHealth USA • Ray Foxworth, DC
888.719.9990 • www.chirohealthusa.com
[email protected]
Description: Want to practice with peace of mind?
Our network model eliminates worry about dual
fee schedules, improper time of service discounts
and OIG violations for offering discounts on noncovered services.
✦ KMC University • Kathy Mills Chang, MCS-P
1-855-TEAM KMC • www.kmcuniversity.com
[email protected]
Description: KMC University provides Chiropractors with tools and solutions to improve and
maintain the reimbursement and compliance
performance of their practice, delivered with
maximum effectiveness, innovation, and ease of
implementation.
✦ Positive Impact Coaching and Consulting
Services • Dr. Michelle Turk
576.921.6116 • www.positiveimpactcoaching.com
[email protected]
Description: Positive Impact Coaching is a company focused on helping you grow towards professional success and a balanced personal life. Via
coaching and practice development services, we’ll
help you define and attain YOUR “point of positive
Impact.” We also offer dynamic speaking engagements for groups and organizations on a variety of
practice building and personal growth topics.
✦ Target Coding • Marty Kotlar
800.270.7044 • www.targetcoding.com
[email protected]
Description: Experts in helping chiropractors
document properly, get paid properly and in audit
prevention.
✦ The Rothenberg Group • Jess Rothenberg, DC
973.694.1981 • www.jrapip.com
[email protected]
Description: Assist doctors with collection services and advice for auto accident patients.
Continued on next page
ANJC Disclaimer: The company or persons providing the within goods or services, though an ANJC sponsoring entity or individual, is an independent organization of the ANJC and its structure, views, techniques, materials and methods are not authorized, reviewed for accuracy, or otherwise approved or endorsed by the
A.N.J.C. The content of the materials and services has not been reviewed or approved by the ANJC for accuracy, completeness or compliance with the various governing statues, regulations, ordinances, or other controlling laws and should not be viewed as a direct or indirect endorsement or verification of the accuracy or
legality of the goods, services, or delivery model. The application and impact of laws can vary widely based on the specific facts involved. Given the changing nature of laws, rules and regulations the A.N.J.C. does not engage in rendering legal, accounting, tax, or other professional advice and services. As such, the sponsor’s association with the ANJC should not be used as a substitute for consultation with professional accounting, tax, legal or other competent advisers. Before making any decision or taking any action, you should consult an appropriately trained professional prior to utilizing the sponsor’s goods or services.
✦ TLC 4 Superteams • Phyllis Bliem
215-657-1701 • www.TLC4Superteams.com
[email protected]
Description: TLC is the coaching company
where everyone’s voice matters. A community
standing strong for chiropractic, shared experiences and hopes – raising servant leaders for
future generations.
Medical/Clinical Services
✦ Advanced Center for Special Surgery –
Montville Health • Dr. David Saint
201.391.8282 • www.montvalehealth.com
[email protected]
Description: A freestanding state of the art
licensed multi-specialty ambulatory surgical
center offering a wide range of out-patient
surgical procedures
✦ Alliance Medical Surgical Group
Sean Hajo • 973.650.4688
[email protected]
Description: Interventional pain management
and Neurodiagnostic services. Key product:
Interventional Pain Management, Neurodiagnostic Services and Orthopedic and Orthodontic Surgery.
✦ Allied Neurology & Interventional Pain Practice
Jack Koczarski • 201.894.1313
[email protected]
Description: Interventional pain management
is the discipline of medicine devoted to the diagnosis and treatment of pair related disorders
principally with the application of interventional
techniques in managing subacute, chronic, persistent and intractable pain, independently or in
connection with other modalities of treatment.
✦ Bergen Pain Management • Lucy Noureldin
Description: Specializes in the treatment/
management of neck and back pain resulting
from a variety of causes including work-related
injuries or automobile-related trauma. We offer
treatments from the simplest interventional
pain management epidural injections to more
advanced techniques in pain management
procedures.
✦ Cancer Treatment Centers of America
Rocco DeCicco • 215.537.7503
www.cancercenter.com
[email protected]
Description: Cancer Treatment Centers of
America (CTCA) provides a comprehensive,
patient-centered treatment model that fully
integrates traditional, state-of-the-art medical
treatments with scientifically supported complementary therapies such as nutrition, naturopathic and chiropractic medicine, psychological
counseling, physical therapy and spiritual
support to meet the special, whole-person
needs of advanced-stage cancer patients. With
a network of cancer treatment hospitals and
community oncology programs in Philadelphia,
Phoenix, Suburban Chicago, Tulsa and Seattle,
CTCA encourages patients and their families
to participate in treatment decisions with its
Patient Empowered Care model.
✦ Hackensack Injury & Wellness Center
Damon J. Noto, MD • 201.288.7246
www.spineandjointcenter.com.com
[email protected]
Description: A health clinic focusing on pain
management and minimally invasive procedures
to help patients with orthopedic and spinal
disorders.
✦ Union & Raritan Anesthesia Associates and
Pain Management • Maria Sanagustin
www.unionspinepain.com
Description: Union Anesthesia & Pain Management specializes in Laser Spine surgery- our
physicians cohesively work together to provide
you with effective pain management and comfortable experience.
Insurance Services/Risk Management
✦ ChiroHealth USA • Ray Foxworth, FICC, MCS-P
1.888.719.9990 • www.chirohealthusa.com
[email protected]
Description: ChiroHealthUSA is a Discount
Medical Plan Organization that provides a
simple solution when it comes to offering legal
network based discounts for cash, underinsured and “out of network” patients.
✦ John C. Crilly Agency • John C. Crilly
732.747.7947 • www.crilly.biz
[email protected]
Description: Recipient of ANJC ’05 award for
Outstanding Effort and Commitment, we offer
the following insurances: Professional Liability
Malpractice Insurance, business owners, employee benefits, employment practices liability,
life, disability, long term care, workers compensation and Health Insurance.
✦ Medical Protective Company • Julie Nycum
www.medpro.com/chiropractors
Description: MedPro’s unmatched A++ A.M.
Best rating and 114 years of experience defending 100,000+ malpractice claims make it
the clear choice for chiropractic professional
liability insurance.
✦ NCMIC • Mike Whitmer
www.ncmic.com
Description: “We Take Care of Our Own” NCMIC has grown to become the largest provider
of Chiropractic malpractice insurance in the
nation, covering more than 37,000 DCs. Key
Products: Chiropractic Malpractice Insurance,
Equipment Financing and Merchant Processing.
✦ OUM Chiropractor Program • Tamara Jackson
www.oumchiropractor.com
Description: OUM’s extensive malpractice
insurance policies offer broad protection that
cover the range of professional chiropractic
services you provide within your state’s defined
scope of practice.
Key Products: Malpractice Insurance
Legal Services
✦ Brach Eichler • 973.403.3103
[email protected] • www.bracheichler.com
Description: Brach Eichler LLC is a full-service
law firm with offices in Roseland, N.J. and New
York City. The firm’s core practice groups are
health law, real estate, litigation and trusts &
estate, and through these groups they cover
many key practice areas such as criminal
defense & government investigations, employment law, business & transactions, family law
and intellectual property. With more than 60
attorneys, the Firm has frequently been recognized by clients and peers alike in Chambers
USA, Best Lawyers in America, and New Jersey
Super Lawyers. Visit www.bracheichler.com.
✦ Davis, Saperstein & Salomon, PC
Garry Salomon • 201.907.5000
[email protected] • www.dsslaw.com
Description: Davis, Saperstein & Salomon is a
plaintiffs personal injury law firm representing
injured clients for over 25 years. Its twelve
attorneys have built solid relationships with the
Chiropractic community and welcomes their
referrals.
✦ Law Office of E. Vicki Arians, LLC
E. Vicki Arians, Esq. • 973.513.9980
[email protected]
Description: Law firm concentrating in PIP
arbitration, insurance company audits and
healthcare.
✦ Law Offices of James C. DeZao, P.A.
Jim DeZao, Jr. • 973.808.8900
[email protected] • www.dezaolaw.com
Description: DeZao Law is a full service plaintiff’s firm that is committed to excellence and
100% client satisfaction.
✦ Law Offices Of Jeffrey Randolph
Jeff Randolph, Esq.
Description: Specialize in healthcare law and
complex litigation.
✦ Law Offices of Sean T. Hagan, LLC
Sean T. Hagan
www.njpiprecovery.com
Description: Specializes in NJ PIP Recovery and
Arbitrations at no costs to you, practice management consultation and handles personal
injury cases throughout all of New Jersey.
Software – Practice Management
✦ PayDC • David Klein
www.paydc.com
Description: PayDC is a fully integrated EHR
solution designed to manage your practice and
the entire course of patient care.
✦ Quick Notes • Ken Schenley
800.899.2468 • www.qnotes.com
[email protected]
Description: Easy-to-Use solutions for Portable
SOAP Notes and Electronic Medical Records
(EMR). Fully-compliant charting on a PDA or
iPad. Templates and Voice Recognition tools.
Quick Notes has been supporting Chiropractic
in New Jersey for 23 years.
✦ Simple Chiro Software • Kurt Strecker, DC
860.395.4424 •[email protected]
www.simplechirosoftware.net
Description: Simple Chiro Software allows
you to quickly create concise patient records
including history and physical examinations,
SOAP notes, and more. Gather demographics
and medical history using a kiosk to expedite
patient flow while keeping complete and accurate charts. Drastically reduce labor costs.
Customize the system for the way you practice.
Automatically track and restock inventory. Effectively market and grow your business.
Compliance
✦ HIPAA Secure Now! • Patrick Felicetta
877.275.4545 x801• [email protected]
www.hipaasecurenow.com
Description: Provides products and services
to help healthcare entities comply with HIPAA.
Includes the required Security Risk Assessment, 18 Policies and Procedures and Training
delivered via Compliance Portal. An annual
Subscription provides an updated Risk Assessment and $100,000 Financial Protection from
HIPAA fines and breach-related expenses.
✦ MedSafe • Wiks Moffat
[email protected] • 800.255.6387 x154
www.medsafe.com
Description: With our program, all compliance
documents and policies and procedures are
completed for the practice for HIPAA, Medicare Fraud Waste & Abuse and OSHA which
will give you the “Total Compliance Solution”.
We are not just “canned training” and you will
never be left with a time consuming “to do
list” of interpreting the laws and writing up
your program. Most importantly, we include
support to keep the program current and you
can contact our certified compliance consultants anytime you have a question or are
being audited. Online trainings include HIPAA,
Medicare Fraud Waste & Abuse, OSHA and
Discrimination & Harassment.
DIRECTORY
ANJC’s Nutrition Education Council and Silver Sponsors work together to educate members on the latest nutritional research, protocols and nutritional supplements. NEC offers
Silver Sponsors a unique opportunity to focus on ANJC member doctors who have shown
a strong interest in incorporating nutrition into their practices. Dr. Christopher Bump,
NEC chair states, “The vision and mission of the NEC is to develop and promote the NEC
as the preeminent nutritional education organization within the Chiropractic profession,
and to facilitate and organize access to clinical nutrition education and resources.”
Anabolic Laboratories
Bob Rosenberg • 609.239.0358
[email protected]
www.anaboliclabs.com
Description: Highest quality manufacturer
of general wellness and condition specific
nutritional supplements. Key Products:
Pain and Inflammation Supplements,
Pharmaceutical GMP’s and Highest Quality Products in the Industry.
Cancer Treatment Centers of America
Rocco DeCicco • 215.537.7503
[email protected]
www.cancercenter.com
Description: Cancer Treatment Centers of
America (CTCA) provides a comprehensive,
patient-centered treatment model that fully
integrates traditional, state-of-the-art medical treatments with scientifically supported
complementary therapies such as nutrition,
naturopathic and chiropractic medicine,
psychological counseling, physical therapy
and spiritual support to meet the special,
whole-person needs of advanced-stage
cancer patients. With a network of cancer
treatment hospitals and community oncology programs in Philadelphia, Phoenix,
Suburban Chicago, Tulsa and Seattle, CTCA
encourages patients and their families to
participate in treatment decisions with its
Patient Empowered Care model.
Deflame.com
Dr. David Seaman • 855.333.5263
www.deflame.com • [email protected]
Description: Deflame.com, the originator
of the “anti-inflammatory diet,” provides
up-to-date information about how diet and
nutritional supplements reduce chronic
inflammation and promote health.
Designs for Health
Sam Gossett • 1.800.847.8302
www.designsforhealth.com
[email protected]
Description: For over 24 years, we have
been the health care professional’s trusted source for research-backed nutritional
products of superior quality, clinical education and practice development programs.
Health Centers of the Future
Warren Philips • 888.600.0642
[email protected]
www.healthcentersofthefuture.com
Description: Our events infuse cutting
edge testing and support protocols for
common conditions. The systems you
learn can be applied in your office the
next day.
Healthlink Diagnostic Laboratories
Mike Toader • 609.508.2010
[email protected] • www.hldlabs.com Description: Healthlink Diagnostic
Laboratories is a state of the art CLIA
certified diagnostic laboratory offering
a broad spectrum of lab tests. HLD utilizes the most advanced technologies to
help healthcare providers and patients
detect hormonal and nutritional imbalances, cardiometabolic risks, vitamin D
deficiency, fertility and thyroid disorders
through accurate, convenient and innovative laboratory testing. HLD is a
preferred ANJC platinum sponsor offering
very competitive prices.
Morgan Medical Group
Ian Gelenter • 973.349.2806
[email protected]
wwwhcpscanner.com, password: login123
Description: Morgan Medical Group
specializes in advanced Anti-Aging
technologies that help improve patient
outcomes and wellness in a measurable way. Key Products include: The
Pharmanex Biophotonic Anti-Oxidant
Scanner; and Pharmanex TR90 Genetic
Based Weight Loss System.
NeuroScience
Pat Dorsey • 732.766.1884
[email protected]
www.neuroscienceinc.com
Description: NeuroScience, Inc. is a research-driven company committed to improving human health through a deep understanding of the interconnectedness of
the neurological, endocrine, and immune
system. Key products and services: Food
Sensitive Testing, Neuro-Endo-Immune
Nutrition Program, GI Repair System.
Nutritional Frontiers
Jamie Dorley • 412.922.2566
[email protected]
www.nutrionalfrontiers.com
Description: Our Mission is to create, develop and provide safe, effective therapeutic
natural solutions and educational programs
to chiropractors and their patients with excellent quality, integrity and service.
Osteo Naturals, LLC
Dr. Keith McCormick • 413.253.9777
www.osteonaturals.com
[email protected]
Description: Osteo Naturals, LLC is an online nutritional supplement retail company
that sells strategically formulated products designed to help maintain or improve
bone health. Our mission is to provide effective natural solutions to bone loss.
Parkway Clinical Laboratories Inc.
Naveed Ashfaq • 609.865.3266
[email protected]
www.parkwayclinical.com
Description: Parkway Clinical Laboratories (PCL) is an emerging national CLIAcertified clinical reference laboratory performing routine and esoteric diagnostic
testing, with a focus on supporting antiaging and wellness providers in the initial
diagnosis and ongoing care of patients
suffering from complex chronic diseases,
nutritional deficiencies and advanced
cardiovascular risk. PCL is proud to be
the preferred reference lab and platinum
sponsor of ANJC. Through our broad menu
of services, we provide personalized and
customized solutions to ANJC members,
including around the clock ambulatory
specimen collection, home draw service
and a discounted fee schedule.
Standard Process
Bruce Poritzsky • 518.226.0197
[email protected]
www.standardprocess.com
Description: For more than 80 years, Standard Process headquarters in Palmyra Wi
has provided health care professionals
with high-quality, nutritional whole food
supplements. Key Products and Services:
Supplements-whole food based, Herbal
Supplements, Education.
XYMOGEN
Richard Malkin • Senior Functional
Medicine Consultant • 908-310-7333
1.800.647.6100
[email protected]
www.xymogen.com
Description: Wellness and Nutrition Integration Programs-Clinical Research, Education and Product Development- 22 Years
Proudly Serving New Jersey Practitioners.
Y
10
Their Problem
Isn’t Your
Problem
EASE
O
ne of the occupational hazards of being a chiropractor
is the inability or unwillingness to establish and recognize clear
boundaries in the doctor/patient
relationship.
The frequent result is chiropractors
who care too much about what a patient does, what a patient thinks, and
more importantly, how quickly the patient experiences relief. The end stage
of this boundary-busting pathology is a
form of debilitating burnout. Just prior
to that, it’s the mistaken notion that to
be a successful chiropractor you must
be capable of relieving the patient’s
symptoms. And hurry up already!
“You bet I have to relieve their symptoms! If I don’t, they don’t come back.”
1
3/28/14
Q: What are the basic requirements to file a Medical Necessity appeal on unpaid claims in New Jersey?
The NJ Department of Banking
and Insurance Independent Health
Care Appeals Program (IHCAP) provides a mechanism to file appeals
on fully funded claims only where
the claim is denied on medical necessity grounds. Fully funded plans
only! Check status on verification of
insurance and Horizon prefix chart.
There is no minimum amount at issue to file such an appeal and your
patient must sign DOBI consent form
to release their medical information
and to permit you to appeal and file
for external review. You must do two
internal appeals using the NJDOBI
11:05 AM
Maximum Omega-3
Over 91% ultra-pure essential omega-3
Most Fish and Krill Oil products provide sub-therapeutic dosages of omega-3 in large, often rancid softgels.
They provide low levels of omega-3, frequently at exceptionally high prices.
Superior anti-inflammatory formula
Thereapeutic 1.5 gram dose of omega-3 in just
two 850 mg softgels.
High purity and blister packed for freshness
Easy to swallow with no odor or reflux
Patented and clinically studied 4:1 EPA:DHA ratio
Shown to safely and effectively manage
cholesterol, and lower triglycerides without
raising LDL.*
Designed to support a proper inflammatory response
Omax3® Ultra-Pure was specifically formulated by physicians affiliated
with Yale University to achieve the optimal balance of eicosapentaenoic
acid (EPA) and docosahexaenoic acid (DHA) in order to deliver anti-inflammatory
benefits. The patented 4:1 EPA:DHA ratio in omax3® Ultra-Pure is preferred
because it’s been shown to significantly inhibit key pro-inflammatory cytokines
better than other ratios of EPA and DHA.*
* Data on File Prevention Pharmaceuticals
Because your patients deserve better!
Learn More at omax3hcp.com
888-677-5453
© 2014 Prevention Consumer Health Products™ a division
of Prevention Pharmaceuticals™, New Haven, CT.
By Dr. Richard C. Healy
- ANJC Medicare Consultant
I
Really? The problem in most practices is patients who don’t come
back after they get relief!
So to recap: We’re afraid patients
will leave if symptomatic improvement isn’t quick. And we’re afraid
patients will leave once they get
symptomatic improvement.
Wow. Sounds like a lose/lose
proposition! Let’s explore the underpinnings of this unhelpful belief.
A patient’s headache or low
back pain or whatever it is that has
brought them to your practice is simply a way their body is attempting
to communicate with its owner. Like
the proverbial check engine light, the
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appeal form and then can file for an
external review with an NJDOBI Independent Utilization Review Organization (IURO) within four months of the
denial of your second level internal
appeal. The IURO external appeal
requires a $25 filing fee and is binding on all parties.
Q: What are the basic requirements
to file a Non-Medical Necessity appeal on unpaid claims in New Jersey?
The NJ Department of Banking
and Insurance Program for Independent Claim Payment Arbitration (PICPA) Program provides a mechanism
to file appeals on fully funded claims
only where the claim is denied on
non-medical necessity grounds (i.e.,
underpayment, coding issues). You
must file one internal appeal with
the insurer using the NJDOBI appeal
form within 90 days of the receipt
of the EOB. If the internal appeal is
denied, you can then file for a major
medical arbitration with Maximus,
Inc., the company that administers
appeals for the state within 90 days
of the denial of your internal appeal.
To do so, there must be at least
$1,000 outstanding, though you
can aggregate claims. Your patient
must sign a HIPAA consent form to
release their medical information.
There is a $210 filing fee that you
will not get back and there is no attorney’s fee award as there is in PIP
arbitrations. A decision should be
issued within 30 days of the closing of the record and the decision is
binding on both parties. If you win
the arbitration, you can be awarded
12% interest.
Q: How do I appeal self-funded
claims if I cannot follow the New
Jersey Department of Banking and
Insurance appeal processes?
Self-funded claims cannot be appealed through the NJDOBI IHCAP or
PCPA appeal process as the federal
ERISA law pre-empts these regulatory provisions. For self-funded claims,
your only avenue of appeal is to file
an ERISA appeal on both medical
necessity and non-medical necessity
appeals. To do so, your patient must
sign an ERISA-specific Assignment
of Benefits form to permit you to
appeal and potentially file suit. You
must do at least one internal appeal
within 180 days of denial. There is
no specific mandatory form but each
plan may have a different number
of internal appeals required but the
plan cannot require more than two
internal appeals. Thus, to be safe,
attempt two internal appeals. The
appeal decision should be issued
by the carrier in 30 days and it is a
good idea to request a copy of the
patient’s Summary Plan Description (SPD), which has all terms of
coverage, including how to exhaust
all internal appeals. There is a statutory penalty imposed on insurers of
$110/day if they don’t provide the
SPD in 30 days. If all internal appeals are exhausted and denied, you
can file an ERISA Section 502(A)
lawsuit in federal court to compel
payment.
have a patient with Railroad Medicare and Palmetto GBA requested
documentation for the 98941
service. Why would they do this after
the second visit?
A: Palmetto GBA began a widespread pre-payment review of chiropractic services submitted with CPT
codes 98940 and 98941 along with
the HCPCS modifier AT.
Q: How long do I have to submit
the requested documentation?
A: Providers must respond no later
than 30 days from the date of the Additional Documentation Request
(ADR) letter.
Q: What happens if I do not respond to the request for additional
documentation?
A: If Palmetto GBA does not receive your documentation within
45 days of the date on the ADR letter, the claim will automatically be
denied.
Q: Does RR Medicare require an
ABN form?
A: An ABN should only be issued if
the provider believes that Medicare
may not cover a service because it is
not medically reasonable and necessary, or if the service is statutorily
excluded from Medicare coverage.
Q: What is one of the major reasons for a denial by RR Medicare?
A: Insufficient documentation is a
key reason for denial. In many instances, it centers around treatment goals.
Documentation of the initial evaluation must provide a clear description
of the mechanism of injury, how it negatively impacts baseline function, and
establish a clear plan of treatment.
The treatment plan must include recommended frequency and duration of
visits, specific goals, and objective
measures to evaluate treatment effectiveness. The most commonly missing
elements from the treatment plan are
specific, measurable goals.
When developing goals at the initial visit, it is essential to identify the
functional problem that chiropractic
treatment is attempting to correct.
Is pain the only problem identified by
the patient? How does that pain affect the patient’s daily activities?
It is imperative to then establish a
baseline for that problem and set a
goal that is individualized to the patient’s needs.
For example, a patient presents
with pain at a level of a nine on the
Visual Analog Scale (VAS). Given the
patient’s history, functional assessment, current limitations, et cetera, it
is reasonable to expect that pain can
be reduced to a three through treatment. Your goal becomes to reduce
pain from nine to three on the VAS.
Another good example is a patient
that presents with the ability to stand
for only 20 minutes due to pain.
Throughout the course of treatment,
the patient will be able to stand for
longer periods of time. Based on the
patient’s history and your assessment, an acceptable goal would be
for the patient to be able to stand for
more than an hour without pain.
Progress towards those specific
goals must be addressed at each
subsequent visit using objective,
rather than conclusory terms. In the
examples listed above, the VAS pain
scale and time are objective measures that will show progress towards
specific goals.
11
Insurance
Medicare
LEGAL
By William D. Esteb
By David Klein, CPC, CHC
Q: How do I bill for education and
instruction on patient home exercises and home injury management?
The code to use depends on the
instruction that is provided. For example, if you are showing the patient
how to do exercises to increase
range of motion, and you spend at
least 8 minutes (based on Medicare
guidelines) one-on-one instructing
the patient on these exercises, then
you would bill CPT 97110: therapeutic exercise one or more areas, each
15 minutes; therapeutic exercises
to develop strength and endurance,
range of motion and flexibility. However if you are instructing the patient
on how to manage their injury at
home so they don’t re-aggravate (e.g. for a hot disc) then you would
bill CPT 97535: Self-care/home management training (eg, activities of
daily living (ADL) and compensatory
training, meal preparation, safety
procedures, and instructions in use of
assistive technology devices/adaptive equipment) direct one-on-one
contact by provider, each 15 minutes.
Q: What codes can I use when I
give a patient a cold/warm wrap for
home use?
Prior to 2011 providers were supposed to bill E0238 (hot pack) and
E0230 (cold pack) when issuing for
home use. However in 2011, both of
these codes were deleted and a new
code was created. The new code for
these products is A9273: Hot water
bottle, ice cap or collar, heat and/or
cold wrap, any type.
Q. I am a non-participating provider for Medicare; do I have the same
documentation requirements as a
participating provider does?
Chiropractic care has documentation requirements. The participating
status of the provider is irrelevant
to the documentation requirements.
Specific details regarding documentation requirements are in the Medicare
Benefit Policy Manual (Chapter 15,
Sections 30.5 and 240) at: http://
www.cms.gov/Regulations-andGuidance/Guidance/Manuals/
downloads/bp102c15.pdf
MLN Matters Article, “Misinformation
on Chiropractic Services.”
Association of New Jersey Chiropractors
(code: VA)
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12
Make Patient Balances a
Thing of the Past
13
Not “Just” the CA
By Kathy Mills Chang, MCS-P
By Abbie Miller, MCS-P
A
re you tired of sending out
statements every month that
get ignored? Making endless
calls trying to collect from patients?
Maybe the answer lies at your front
desk or with your office procedures.
With proper third-party verification processes, sound financial policies, and
automated payment options, it’s easier
than ever to manage patient financial
matters and collect more money.
From the very first phone call a patient makes to schedule an appointment with your office, you must set
the tone for how you handle finances.
When getting personal data over
the phone, be sure to ask if there is
a third-party payer that may be assisting with a portion of the financial
responsibilities for care. This not only
tells the patient that your office is
efficient and proactive, but also that
care at your office has value and you
expect to be paid for the services.
When you collect any third-party
insurance information over the
phone, you can verify the coverage
and determine the patient responsibility for the first visit before the
patient ever sets foot in your office.
When the patient comes in, it’s essential that you project confidence
when telling the patient what they
owe at the end of the first visit, and
that you collect their portion before
they leave your office. Letting them
leave that impression-setting first
visit without paying implies that you
have haphazard collections procedures and don’t really care if you get
paid or not.
The time between the initial exam
visit and the report of findings, which
is usually done on the second visit,
is used to take the doctor’s treatment plan recommendations and the
insurance verification information to
come up with an estimated cost of
care. At this point, the only number
the patient usually cares about is the
amount for which they are personally
responsible. Using the best information you have, come up with the most
accurate estimate possible and create some monthly payment options.
Keeping that monthly payment affordable is key to a patient accepting
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care in your office—which usually
means keeping it to somewhere
between $150-$200 per month. If
you listen carefully, however, the
patient will usually tell you what
their budget will allow.
If you must stretch payments
beyond the active care portion of
treatment, go ahead and include
monthly wellness care in your total
for as many months as you need
the payments to cover. Since you
now have a payment everyone can
agree on, the next vital step in your
collection process is to automate
those monthly payments using a
form of auto-debit withdrawals from
a credit card, debit card, checking
account, or savings account.
In those situations where a patient may not be within an active
episode of care, but is coming in
on a short-term treatment basis,
it would be appropriate to verify
applicable insurance coverage, if
any, and then have a conversation
with the patient to clarify their
responsibility—and to get them to
acknowledge this in writing. In this
era of large copays and even larger
deductibles, the patient will most
likely be paying for the majority of
the care and that can be handled
at the time of service.
When finances are handled properly at the beginning of the doctorpatient relationship, this eliminates
the need for a patient to carry a
balance and, therefore, eliminates
the need for monthly statements.
A proper Office Financial Policy
should be established as part
of your compliance program and
should address the multiple types
of patient financial situations. The
patient reads and signs this before
ever going back to see the doctor.
When policies are established and
addressed openly and in writing,
there is no need for negotiations
regarding collections procedures or
hardship situations.
The most successful offices
have clear procedures for everything that happens within the
practice. If the team members
are not trained properly and do
not feel confident about what,
when, and how to collect from
the patient, it’s easy to see how
patient balances can climb out of
control. Simply decide how your
office will address every aspect of
the patient financial relationship,
make sure everyone is trained on
how and why you do what you do,
and stick to your procedures. Soon
you will find that patient balances
are down and your collections are
up. Set some goals, make it fun,
and enjoy the fruits of your labors!
Abbie Miller is a Certified Medical Compliance Specialist
and works for KMC
University as a practice
performance
analyst, Medicare
Enrollment Specialist, coach, and consultant. She has
sixteen years’ experience managing
her husband’s chiropractic office.
I
was at a seminar not too long ago
and someone asked the woman
next to me if she was a DC. “Oh,
no,” she said, “I’m just the CA.”
Trust me, there is no such thing
as “just” anything, let alone “just” a
chiropractic assistant. As far as I’m
concerned, a CA is by far a doctor’s
most valuable asset, especially when
it comes to the role he or she plays
in keeping patients on track with
appointments and in supporting the
doctor’s instructions and suggestions
for ancillary treatment and supplies.
Consider the two very different outcomes of the following hypothetical
scenario:
Patient (halfway out the door):
Hey, I forgot my iPad. It’s got my
credit card info and my calendar
in it, so just bill me and I’ll call to
make my next appointment, ok?
Bye!
CA #1: Um . . . okay. . . .
CA #2: No worries, that’s why
we have your credit card on file,
remember? I’ll go ahead and bill
your co-pay to your card as we
agreed. And your next regular appointment is Friday at 11. I’ll give
you a call on Thursday to remind
you. Hey, your gait has really improved with those orthotics! Have
a great day!
Which CA got the practice paid?
Which CA made sure the patient is
coming back and following their treatment plan? Which CA does the patient—and the DC—likely have more
confidence in?
Now, CA#2 didn’t just pull all that
out of thin air. That was the result
of intentional and focused advance
work. Let’s break it down.
First, keeping patients on track
with appointments is one of the most
important tasks a CA performs. If patients don’t keep appointments, they
don’t get better. And when they don’t
get better, you can believe they don’t
blame themselves—they blame the
office. You know what else they don’t
do? They don’t pay.
What a mess, right?
Because of this, it’s vital that all
appointments are scheduled in advance in accordance with the DC’s
treatment plan (once a week, twice a
week, three times a week—whatever
frequency the doctor recommends
for the patient at that point in their
care). Once scheduled, a CA’s job at
the end of the appointment is to wave
and say, “See you Monday at 5!”
After every patient’s first visit, ask
them to bring their calendar or digital
device to the report of findings. At
that time, schedule all recommended
visits up to the next re-evaluation. A
patient’s willingness to schedule these
multiple appointments will gauge their
commitment to care. It also shows
them that your office has a plan, and
this isn’t “band-aid” chiropractic.
Going forward, consider three or
more rescheduled appointments a red
flag and notify the doctor. Patients
lose their commitment to care for
many reasons: not improving as fast
as they expected, being unable to
afford the care, or simply feeling better and thinking it’s okay to drop out.
They may need a review of the care
plan with the doctor and a reminder
of the commitment they made in
the report of findings. CAs can and
should reiterate to the patient that
only the doctor has the authority to
change the treatment plan.
Supporting the doctor’s recommendations to the patient within
the treatment plan is also vitally
important. When rehabilitation, use
of cervical pillows, or orthotics is ordered, constant reinforcement by the
CA keeps the patient on track. This is
also true of doctor-ordered strengthening, stretching, or other supportive
exercises, or devices for home exercise such as the Neck-Sys. When a
patient has been ordered to purchase
this type of rehabilitation device, it
makes for great chiropractic only talk
in the office when a CA asks, “Hi,
Mary, how have your exercises been
going?” This allows the staff member
to communicate a patient’s compliance to the doctor.
Many times, patients look to CAs
to reinforce what the doctor has told
them in the room. How often have
you had a patient come out after the
doctor has ordered orthotics and ask,
“Do I really need these?” It’s important to know the scripting ahead of
time so when asked, you can support
what the doctor has told them in the
room. “Mary, I’ve seen so many of our
patients respond beautifully to having custom orthotics. They say that
they can feel the difference in how
their adjustments hold when they
are stabilized from the ground up. I
wear them myself, and if Dr. Smith is
recommending them for you, I know
you’ll be happy with the decision.”
Use staff meetings to role play the
different responses your doctor would
like you to use.
As for the I-forgot-my-wallet excuse,
don’t let that ever become an issue.
In addition to all the patient education
you do up front about patient responsibility for payment at time of service,
set up a credit or debit card on file
so that a patient can never walk out
the door without paying. You’d be surprised how many patients are relieved
to have this taken care of!
As chiropractic assistants, we play a
vital role in being the eyes and ears of
the doctor in the front office and gently
nudging patients into compliance with
the doctor’s recommendations. Remember the power of your words when
spoken in reinforcing the doctor’s orders—including treatment and appointment compliance as well as payment
for services. It’s a vital role in keeping
patients on track to health.
Kathy Mills Chang is
a Certified Medical
Compliance Specialist
(MCS-P) and since
1983, has been providing chiropractors with
reimbursement
and
compliance training, advice, and tools
to improve the financial performance
of their practices. Kathy leads a team
of 14 at KMC University, and is known
as one of our profession’s foremost
experts on Medicare. She or any of her
team can be reached at (855) TEAMKMC or [email protected].
View from the Back: Benefits of Using
a Foam Roller with Active Therapy
By Amber Wichmann, CA
D
uring your work day, you may
have the opportunity to work
with patients on their active
therapy treatment plan. While the
doctor will prescribe the treatment
methods and duration according to
the patient’s symptoms and desired
outcomes, you can also play an active role in helping the patient work
through their exercises. There are
many exercises available to achieve
particular goals, including those
done with or without weights, prone
or supine, and in all three planes of
movement.
One of the ways to challenge a
patient’s strength and balance when
doing the exercises is to incorporate a foam roller. When choosing
a foam roller for your office, choose
one that is very dense and that will
fit the needs of the majority of your
patients. Foam rollers come in different sizes and lengths and are either
half or fully round. For the purposes
of this article, we’ll talk about using
a 36” round roller.
By applying pressure to specific
points, or trigger points, on the
body, your patients are able to aid
in the healing of muscle tissue and
assist return to normal muscle function. Normal function means their
muscles are elastic, healthy, and
without pain. A common example of
trigger point pain is when patients
experience discomfort while foam
rolling over the iliotibial (IT) band.
Rolling may cause pain to radiate
up to the hip or all the way down
the leg to the ankle. When rolling or
working on muscles around trigger
points, tell your patients to expect
to experience the degree of discomfort they might get with a good
stretch. It should be uncomfortable
but not unbearable, and when completed, it should feel better.
Essentially, foam rolling is a form
of self-myofascial release, or selfmassage, that gets rid of adhesions
in muscles and connective tissue.
These adhesions can be points of
weakness or susceptibility in the
muscle tissue. When muscles don’t
contract uniformly from end-to-end,
this could lead to injury, pain, and
improper muscle recruitment for
movement. Additionally, foam rolling
also increases blood flow to muscles
and creates better mobility, helping
with recovery and improving performance. Releasing trigger points aids
in reestablishing proper movement
patterns and pain-free movement.
To foam roll properly, your patients should apply moderate pressure to a specific muscle or muscle
group using the roller and their body
weight. Encourage them to roll slowly and evenly, staying as relaxed
as possible. People should slowly
start to feel the muscle releasing,
and after less than a minute, the
discomfort or pain should lessen. If
an area is too painful to apply direct
pressure, shift the roller and apply
pressure on the surrounding area
and gradually work to loosen the
entire area. The goal is to restore
healthy muscles—it’s not a pain
tolerance test.
Patients might roll through their
thoracic vertebrae, IT bands, quadriceps, hamstrings, buttock muscles,
and calves. Proper posture is important as they learn the techniques
specific to each body area.
Most importantly, understand the
origin of your patient’s pain before
you start. Understand what the doctor and patient are trying to achieve
through active therapy, including
foam rolling, and how you might
show proper use. To get the benefits of foam rolling, just like active
therapy, repeated exposure will be
key.
Amber
Wichmann
has been a chiropractic assistant for five
years and loves taking care of patients.
She is a certified CA
and is a credentialed
x-ray technician. She lives near
Rapid City, South Dakota and is
an avid runner and certified Pilates
instructor. Amber is enthusiastic
about teaching others about active
and passive care in the chiropractic
clinic. She or any of the other Reimbursement Specialists at KMC University can be reached by emailing
[email protected].
14
Does Verifying Medicare Part B
Affect Reimbursement?
By Rebecca Walter, MCS-P
A
s a reimbursement specialist, I often ask offices if they
verify Medicare. Many staff
members admit that it’s one of
those tasks allowed to drop off the
list because “after all, Medicare only
covers one service in our office.”
While it may seem at first glance
that you wouldn’t get much information on a Medicare verification call,
that’s not always true.
If we first consider the changing nature of Social Security benefits, which
is the origin of Medicare, a small hint
lies in the fact that the eligibility age
for full benefits for retirees is rising.
For Americans born after 1953, the
age to receive 100% of Social Security
retirement benefits has been increasing gradually up to a current maximum
age of 67. You can determine your exact age for maximum Social Security
benefits by visiting their website at
ww.ssa.gov/retirement.
At the same time, eligibility for
Medicare has not changed and is
still at age 65. Part B Medicare,
which covers physician treatment, is
voluntary beginning at 65 and can
be delayed. Delaying onset of paying
Part B premiums increases those
premiums as a sort of penalty for delaying. You can see the conundrum
here. This results in many Medicare
beneficiaries continuing to work but
enrolled in Medicare Part B. According to a May 2014 Money Talk News
article, a Gallup poll has indicated
the highest retirement age since the
onset of Social Security (1).
So what does that mean for your
verification process? Simple: you’ll be
seeing Medicare patients in your offices present with different payment
scenarios. One indication may be
the famous red, white, and blue card
itself. Medicare Part B beneficiaries
who are still working can be issued
a card with a –T extension after the
number. That’s a sure sign for you to
verify if there is another payer that
might be primary. Group policies that
might be available through employers are often primary payers, which
means they must be billed first. If you
fail to verify and bill Medicare first,
you’ll receive a denial indicating there
may be another payer. That will delay
your reimbursement while you rebill
to the group plan and then wait for
processing, followed by resubmitting
the claim and explanation of benefits to Medicare.
Let’s do the math. That’s at least
a 14-day turnaround from Medicare
to get that denial. Then there’s the
time necessary to resubmit and process to the group plan, which takes
an average of over 30 days. Add in
yet more time to resubmit and receive a response from Medicare, and
your office is looking at a 60 or more
days from service date to resolution—all because you failed to verify.
Even without a telltale difference
on the Medicare subscriber ID card,
you could have a situation such as
a primary policy with the spouse
still being employed and covered by
a group plan. Other scenarios that
you could discover during verification include Medicare Advantage
Plans that replace Medicare benefits or no enrollment in Part B at all.
Many Medicare beneficiaries
aren’t clear on what coverage they
have. After all, Medicare and the
supplements, secondary plans, and
Advantage plans confuse us and we
work with it daily! So don’t be surprised when a senior doesn’t understand their coverage. As a registered
provider, you’re required to bill for
a covered service if Medicare has
something to pay. You should make
that process as systematic as possible to avoid payment delays. The
rewards of establishing a systematic
verification of Medicare will be not
only less time processing claims, but
an easier way to explain the process
to the Medicare beneficiary. A less
measurable—but no less valuable
benefit of verification—is the vote of
confidence you’ll receive from your
Medicare patients when they notice
how well you handle their account.
KMC University offers training in
reimbursement and verification utilizing standardized forms, systemic
processes, and follow-through. Implementing a system for your Medicare patients will definitely improve
your cash flow and decrease your
workload, making for happy doctors
and staff.
Reference
1. A new Gallup poll indicates that, on
average, Americans don’t retire until
age 62, later than they used to but
years before they had planned.
Rebecca Walter currently is a consultant
for KMC University
as well as an active
practice manager in
Virginia. She holds an
MCS-P certification
as well as BS in Organization Management. She is an active speaker for the Unified Virginia
Chiropractic Association, holds a CA
certificate from NCC (now NUHS),
and is a licensed X-Ray Technician.
She speaks on a variety of topics,
including Medicare, compliance,
billing, documentation, and office
management. She or any of the
reimbursement specialists can be
contacted through KMC University
at [email protected].
15
Set Your 2015 Goals Now
and Plan For Success!
By Dr. Michelle Turk
I
t seems hard to believe, but
2015 is just around the corner.
As we begin the final quarter of
2014, it is important to write your
goals for the New Year. Why now?
Well it takes our brains 90 days to
fully embrace a new concept. So
rather than set some New Year’s
resolutions for yourself and your
practice that you first think about
during the week between Christmas
and New Year’s, write your goals
now so when the New Year begins
you are prepared to come charging
out of the gate.
First of all, why have goals? Having goals allows you to define and
prioritize your wants and to clarify
the necessary actions. It will also
allow you to develop the attitude
and habits needed to achieve them.
It is imperative that your goals
be written and read daily! An unwritten goal is a wish. Writing and
reading them keeps your goals in
the present, and helps you stay
committed to the actions needed
to make them reality.
When writing goals, be sure to
be as specific as possible. Each
goal must have a target date, as
well as the specific action steps
needed to achieve it. Also, for each
goal, write what your motivation is.
Trust, but Verify
In other words, what will achieving that goal do for you or mean to
you? Finally, organize your goals in
a manner that works best for you,
such as personal goals, professional goals, and financial goals.
Keep your written goals in a place
that will allow you to easily read
them, out loud, daily. Remember to
update your goals throughout the year
as necessary. As life changes and you
change and grow, so do your goals!
My hope is that you will truly devote some time and energy to the
process of creating, writing, and
reading your goals, and that one
year from now, when you sit to write
your 2016 goals, you will look back
and be proud of all you achieved in
2015!
Dr. Michelle Turk
has been coaching
chiropractors
and CAs for over
a decade on personal and practice
development
with
particular emphasis
on helping doctors develop their
ideal practice while maintaining a
fulfilled and balanced personal life.
For more information visit www.
PositiveImpactCoaching.com.
ANJC’S New Public Website
Is Now Live!
because she wants to improve herself
personally and professionally. She
also wants to improve her practice by
learning more about her productivity,
effectiveness, documentation, compliance, and billing. She shared that she
doesn’t simply attend the CEU required hours for her license; she puts
in seminar hours to improve her practice, her clinical skills, her compliance,
and her business insight.
Her problem? The conflicting information she receives from various
“experts” at each seminar. How,
she asked, can they all be right if
they say different things? As a result of her experience, she wanted
to know why a Discount Medical
Plan Organization (DMPO) like
ChiroHealthUSA was of value in today’s practices. Why, she asked, is
this even necessary? What are my
resources?
I passed her third-degree with flying colors, by the way.
I could appreciate her position,
because I am a bit of a skeptic
myself. In fact, that’s how all this
started for me. I was a chiropractor
in practice, just like you, trying to
maximize my insurance payments so
I wasn’t leaving money on the table
while still working to come up with a
way my uninsured patients could afford those fees.
Because of my activity within
my state (as a governor-appointed
health expert, as an active participant in my state chiropractic association, and the state representative for the American Chiropractic
Association), I knew the rules to
follow to avoid compliance issues
when creating our fee schedule. I did
my research, and initially started a
Discount Medical Plan Organization
(DMPO) for my state alone. I knew
this would legally protect my practice and my colleagues and that, at
the time, was my only goal.
And, as skeptic, I wouldn’t even
take my own word for it when it
came to believing that a Discount
Medical Plan Organization (DMPO)
was the simplest way to keep my
fee schedules compliant, legal, and
safe. That’s why I became a Certi-
fied Medical Compliance Specialist
(MCS-P), so skeptics like me could
get a breath and feel at ease. As an
MCS-P, I’m quite simply held to a
higher standard. I have to be able to
quote chapter and verse about why
any possible fee or activity is or
isn’t compliant.
We know there’s a plethora of
inaccurate information that gets
disseminated in our profession. I’m
sad to say that I had to agree with
my frustrated colleague when she
was venting about all the conflicting
advice she was receiving. That’s why
ChiroHealthUSA has relationships
with many MCS-Ps, to help get accurate, reliable information out there.
Many of the brightest minds in our
profession agree with and recommend ChiroHealthUSA to their chiropractic colleagues.
Looking back, when I set up my
first DMPO within my state, I can
see how shortsighted I was. I now
know that taking ChiroHealthUSA to
a national audience, to protect all
chiropractic practices in the country,
was the vision I should’ve had at the
start. I’m glad I had an encounter
with one of my fellow MCS-Ps who
gave me this bigger vision.
Learn more about how ChiroHealthUSA can help your practice be more
compliant. You can attend a free webinar this Tuesday. Register at www.
ChiroHealthUSA.com today to find
out more.
–––––––
Dr. Ray Foxworth is a certified
Medical Compliance Specialist and
President of ChiroHealthUSA. A
practicing chiropractor, he remains
in the trenches facing challenges
with billing, coding, documentation,
and compliance. You can contact Dr.
Foxworth at 888-719-9990, info@
chirohealthusa.com, or visit the
ChiroHealthUSA website at www.
chirohealthusa.com. Join us for a
free webinar that will give you all
the details about how a DMPO can
help you practice with more peace
of mind. Go to www.chirohealthusa.
com to register today.
A simple two step process opens
your door to more patients and
knowledge:
Log into www.njchiropractors.com.
Type in your email address to receive
the ANJC Free Report and you will be
added to our email list to receive our
blog and additional updates. That’s
it! In two easy steps, you have just
opened a portal to enhance the understanding of chiropractic benefits
for your patients.
Best part? The public will ALSO be
able to sign up for the Free Report
and will receive updates and blog
posts. The goal is to educate the public on the benefits of chiropractic care
while allowing them to partner with
their chiropractic physician to learn
about new techniques and health updates. It’s a win, win! Even better, all
patients who sign up will be guided to
the “Doc Finder” area of the site so
they can find YOU, an ANJC Chiropractic Physician! What are you waiting
for? Sign up today!
16
By Dr. Steven Lavitan
Y
By Brian D. Jensen, DC
T
Biomechanics
During gait, the normal foot reacts
to heel strike by redistributing energy and weight through controlled
calcaneal eversion. This important
movement provides the body with its
primary reduction of contact shock.
During midstance, proper joint alignment allows a fluid transfer along the
lateral foot border, which leads to a
propulsive toeing off the metatarsal
heads.
The high-arch foot places the first
metatarsal in excessive plantar flexion. Combined with prominent arches,
this configuration resists calcaneal
eversion, lacks motion in the lateral
foot, and concentrates stress over
the first metatarsal head before toe
off. “The ankle feels unstable and
weak. It is the combination of the
lack of shock absorption and the inward tipping of the foot that leads to
the numerous clinical maladies that
are frequently seen (2).”
Musculoskeletal Complications
These clinical conditions include:
• inversion sprains
• stress fractures
• scoliosis
• degenerative conditions
Research suggests that higharched feet may increase the incidence of stress fractures (3,4). While
the hyperpronated individual is more
susceptible to stress fractures of the
metatarsals, the supinated individual
is more susceptible to stress fractures of the tibia (5). Regardless of
the foot type, everyone can benefit
from shock absorption.
Moe correlates the incidence of
pes cavus with idiopathic scoliosis
(6). In his study he found that of 130
subjects with scoliosis, 85 (or 65%)
demonstrated a pes cavus pedal
foundation. In the control group of
200 subjects without scoliosis, only
19 (or 9.5%) demonstrated pes cavus
formation. This is a significantly statistical correlation.
Associated Neurological Conditions
The musculoskeletal complications listed above are by far the most
common. However, the high arch has
also been associated with serious
neurological conditions. Your differential diagnosis must include cerebral
palsy, Charcot-Marie-Tooth disease,
spinal-cord tumors, and peripheral
neuropathies (7).
Examination
Here are five characteristics to
look for:
1. High medial arch (visual inspection or with a postural stability
indicator card)
2. Limited movement into pronation
when the foot moves from heel
strike to midstance
3. A tight, stiff foot that lacks flexibility during palpation
4. Callus formation over the first
and/or fifth metatarsal head(s)
5. Effects of poor shock absorption
Because visual inspection of pes
cavus can be difficult to differentiate
from a normal foot, look for the peeka-boo sign (8) while observing your
patient’s feet from the front. Because
the normal foot lacks calcaneal inversion, the posterior foot conceals the
heel. However, in pes cavus, a visible
portion of the heel pad will be seen
medially, as it peeks out from the border of the foot.
Solution
Once the presence of excessive
supination has been determined,
several things can be done to relieve
symptoms and prevent future problems. Any joint fixations should be
adjusted. Common problem areas include the cuboid and calcaneus. The
patient should begin a rehab program
that includes stretching of the triceps surae and tibialis anterior while
strengthening the peroneal group.
For the supinated foot and ankle
individually designed orthotic stabilization will help to:
• reduce heel-strike shock
• support arches and reduce biomechanical stress
• accentuate toe off and reduce
callus formation
• prevent further complications
Some healthcare providers have
used rigid orthotics to “fill” the high
arch. However, according to Manoli,
“these rigid, conforming orthoses actually make the problems of foot stiffness and reduced shock-absorption
worse (2).” Individually designed stabilizing orthotics provide biomechanical support and shock absorption
necessary for symptom reduction and
prevention of future problems.
References
1. Kuhn DR, Shibley NJ, Austin WM, Yochum TR. Radiographic evaluation of
17
The Nutritional Implications of the
Chiropractic Adjustment, Part II
High Arches = High Risk
of Spinal Problems
hat flat feet have the ability to
destabilize the lower extremity,
pelvis, and spine has been well
documented (1). The satisfying characteristic about a flat foot is that you
know one when you see one! However, although a foot with a high arch
(pes cavus) may appear healthy or
desirable, this condition of supination
comes with its own set of clinically
significant challenges.
This article will focus on the musculoskeletal effects of pes cavus,
potentially associated conditions,
and simple evaluation procedures.
There is a wide range of pedal presentations. A hybrid foot condition
called “pes cavovarus,” which represents the eventual deterioration of
a supinated foot, combines rear-foot
supination and forefoot pronation.
With this expanded knowledge of foot
presentations, you will be better prepared to support patients’ postural
platforms—the feet.
Keep in mind that supination problems are much less frequent than
pronation problems, and you will most
likely encounter supination when
patient complaints include foot pain.
Manoli reports, “A simple survey in
(their) center showed that, surprisingly, almost twice the number of
painful feet had a cavovarus posture
than had a flat foot (2).”
weight-bearing orthotics and their effect
on flexible pes planus. J Manip Physiol
Ther 1999; 22(4):221-226.
2. Manoli A, Graham B. Cavus foot diagnosis determines treatment. Biomech
2001. www.performancezone1.com/
cavus_foot_diagnosis.html [accessed
5/21/13].
3. Giladi M, Milgrom C, Stein M et al. The
low arch: a protective factor in stress
fractures -- a prospective study of 295
military recruits. Orthop Rev 1985;
14:709-712.
4. Matheson GO, Clementi DC, McKenzie
JE et al. Stress fractures in athletes. A
study of 320 cases. Am J Sports Med
1987; 15:46-48.
5. Matheson G. Stress fractures in athletes: a study of 320 cases. Am J Sports
Med 1987; 15:46-58.
6. Moe JH: Scoliosis and Other Spinal
Deformities. Philadelphia: WB Saunders
Co, 1982:209-212.
7. Brewerton DA, Sandifer PH, Sweetnam
DR. Idiopathic pes cavus—an investigation into its aetiology. Br Med J 1963;
2:659.
8. Manoli A, Smith DG, Hansen ST. Scarred
muscle excision for the treatment of
established ischemic contracture of
the lower extremity. Clin Orthop 1993;
292:309-314.
–––––––
Dr. Brian Jensen is currently the Associate Director of Professional Education
at Foot Levelers. He speaks on a wide
variety of topics, including orthotic
therapy, posture, structural preservation, breaking free of the medical
model of healthcare, and innovations
in nutrition. Dr. Jensen can be reached
at 800.553.4860.
ou just gave your best adjustment, and before the patient
even gets up you hear them
say those dreaded words, “I don’t
feel better,” or the more devastating,
“Doctor, I feel worse than before.” If
you used up your bag of chiropractic
tricks, you may think, now what? You
immediately contemplate damage
control, but lots more than your PVA
(patient visit average) is on the line.
Situations like this actually provide
you with a great opportunity to talk
about supporting the body with good
nutrition and the value it brings to
chiropractic care. There are nutritional implications in controlling a
patient’s pain level and getting them
to hold their adjustments. These
include calcium to support muscle
and bone function, and herbal approaches to reduce inflammation and
improve healing through enhanced
microcirculation.
Supporting muscle function is
especially important during times of
physical stress. If a patient is experiencing muscle spasms it may be the
result of calcium deficiency, which
can cause uncontrolled contractions.
The cuff test provides an easy way
to confirm this. Assuming you have
ruled out vascular complications in
the legs, put a blood pressure cuff
over the calf and try to inflate it to
200 mmHg. If you cannot due to
pain, start thinking in terms of ionizable calcium in proper balance with
magnesium.
Calcium comes in many forms. For
our bodies the most supportive form
is calcium bicarbonate and the least
supportive is calcium carbonate. An
easy way to remember the difference
is “bicarbonate is the best” (totally
ionizable and soluble) and used by
the body’s blood stream and interstitial fluids in that form. When patients
bring in calcium carbonate (i.e.,
ground up limestone), the cheapest
and most common form of calcium, I
explain that it offers the same nutritional benefit as concrete. Calcium
bicarbonate is in ground water, and
barring that source, calcium lactate
is the preferred form. It is affordable
and is quickly synthesized to form
calcium bicarbonate. It is traditionally
in real milk, but if you cannot get raw
milk, red beet tops are best (dairy
intolerance is not an issue). Note the
body needs a touch of magnesium to
assimilate the calcium, and a proper
formulation would be primarily calcium lactate with a touch of soluble
magnesium citrate, or a 5:1 ratio.
If a patient fails the cuff test, you
can give them calcium lactate powder from a whole food supplement
source. Approximately 80 percent
of the time, calcium lactate is effective; when it is not, you can suggest
magnesium lactate. Patients can
take calcium lactate powder with a
water chaser, and if that handles the
spasms or the pain on the retest,
they can continue with it, or more
likely switch to calcium lactate tablets. Generally, patients at home comply with pills more readily than the
powder, though swallowing the pill
is not effective for an instantaneous
response unless they are chewed or
taken in the form of powder. Having
said that, swallowing calcium lactate
tablets without chewing is fine for
If a patient is experiencing
muscle spasms it may be
the result of calcium deficiency, which can cause uncontrolled contractions. The
cuff test provides an easy
way to confirm this.
maintaining calcium levels, but it
takes approximately 20 minutes for
the body to assimilate them.
As people age, normal wear and
tear on the joints may begin to affect their function, and you may hear
patients complain about ongoing
aches and pains. This presents an
opportunity to help your patients support their joints. If your patients were
satisfied with their over-the-counter
options, they would not be in your office. This is the time to suggest natural and effective therapies to support
the body’s anti-inflammatory responses. My first choice for patients in
need of joint support is a combination
of Boswellia serrata, celery seed, turmeric, and ginger. While shown to be
effective alone, the synergistic effect
of these herbs used in combination is
outstanding.
Research is continuously proving
the efficacy of herbs. For example,
in a randomized study conducted in
India, Boswellia was as effective as
valdecoxib, a selective COX-2 inhibitor, for wear and tear of the knee.1
Boswellia had a slower onset, yet relief continued after the herbal therapy
was stopped, suggesting it benefits
the body’s normal inflammation response function. Unlike conventional
anti-inflammatories, which may cause
gastrointestinal distress, Boswellia
also provides support for normal gastrointestinal function. Gotu Kola is
another herb you may find particularly
useful in a complex form combined
with grape seed and Gingko leaf to
support the body’s normal tissue repair process.
Many chiropractors are leery of
using herbs due to concerns about
side effects. While understandable,
these concerns are generally unwarranted, and most can be set at
ease by reviewing and using a drug/
herb interaction chart in practice.
I frequently use a Drug/Interaction
Chart found online at: https://www.
standardprocess.com/MediHerbDocument-Library/Catalog-Files/
herb-drug-interaction-chart.pdf. If you
are seriously considering herbs, and
you should be, I highly recommend
you study Principles and Practices
of Phytotherapy written by renowned
herbalists, Simon Mills and Kerry
Bone, as well as attend educational
seminars and workshops.
If adjustments are not holding due
to structural spinal issues, you can
recommend chelated manganese.
Chelated manganese is, in my opinion, the best glue to help support
ligaments, tendons, or virtually any
other collagen structures in the body
that have been subject to excessive
physical stress. Throughout my 40
years in practice I have experienced
great success using two nutritional
compounds that contain manganese
for support of proper formation and
maintenance of skeletal tissues, including support of the body’s normal
connective tissue repair and synthesis process. For acute support, you
can use a whole food product combining manganese and vitamins A,
B12, C and E, and another whole food
product combining those ingredients
with nutritional yeast for more longterm support. The nutrients in these
two products are necessary to help
strengthen connective tissue and get
an adjustment to hold.
If the problem concerns the structure of the bones themselves, raw
bone in a chewable wafer may help
feed living bone, as Hippocrates prescribed, “Let food be thy medicine
and medicine be thy food.” It has
shown itself to be effective for bone
formation in a complete matrix. It
along with weight bearing exercise
and the vibrating platform are the
non-bisphosphonate natural choice
for patients with structural challenges. If there are arthritic challenges
and osteoporosis, this is where you
need to go.
What you recommend will help
benefit patients’ safety, recovery, and
overall health. As a great nutritionist once said, “One of the biggest
tragedies of human civilization is the
precedents of chemical therapy over
nutrition. It is a substitution of artificial therapy over natural, of poison
over food, in which we are feeding
people poisons trying to correct the
reactions of starvation.”2
Endnotes
1
Mills, Simon and Bone, Kerry. Principles
and Practice of Phytotherapy, 2nd edition, p. 445.
2 Anderson, M. The Lectures of Dr. Royal
Lee, Volume I, 2nd edition 2001. p. VII.
–––––––
Dr. Lavitan has been in private practice since 1976 in Teaneck, NJ and
seen thousands of patients. He is a
graduate of Rutgers College, Columbia
Institute in 1976, and the Eastern
School of Acupuncture and Traditional
Medicine. He is both an acupuncturist
and a chiropractor.
18
By Dr. Christopher J. Bump
– ANJC NEC Council
A
pplying nutrition as a therapy
in our chiropractic practices
can be a bit daunting, especially considering that the nutrition
classes we took during school were
often perfunctory and usually without clinical relevance. And given the
amount of information we have at our
disposal via the internet it is difficult
to know what is a sales pitch or useful advice. The internet tends to make
things very complicated, as is often
the case with webinars and seminars
offered by nutraceutical manufacturers. However, there is a great amount
of value and benefit for our patients if
we can offer them clear, sound, and
useful nutritional advice. Our advice
does not need to be complicated, nor
infused with the detail of biochemical pathways. So I would like to offer
Water Soluble Vitamins:
A Few Clinical Pearls
a few clinical pearls that you can
begin using in your clinics. These are
simple and fundamental insights into
the therapeutic role of some of the
major vitamins.
Vitamins, originally vitamine, have
been researched for over the past
century and there is clear association with deficiency and excess syndromes for each. Diseases such as
pellagra, beri beri, and rickets are
examples of deficiencies related to
specific vitamins, and it is not my intention to discuss these, but to look
at functional deficiencies. What are
the signs and symptoms that a patient may present with that indicate a
subclinical need for a vitamin? Below
is a brief overview with some clinical
pearls of the primary water soluble
vitamins.
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Vitamin C (Ascorbic Acid): Of any
single nutrient researched, Vitamin
C stands volumes above the rest. It
is water soluble, and therefore needs
to be replenished daily as humans
and guinea pigs are the only vertebrate animals not to synthesize our
own Vitamin C. Unfortunately, many
people fail to consume enough Vitamin C and therefore do not take
advantage of its numerous health
benefits. Most adults wrongly assume that the 75-90 mg of vitamin
C recommended by the federal government is an optimal daily dose.
In fact, this “recommended dietary
allowance” is only enough to prevent
the deficiency state scurvy—but not
nearly enough to support optimal
health. Vitamin C is ubiquitous in
its benefits and functions in human
physiology. It is best known for its
immune system support but also for
its connective tissue and epithelial
cell support. When you think flexibility, in any arena of health, Vitamin C
is present, including behavioral disorders. Vitamin C has been shown to
improve Schizophrenia in numerous
studies. Clinical Pearl: Every patient
needs Vitamin C (and magnesium).
Dose them to bowel tolerance beginning with 1000 mg/day and increasing daily until they have loose stools.
Then reduce by 25%. You’ll be
amazed how much they need. Also,
easy bruising and wounds that don’t
heal—think Vitamin C.
Vitamin B: Vitamin B complex is
too complex to discuss in this simple
article! So I will go through some of
the major players in the B-family and
offer insight into their roles and clinical usefulness. However, in a general
sense, when you think of energy
production and stress management,
think B-complex. And because B Vitamins are water soluble and we have
significantly increased need during
stress, it is safe to assume every
patient will do well with a B-complex
supplement.
Vitamin B-1 (Thiamine): Requirements increase with diets high in
carbs and sugars. Your body needs
B1 to form adenosine triphosphate
(ATP), which every cell of the body
uses for energy. Alzheimer’s disease
and cataracts along with heart failure are all associated with thiamine
deficiency.
Clinical Pearl: Benfotiamine, a
synthetic form of vitamin B1, is beneficial for patients with neuropathies,
diabetic retinopathy, and glycated
proteins.
Riboflavin (B2): Riboflavin is that
part of the B-complex that makes our
urine bright yellow. It is an indication
that we are absorbing the vitamin
and not that we are micturating it
down the toilet. Deficiencies are
suspected in patients who have sensitivity to bright light, bulbous, red
(alcoholic) noses, and cracks at the
corner of the mouth. Clinical Pearl:
Higher doses have been shown to reduce migraine headaches.
Niacin (B3): Pellagra is the extreme deficiency state of B3. Niacin
helps increase energy; and it’s needed for DNA repair. The niacin form can
cause flushing but this can be prevented by taking it with apple or baby
aspirin. Current research supports
high dose niacin for managing choles-
terol. Patients with carpal tunnel syndrome and chronically tight muscles
respond well to niacin. Schizophrenia
is associated with severe Vitamin B3
deficiency.
Clinical Pearl: Look at the tongue;
when it is cracked, fissured or geographic, think B3 deficiency. (Nonflushing niacin timed release capsules are now available.)
Pantothenic Acid (B5): In addition
to playing a role in the breakdown of
fats and carbohydrates for energy,
vitamin B5 is critical to the manufacture of red blood cells, as well as
sex and stress-related hormones produced in the adrenal glands. Vitamin
B5 is also important in maintaining a
healthy digestive tract, and it helps
the body use other vitamins, particularly B2 or riboflavin. Your body
needs pantothenic acid to synthesize
cholesterol.
Clinical Pearl: Coenzyme A, a major
energy production cofactor, is B5 dependent. Think high doses of B5 for
patients with chronic fatigue issues.
Pyridoxine (B6): Pyridoxine-5-Phosphate (P-5-P) deficiency is associated
with carpal tunnel syndrome but also
mood disorders, and fatigue. It is essential for the synthesis of neuropeptides like serotonin, dopamine, and
epinephrine.
Clincal Pearl: Patients who suffer
from seasonal affect disorder (SAD)
are often unable to convert Pyridoxine HCl to P-5-P. Supplement with the
latter, as it is the bioactive form of
B6 especially for depression, sleep
disorders, and SAD.
Folic Acid: Currently there is an
increased interest of the importance
in folate metabolism in its role in
methylation process and gene regulation. Homocysteine is one biomarker
useful in assessing functional folate
metabolism. Levels that approach
the 11 umol/L level indicate a need
for the bioactive form of folic acid,
5-methyltetrahydrofolate.
Clinical Pearl: Women who present
with abnormal PAP smear are also deficient in folic acid and respond well
with super high doses of folic acid for
a month or two.
Vitamin B-12: B-12 improves mental fogginess and memory. B-12 deficiency is associated with poor digestion, especially low levels of stomach
acid. Numbness, tingling, and abnormal sensations on the skin suggest
decreased B-12. Pernicious anemia is
a B-12 deficiency.
Clinical Pearl: A sensation of an
electric shock running down the
spine with chin flexion is called Lhermitte’s syndrome and is related to
B-12 deficiency.
You will notice that I have deliberately avoided offering specific
doses for each nutrient listed above.
This is in part because of the unique
biochemical needs of our patients,
and sitting here writing this article
I cannot know your patient’s need.
However, there are some general,
safe guidelines you can follow. Email
me your questions about specific
patients and I will be glad to offer
insight at [email protected]. Also,
I provide consultation service for
your nutritional patients and in-office
tutorials for applying clinical nutrition
with a functional medicine orientation, into your practice.
By Dr. David R. Seaman
– ANJC NEC Advisor
W
hen taken in adequate
amounts, ginger can be a
great adjunct in the treatment of musculoskeletal pain. This
article is a summary of a 1992 study
that describes the outcome of 56 patients (28 with rheumatoid arthritis,
18 with osteoarthritis, and 10 with
muscular discomfort), all of whom
used powdered ginger. Most of the
subjects experienced relief in pain
and swelling to varying degrees. Ginger consumption ranged from three
months to three years. Importantly,
none of the patients reported adverse
effects (1).
One subject was an 80-year-old
female with osteoarthritis, who consumed six grams of ginger per day for
the first six months, and two grams
for the following two and a half years.
This subject experienced both the effectiveness and safety of ginger. Years
before she began taking ginger, one of
her kidneys was removed. As NSAIDs
can damage the kidney, she would
have been especially vulnerable if she
was taking the medications. However,
with ginger, she experienced no side
effects, suggesting that ginger may be
the anti-inflammatory agent of choice
19
Ginger: A Great Complement
to Chiropractic Care
in osteoarthritic patients in general
and especially those with renal and
cardiovascular issues.
A 69-year-old female began taking ginger because she suffered
from low back pain since she was 17
and later on, also developed neck,
elbow, hand, and knee pain. The use
of NSAIDs created gastrointestinal
distress for her. She began taking
about 7-8 grams of ginger per day
and after two months her knee swelling disappeared. At four months her
spine symptoms improved. The only
complaint that persisted to the same
degree as before she started taking
ginger was the swelling in her thumb
and first finger. After taking ginger six
months, she stopped taking NSAIDs.
A 50-year-old male with rheumatoid arthritis began taking ginger one
month after he was diagnosed. He
consumed 50 grams raw/fresh daily
in lightly cooked vegetable and meat
dishes. After just one month, relief in
pain and swelling was evident and he
was completely free of pain and swelling after three months of ginger consumption. He was active as an auto
mechanic, and 13-14 years passed
thereafter without relapse of symp-
toms. While he did develop some
nodules on some of the joints of his
fingers, there was no associated deformity, loss of function, or pain.
A 49-year-old male physical laborer
developed muscular pain and joint
pain, which lasted for five years before trying ginger. He was prescribed
analgesic medications that irritated
his gut. At one point, his condition
was so bad that he was disabled from
work. He began taking one teaspoon
of powdered ginger a day and within
one month he was completely free of
pain. He continued taking ginger for
several months more before stopping,
at which time he was able to work
without suffering.
While such outcomes cannot be
guaranteed in all individuals, it should
be quite obvious that ginger should
be viewed as a key botanical for patients in pain. The subjects in this
study took powdered ginger or the
root itself. Ginger root can be purchased in most grocery stores and
powdered ginger is available in bulk
at most heath food stores. Supplemental powdered ginger is also available as are the more potent standardized extracts. A great review article
published in the American Family Physician is available online and worth
reading if you have never used ginger
before (2).
Reference
1. Srivistava KC, Mustafa T. Ginger (Zingiber officinale) in rheumatism and musculoskeletal disorders. Med Hypothesis.
1992;39:342-48.
2. White B. Ginger: an overview. Am Fam
Physician. 2007;75(11):1689-91.
–––––––
Dr. Seaman is a Professor of Clinical
Sciences at the NUHS Florida site in
Pinellas Park, where he teaches nutrition and evaluation and management
courses for the musculoskeletal and
cardiorespiratory systems. Dr. Seaman has authored a book on clinical
nutrition for pain and inflammation,
and has written several chapters and
articles on this topic. His academic
and clinical interest is focused on how
pain and symptom/disease expression can be modulated with lifestyle
choices and manual and rehabilitative
interventions. For more info email [email protected].
By Dr. Marty Kotlar
I
n my opinion, many insurance
carriers are incorrectly denying
payment for physical performance tests and measurements
when performed on the same day
as CMT. These denials are occurring
without complete understanding of
the way these code pairs are intended to be used.
According to the American Medical Association, CPT code 97750 is
a physical performance test or measurement (e.g., musculoskeletal, functional capacity) with written report,
each 15 minutes. This code describes
varied tests and measurements performed by a provider. The testing may
be manual or performed using computerized automated equipment. The data
from the tests and measurements
is gathered by standardized tests,
structural analyses, or application of
electrophysiologic or electromechanical technology. Examples include but
are not limited to the following: electrophysiologic testing, muscle performance testing, work capacity testing,
testing of balance and posture reactions, somatosensory testing, electromechanical testing, developmental
assessment, movement and gait
analysis, and graded exercise testing. Because it is a time-based code,
multiple units can be reported at each
visit. Example: a total of two units
would be reported if the procedure
took 30 minutes to perform. These
functional assessments, tests, and
measurements may be medically necessary for patients with neurological
or musculoskeletal conditions when
such tests are needed to formulate
or evaluate a specific treatment plan
or to determine a patient’s functional
capacity. The patient’s record must
document the problem requiring tests,
the specific tests performed, and a
measurement report. The provider’s
interpretation of the results, with preparation of a separate, distinctly identifiable, signed written report is required
when reporting code 97750.
Academic
Excellence.
Professional
Success.
According to the American Medical
Association, chiropractic manipulative treatment (CPT codes 98940,
98941, 98942, 98943) is a form of
manual treatment to influence joint
and neurophysiological function. This
treatment may be accomplished using a variety of techniques.
The chiropractic manipulative
treatment codes include a pre-ma-
nipulation patient assessment. Additional Evaluation and Management
services may be reported separately
using the modifier -25, if and only if
the patient’s condition requires a significant separately identifiable E/M
service, above and beyond the usual
pre-service and post-service work asContinued on Page 26
Dedicated to:
• AcademicExcellence
• QualityPatientCare
• ProfessionalLeadership
Degree Programs include:
• DoctorofChiropractic
• MasterofScienceinAcupuncture
• MasterofScienceinAcupuncture
andOrientalMedicine
• MasterofScienceinAppliedClinical
• Nutrition(onlinedelivery)
• MasterofScienceinHumanAnatomy&
PhysiologyInstruction(onlinedelivery)
For more information call NYCC at
1-800-234-6922 or visit www.nycc.edu.
Finger Lakes School of
Acupuncture & Oriental
Medicine of New York
Chiropractic College
School of Applied
Clinical Nutrition
2360Route89
Seneca Falls, NY 13148
20
Research
Answers to Your Important
Malpractice Questions
UPDATES
By Keith Henaman, NCMIC Assistant Vice President-Claims
Q
: One of my colleagues
recently started having patients enter into agreements
whereby the patient prepays a set
amount of money per month for a predetermined number of chiropractic
visits, or a larger amount per month
for an unlimited number of visits. He
promotes these as a convenience for
his patients, but he is clearly benefiting financially. Are these plans a
good idea for both the doctor and the
patient? Are there legal issues that
I should be aware of before I think
about doing something like this?
A: I would strongly recommend
against entering into such agreements with your patients. There are a
number of different types of prepaid
chiropractic contracts and, while
some are legal in some states, some
are not. In any event, all have potential adverse ramifications.
The agreements that provide for an
unlimited number of visits, sometimes
called UCCAFF (Unlimited or Universal Chiropractic Care at a Fixed Fee)
contracts, are viewed in some states
as practicing insurance without a
license. The rationale is that the D.C.
(an insurer), is obligated to confer a
benefit monetary value (treatment)
to the patient (an insured), upon the
happening of a fortuitous event (like
an injury). Unless a D.C. has an insurance license, they may be acting in
violation of a state statute.
Additionally, it becomes unclear at
times exactly what constitutes a “fortuitous event.” Of course, if someone
sustains an injury in an auto accident,
that is usually something that would
not create any confusion. But, as
everyone knows, many people experience neck or back pain due to subluxations that are just part of everyday
living. A doctor may not view the latter
as a fortuitous event for which he has
agreed to provide treatment, whereas
the patient may think otherwise. A
D.C. exposes himself to board complaints if he doesn’t treat patients
whenever they say they have pain, or
he may end up unnecessarily treating
patients on an almost daily basis.
The agreements that provide for a
pre-determined number of visits, say
weekly, prepaid for a year, may cause
problems for the D.C. when a condition arises where the patient needs
more than weekly treatments.
The patient will either forego necessary treatment because he does
not want to incur the costs associated with such treatment, or may
elect to have additional treatment
but be resentful about the expense.
Additionally, a patient may become
completely asymptomatic and not
desire weekly treatments and be resentful because he or she has spent
money for something he or she does
not want or need. Resentful people
are people who file board complaints.
If a patient files a board complaint
based upon dissatisfaction with a
prepaid agreement, most boards are
likely to review the matter with strict
scrutiny, because their jobs are to
protect the public. This could lead to
serious financial consequences, such
as refunds to a patient for services
already rendered, a significant fine, or
even a disciplinary action. Worse still,
a disgruntled patient may file a civil
suit for breach of contract. Then, the
D.C. will incur not only his own attorney’s fees, but also, if he loses, the
patient’s attorney’s fees.
Any apparent financial benefit to
a D.C. by entering into these types
of agreements is negated by the
substantial risks involved. The better
course is to stick with the traditional
“as needed” and “pay as you go”
treatment plans.
–––––––
NCMIC was founded in 1946 for the
express purpose of providing the chiropractic profession with malpractice
coverage. Today, we are the company
trusted by more than 40,000 D.C.s—
and growing—and chiropractic colleges and universities across the U.S.
For more information about NCMIC,
call 1-800-769-2000, ext. 3809.
©2014 NCMIC Group, Inc. All rights reserved.
What Fees Can a Provider Charge
for Medicare Beneficiaries?
COST-EFFECTIVENESS OF GUIDELINE-ENDORSED TREATMENTS FOR
LOW BACK PAIN1
With skyrocketing increases of
healthcare costs, and for low back
pain (LBP) in particular, it is mandatory to apply treatments that are
cost-effective as well as effective. A
recent systematic review evaluated
the cost-effectiveness of guidelineendorsed treatments for LBP, searching
nine clinical and economic electronic
databases as well as the reference list
of relevant systematic reviews. The
guidelines consulted were those of the
American College of Physicians and the
American Pain Society. The 26 studies
evaluated by two independent reviewers found that interdisciplinary rehabilitation, exercise, acupuncture, spinal
manipulation, or cognitive-behavioral
therapy were cost-effective for individuals with subacute or chronic LBP. Results were inconsistent for advice, and
there was insufficient evidence on spinal manipulation for people with acute
LBP, with no evidence available on the
cost-effectiveness of medications,
yoga, or relaxation. Massage alone was
unlikely to be cost-effective.
1. Lin C-W C, Haas M, Maher CG, Machao
LAC, van Tulder MW. Cost-effectiveness
of guideline-endorsed treatments for
low back pain: A systematic review.
European Spine Journal 2011; 20(11):
1024-1038..
RESPONSE TO THORACIC MANIPULATION IN NECK PAIN PATIENTS1
To buttress the literature documenting the effectiveness of spinal
By Anthony L. Rosner, Ph.D., LL.D.[Hon.], LLC
ANJC Consultant - Research Analyst
manipulation in managing neck pain,
a randomized controlled trial was
conducted to compare the effects of
thoracic thrust manipulation to nonthrust mobilization in patients with
bilateral chronic mechanical neck
pain. Fifty-two patients were randomized to thrust manipulation or mobilization. Outcome measures included
pressure pain thresholds (PPTs) over
the C5-C6 zygopophyseal joint, second metacarpal, and tibialis major
anterior muscles as well as numerical
pain scales. The results indicated
that (1) there was a greater decrease
in neck pain in the manipulated group
(odds ratio 1.4); (2) the between
group effect size was large, favoring
the manipulated group, and; (3) the
effects in the decrease of the PPT
was similar in both groups. In conclusion, this investigation supported the
effectiveness of spinal manipulation
in managing mechanical chronic neck
pain and displayed some advantages
over non-thrust mobilization.
1. Salom-Moreno J Ortega-Santiago R,
Cleland JA, Palacios-Cena M, TruyoisDominguez S, Fernandez-de-las-Penas
C. Immediate changes in neck pain
intensity and widespread pressure sensitivity in patients with bilaterial chronic
mechanical neck pain: A randomized
controlled trial of thoracic thrust manipulation vs non-thrust mobilization.
Journal of Manipulative and Physiological Therapeutics 2014; 37(5): 312-319.
MANAGEMENT OF IRRITABLE
BOWEL SYNDROME WITH OSTEOPATHIC MANIPULATION 1
By David Klein, CPC, CHC – ANJC Insurance Consultant
I
frequently get questions regarding
fees and how much a provider can
charge Medicare patients. Most
of the time it’s a provider who is out
of network and they are not sure how
much they can charge. For both innetwork and out of network providers,
Medicare law places specific limitations on how much they can charge as
fees for their services or supplies. Of
course for in-network providers they
have to limit their fees to the allowed
amount, however for out of network
providers the limitations are referred
to as the limiting charges.
42 Code of Federal Regulations,
Section 414.48 is entitled, “Limits
on actual charges of nonparticipating
Elevate your Practice
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How Much Can Nonparticipating
Providers Charge under State Law?
I know of four states that have
passed balance billing statutes—
statutes that potentially restrict what
Medicare non-participating providers
can charge as fees for their services
and supplies. Research revealed New
Jersey is not one of them.
The four states include Ohio,
Pennsylvania, New York, and
Massachusetts.
How to Calculate the Allowable
Charges under Medicare
Given the above information, Medicare providers (participating and
nonparticipating) can determine how
much they can charge for their services by performing some simple steps:
Register for a Free Demo at
PayDC.com or call 888-306-1256.
www.PayDC.com
NJChiroSpring_Feb14_v1.indd 1
suppliers.” Section 414.48 provides:
(b) Specific limits. For items or
services paid under the physician fee
schedule, the limiting charge is 115
percent of the fee schedule amount...
For items or services CMS excludes
from payment under the physician
fee schedule…, the limiting charge
is 115 percent of 95 percent of the
payment basis applicable to participating suppliers as calculated in §
414.20(b). - 42 CFR, Section 414.48
3/25/14 12:00 PM
Step 1
Determine the Medicare fee schedule allowed amount based on a particular location. If you do not know
the exact fee schedule for Medicare
in your geographical area you can
determine it by clicking on the link
below and following the instructions:
http://www.cms.gov/apps/physicianfee-schedule/license-agreement.aspx
1. Enter in the current year
2. Select a Single Code, Range of
Codes or List of Codes
3. Select Pricing Information
4. Select Specific Locality
5. Select Default Fields
6. Enter the CPT/HCPC code(s)
desired
7. Select All Modifiers from the drop
down list
8. Select your practice’s Locality
from the drop down list based on
geographic location
9. Click submit
A chart will appear listing the
Medicare fee schedule amount for
your geographical area.
10.Most if not all chiropractors
should select the fee schedule
amount for the code(s) searched
from the column labeled NonFacility Price.
11.According to CMS’s web site,
providers should select the fee
schedule amount for the code(s)
searched from the column labeled
Facility Price, if they are performing services under the following
circumstances:
• inpatient or outpatient hospital
settings,
• emergency rooms,
• skilled nursing facilities, or ambulatory surgical centers (ASCs),
Continued on Next Page
What Fees Can a Provider Charge
for Medicare Beneficiaries?
• inpatient psych facilities,
• comp inpatient rehabilitation
facilities,
• community mental health centers, military treatment facilities, ambulance (land, air or
water),
• psychiatric facility partial hospital, and psychiatric resort
treatment centers.
Step 2
On the chart you will be able to
choose from the list of fees. If you
are a nonparticipating provider, select
the fee(s) from the limiting charge
column to determine the maximum
amount you can charge your patient.
I would run this report for all services
and supplies provided by the practice.
Even if a service is not covered (e.g.
CPT 97140), Medicare will publish
the fee schedule as long as Medicare
recognizes the code.
What about Services Not Covered
by Medicare?
Of course for chiropractors, Medicare only covers CPT codes 98940,
98941, and 98942. Therefore all
other services provided are statutorily excluded from coverage and may
not be subject to the Medicare fee
schedule’s restrictions. According to
Medicare Carriers Manual 50.7.7.4
[emphasis added]:
21
“When an ABN was properly executed and given timely to a beneficiary
(who, if RR applies, agreed to pay in
the event of denial by Medicare) and,
in fact, Medicare denies payment on
the related claim (whether assigned
or unassigned), the physician or supplier may bill and collect from the
beneficiary for that service. Medicare
does not limit the amount which the
physician or supplier, participating
or nonparticipating, may collect from
the beneficiary in such a situation.
Medicare charge limits do not apply to
either assigned or unassigned claims
when collection from the beneficiary is
permitted on the basis of an ABN.
Based on the above, some providers
will charge their full fees to patients if
the service is not covered. In my opinion, providers should take a cautious,
practical approach to charging Medicare patients for non-covered services.
Consistency is key and a provider
charging Medicare beneficiaries the
Medicare published fee for services,
even if they are non-covered, is the safest, most practical approach. Notably,
I strongly suggest that providers speak
with a healthcare attorney before
adopting a policy regarding charging
fees in excess of the published Medicare fee schedule. Overcharging Medicare beneficiaries can have serious
consequences, both from a business
standpoint and a legal one.
To assess the effectiveness of
osteopathic manipulation (OMT) in
adults for whom irritable bowel syndrome was diagnosed, an evaluation
of published randomized trials addressing this problem was conducted.
Studies were excluded if OMT was
not the sole intervention employed.
Two reviewers extracted data from
the Cochrane Collaboration, using
a consensus method to resolve disagreements over study quality. Five
studies met the inclusion criteria
out of the ten retrieved. All studies
reported more pronounced short-term
improvements with OMT compared to
sham therapy or standard care only,
the differences remaining statistically
significant after variable lengths of
followup in three studies.
1. Muller A, Frank H, Resch K-L, Fryer G.
Effectiveness of osteopathic manipulative therapy for managing symptoms of
irritable bowel syndrome: A systematic
review. Journal of the American Osteopathic Association 2014; 114(6):
470-479.
SPINAL MOBILIZATION EFFECTS
ON THE SYMPATHETIC NERVOUS
SYSTEM1
The objective of this systematic
review of the literature was to investigate the effects of spinal mobilization
compared to a control or placebo with
respect to sympathetic outcome measures, as well as establishing the level
and direction (excitatory or inhibitory)
of change. Five electronic databases
were selected for randomized controlled trials, using two independent
raters to apply inclusion criteria and
ratings for methodological quality.
All studies demonstrated consistent
increases in sympathetic outcome, irrespective of the segments mobilized.
There was strong evidence for positive
changes in skin conductance, respiratory rates, blood pressure, and heart
rates among healthy populations.
One study revealed a decrease in skin
temperature. Overall, the evidence
supported a sympatho-excitatory response to spinal mobilization, regardless of the segment mobilized.
1. Kingston L Claydon L, Tumilty S. The
effects of spinal mobilization on the
sympathetic nervous system: A systematic review. Manual Therapy 2014; 19:
281-287.
–––––––
Anthony Rosner is an interdisciplinary research in the health sciences,
serving as Research Director of the
International College of Applied Kinesiology, previously having been Director of Research and Education at the
Foundation for Chiropractic Education
and Research, Director of Research
Initiatives at Parker College, Department Administrator in Chemistry at
Brandeis University, and Technical
Director of multiple laboratories at
Beth Israel Hospital (a teaching
hospital of Harvard University), and
of an affiliate of the Mayo Clinic. He
obtained his Ph.D. from Harvard in
Medical Sciences/Biochemistry in
1972. His bibliography lists over 85
peer-reviewed publications.
22
By Jeffrey Randolph, Esq.
- ANJC Legal Counsel
LEGAL
EASE
Landmark Decision Holds There
Is No Right to a Jury Trial
Under the New Jersey Insurance Fraud Prevention Act
O
n October 9, 2013, the New
Jersey Appellate Division issued its decision in the case
of Allstate v. Lajara, a case brought
by Allstate Insurance Company
against multiple healthcare providers,
including chiropractors, under the
New Jersey Insurance Fraud Prevention Act (NJIFPA), N.J.S.A. 17:33A1. This decision is important to all
healthcare providers that practice in
New Jersey because for the first time
an appellate court has held that there
is no right to a jury trial for a healthcare provider sued for insurance fraud
under the NJIFPA, raising significant
constitutional concerns of abrogating
the constitutional right to a jury trial.
In Lajara, Allstate Insurance Company alleged they paid $8.2 million
in personal injury protection (PIP)
benefits to numerous physicians,
chiropractors, and healthcare facilities that were later determined to be
fraudulent. Allstate sued the defendants in a 42 count complaint alleging violation of the NJIFPA and other
statutory and regulatory provisions.
The complaint sought a declaratory judgment that Allstate was not
obligated to pay PIP benefits to the
defendants; disgorgement of sums
already paid to the defendants; imposition of a constructive trust and
equitable lien on defendants’ assets
until they disgorged the sums sought,
and; triple damages and attorney’s
fees under the NJIFPA.
The trial judge struck the defendants’ request for a jury trial finding
that there was no express or implied
right to a jury trial under the NJIFPA.
The defendants appealed and the Appellate Division unanimously affirmed
the trial judge’s holding, stating that
they “. . . decline to find by implication
a right that does not exist in the statute’s plain language, nor is compelled
by the legislative history or the intent
of the statute.” The Appellate Court
found it compelling that New Jersey
legislature could have included an express right to a jury trial in the NJIFPA
statute, but it did not. The court further reasoned that the Constitution
does not guarantee a trial by jury for a
statutory claim that was unknown to
the common law, such as the claims
created by the NJIFPA. The court held
as such despite the fact that the New
Jersey Constitution provides that the
“right of trial by jury shall remain inviolate” N.J. Const., art I, ¶ 9.
Following the Appellate Division decision, the defendants filed a petition
for certification to appeal the case
to the New Jersey Supreme Court.
This request for appeal was granted
on March 14, 2014, and the case is
presently pending before the Supreme
Court. The ultimate determination of
the court on this case is of utmost
importance to chiropractors and all
healthcare providers for a number of
reasons. First and foremost, as stated
before, the right to a jury trial in important matters such as insurance fraud
cases, which could subject a doctor
to millions of dollars in damages as
well as corollary criminal or licensing
board matters, is guaranteed by the
New Jersey Constitution. This decision
as it stands takes away this constitutionally guaranteed right and requires
such cases to be tried before a judge
in a “bench trial” as opposed to before
a jury of the doctor’s peers. Second,
should the decision be affirmed on appeal, it could be the proverbial “camel’s nose in the tent,” which will lead
to the denial of a jury trial in other
cases wherein the statute sued under
does not clearly and expressly grant a
right to a jury trial. This slippery slope
must be avoided.
The New Jersey Supreme Court
has the final call on this significant
issue to chiropractors and healthcare
providers across our state. The ANJC
will keep its membership apprised of
the proceedings in the case as they
occur.
Chiropractic and the Paleo Diet, Part 2
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135 Bloomfield Ave., Suite B,
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The thermal scan is used to see
inflammation patterns around the
patient’s spine. The sEMG is used to
detect muscle spasm patterns and
overused muscles. HRV allows us to
see what level of stress the patient
is in and how balanced their parasympathetic and sympathetic nervous
system is. With these three scans the
system creates what is called a CoreScore. This is a singular number that
integrates the three scans into one
neat number. This keeps our version
of a 30 Day Paleo Challenge uniquely
chiropractic. With the CoreScore we
can track how their neuromuscular
system is responding to their weekly
adjustments and how their shift away
from an inflammatory diet to the antiinflammatory paleo diet has affected
their overall health and wellness as
well. We scan and weigh people on
the first day of the challenge, two
weeks later, and then the last day of
the challenge. We tabulate the winners using the formula of 67% weight
loss and 33% increase in overall
CoreScore. This we be explained with
our overall results in detail in the
third part of this series.
Step #6: Announce the winners.
Once all of the information is gathered we present the first place and
second place winners with their monetary awards with great enthusiasm.
In part three of our series, we will
outline the successes and results of
our 30 Day Paleo Challenges, what
the scans represent in greater de-
tail, the pitfalls, and what we have
learned along the way.
–––––––
Dr. Michael Acanfora has been a
chiropractor serving the Bayonne
community for the last 17 years. He
received his Doctor of Chiropractic
from Life University in Marietta, Georgia. Dr. Acanfora is a paleo advocate,
published author, and noted public
speaker. Dr. Acanfora is an ANJC
member, SHINE doctor, and cofounder
of EPOC NJ. For more information he
can be reached at [email protected] or 201-858-0444.
Dr. Noah is a lifelong chiropractic
patient and paleo diet enthusiast. At
a very early age, Dr. Noah suffered
from chronic strep throat and earaches. His health was restored from
specific chiropractic adjusting. Dr.
Noah graduated in December 2000
from Life University. He is a member of
the ANJC since its inception, an avid
runner, a Toastmaster, a Rotarian,
Board Member of the Ahern Scholarship Foundation, SHINE Doctor, and
co-founder of EPOC NJ. He has been
married to his beautiful wife Kerri
for 12 years and has two incredible
children. Dr. Noah can be reached at
201-437-0033, on Facebook, at his
Blog drnoah.wordpress.com, at his
app in the iPhone app store, or at
www.fccofbayonne.com.
Don’t Play It Again, Sam
portion of many systems. This is not
the result of limited quality or options
from software companies. It is a result of the diversity of chiropractic.
I have taught and consulted with
chiropractors across the country over
the past twenty years, and I have visited many of their offices. Going from
one chiropractic office to the next is
not like going from one McDonald’s
to the next. We are, with few exceptions, thousands of independent
islands in the sea of healthcare, particularly when it comes to treatment
and recordkeeping methods.
Our traditional arrangement of
independent practice has created
diversity unlike any other healthcare
profession. In many cases our diversity has been our strength. It has
taken independent, strong-minded
individuals to march to the beat of a
different drummer in healthcare for
over a century.
Unfortunately, our demand for
equal healthcare rights in government
and insurance programs has now
placed us in the boat with all other
providers. We can no longer afford
the degree of independence we once
enjoyed. Everyone must meet the
government’s standards under the Affordable Healthcare Act by participating in electronic healthcare records,
HIPAA, PQRS, Meaningful Use, and
other programs now mandated. Everyone is accountable to outside entities
now more than ever before.
To make the transitions as easy
as possible, it is best to select the
system that offers the best combination of billing software and customizable health records. The billing portion system is vital for the continued
flow of income. The customization
portion of the system is vital for recording records in accordance with
regulations and the doctor’s methods of care.
Each system will have a baseline
of clinical procedures that all doctors
perform. The only variance may be
the order they occur within the system. This creates the need to have a
system that allows rearranging clinical fields. Beyond this the system
should be easy for the doctor to add
or subtract clinical fields and choices.
Easy cannot be stressed enough
here—we are doctors, not information technologists.
Customization will be a process. It
will take time to learn how to customize and to determine the content and
extent of the needed customization.
When focusing on the extent of
the customization, the principle
consideration must be on diversity.
Notes that read the same day in and
day out are to be avoided. Canned
notes have been a criticism of electronic records for years.
Conversely, in some situations this
is unavoidable. Patient conditions and
our procedures do tend to repeat. It
is the nature of what we do. However,
there has to be some diversity between repeated patient encounters.
Updating signs and symptoms,
pain scales, outcome assessments,
and other procedures must be performed frequently enough to reflect
the changes in a patient’s response
and care. There must be progress.
Otherwise, the records reflect prolonged unsuccessful care and do not
substantiate continuation of care.
This last thought is the exact opposite of many chiropractors’ views.
It is not uncommon to hear the statement, “The reason the records are
the same is the patient has a severe
case and it will take a long time to
see change in his condition.” This
opinion cannot be supported in the
majority of cases.
Progress is expected early and
progressively in acute conditions and
in chronic conditions until they either
resolve or enter a stage of remission
or stabilization.
This view of progress is not limited
to third party payers. It is the view
taken by many in our profession. The
CCGPP guidelines are an example.
This discussion is meant to alert
the doctor to the need to deliberately
pay attention to clinical detail. Third
parties judge a doctor’s performance
based not only on notes that repeat
but also on what is repeated in the
notes.
Efforts must be made to avoid redundancy of information that should
have been one-time or intermittent
entries. Mistakes here often happen
with systems that allow a note to be
repeated if nothing changes between
visits.
For example, I customized an EHR
system for a group to include statements similar to the following.
Imaging is not warranted at this
time. Imaging will be considered in the future based on the
patient’s response to care and
necessity.
The patient received a report of
findings today. The patient’s clinical findings, diagnosis, treatment
recommendations, treatment options, and risks were all explained
during the report. Care was
accepted.
These are great one-time statements. In the first the doctor did
not feel imaging the patient was
necessary initially but was leaving
the door open to future need. In the
second the doctor was documenting
the process that leads to patient
consent.
Once these statements are used
however, they should not be repeated. In systems where notes can
be duplicated, if the statements are
not removed they will automatically
repeat every visit until it is noticed.
I have seen the report of findings
statement appear seven or more
times in the group’s patient notes.
Repetitiveness of this nature is
much worse than simply repeating
a daily note when the patient’s daily
notes are routine. It shows the doctor
was not paying attention while documenting the patient’s care. When
this occurs, the question “What else
wasn’t he paying attention to?” will
come to the reviewer’s mind.
Many of these one-time statements occur during the patient’s first
or second visit. A short checklist can
be developed by the doctor to double
check the first two to three notes in a
patient’s course of care to make sure
the statements do not repeat in subsequent notes.
Repetitive, canned notes are a
problem that can be corrected with
thought and attention. The efforts
must be made for patients and the
profession. In the long run the efforts
will be well worth the initial struggles
encountered with implementation. Records will be readable, clear, and accurate. The days of travel cards with
hieroglyphics and bad handwriting are
over, as they should be.
23
ANJC Submits
Comments Defending
the Provider NonDiscrimination Clause
of Obamacare
Response Is at the Request for Information
from the Department of Health and Human
Services (HHS)
B
RANCHBURG, N.J., June 13,
2014. The Association of New
Jersey Chiropractors (ANJC)
submitted comments this week to
the Department of Health and Human
Services (HHS) defending the Provider
Non-Discrimination clause, Section
2706(a), in the Patient Protection and
Affordable Care Act (PPACA), more
commonly known as Obamacare.
The ANJC, in a response to a request for information from HHS, is
asking officials to strengthen and
clarify the interpretation of Section
2706(a) regarding non-discrimination. As it stands, this law strives
to eliminate provider discrimination,
thus enhancing patient choice and
reimbursement for healthcare services. However, this section of the
federal law has come into question
recently with some states experiencing reimbursement discrimination
for services provided to patients due
to inconsistent interpretation of the
federal law by insurance companies.
The ANJC maintains that the govern-
ment’s intent in these laws is clear,
and that the insurance companies
must be required to strictly adhere to
this intent.
“These comments submitted by
ANJC, and organizations like it across
the nation, seek to protect patients
and their choice of doctors, as well
as bring an end to discriminatory
practices of insurers. There is a
problem and we are asking the HHS
to arrive at a better, more accurate
application of the federal law,” said
Dr. Joe D’Angiolillo, president of the
ANJC. “Non-discrimination for providers gives patients a broader choice
in doctors and services provided by
those doctors. It allows patients to
have access to physicians who are
the most qualified and highly trained
to perform specific procedures.”
The ANJC is committed to making
chiropractic care information available to the public. For more information or to locate an ANJC chiropractic
physician, visit www.njchiropractors.
com or call 908-722-5678.
24
25
Their Problem Isn’t Your Problem
Are You Keeping A Finger on the Pulse of
Your Practice? How a Policy’s Processing
Method Affects Claims Payment
By Lynette Contreni – ANJC Insurance Consultant
I
nsurance carriers keep paying
less!” If I had a quarter for every time a provider said that to
me. My response—I agree! It sure
seems like the insurance carriers
are finding more and more ways to
decrease their financial liability while
increasing the patient’s responsibility. This shift in cost share could
obviously affect the overall income
stream of a healthcare provider. It
is imperative to keep a finger on the
pulse of the practice to know when
such things are effecting the practice’s overall financial picture.
It’s long been a suggestion of
mine for providers to make sure that
the carrier’s processing method,
which is policy specific, be identified
in the insurance verification process,
and then subsequently monitored in
the EOB evaluation. Unfortunately,
I find that both of these processes
are often lacking and could use
improvement.
Years ago there was generally one
out of network processing method:
Reasonable & Customary (aka
R&C or UCR). So for example, if
the nonparticipating provider billed
$150.00, and the patient is covered
80/20, then the insurance payment
would be approximately $120.00 and
the patient responsibility would be
$30.00.
But the R&C processing method
is no longer the only processing
method for out of network claims.
Unfortunately other processing methods are decreasing the insurance
liability and increasing the patient
responsibility. Providers need to
understand these other processing
methods and how they effect insurance reimbursement, which then affects the practice’s overall income.
Consider this. Most offices have
an insurance verification process in
place, and most offices have financial discussions with their patients
based on that verification. Generally this is done to ensure that the
provider’s financial interests are
protected and to educate the patient
about what they will be expected to
pay. This process is imperative to
streamline the overall management
of the patient’s account. Therefore,
can you see how much less effective
this process is if the information being used in the process is less than
adequate? Shouldn’t it be obvious
that the amount of anticipated insurance payment vs. the anticipated patient responsibility have a big impact
on this discussion? Knowing the
processing method of the policy will
allow you to base these discussions
on more accurate information.
Let me elaborate. In the example
above, the insurance would pay
approximately $120 and the patient would pay $30 with an R&C
processing method. So how would
another processing method change
that equation? What if the processing method is what I refer to as a
percentile processing method. This
processing method is actually more
common than you think. In this processing method the carrier calculates the allowed amount based on
a percentile of R&C and then compares that to your billed charges.
The lesser of the two will become
the new allowed amount. Then the
carrier will process the charges from
there. Please don’t misunderstand
this. This is not the 80% in the example above. Sounds complicated?
Let me clarify.
Let’s say the provider bills $75 for
98942 (for the purpose of this example). Now let’s say that the R&C
scale the carrier is using reflects
$80 as R&C for 98942. Let’s also
say that the processing method in
the patient’s policy is based on the
90 th percentile. The carrier will calculate the $80 at 90 th percentile,
which is $72. That means your $75
billed charge will be reduced to $72
and then the claim is processed at
80%. Of course, if your fee is the
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calculated the carrier will leave your
billed charge as the allowed amount.
So just to build on that same example, if the policy processes at
the 85th percentile then the 98942
billed at $75 is reduced to $68.00
and then processed at 80%, and
so on and so on. Have you ever noticed that for the same carrier and
your same CPT, the allowed amount
changes from the provider’s billed
charge to a $5 reduction or to a $10
reduction on yet another EOB? The
insurance carrier is the same. Your
CPT and fee is the same. But the
allowed amount is different. That is
because the patients all have a percentile processing method in their
policy guidelines and it is a different
percentile for each of those patients.
It is important to know for that
financial discussion with the patient
that the insurance reimbursement
may be slightly less (or significantly
less) than what you were thinking
when you were only considering the
80/20 coinsurance. And ultimately,
the patient’s responsibility is higher
than what you were thinking. The
patient is still responsible for the
20%, but they are also responsible
for the amount between the $150
billed charges and the new allowed
amount.
Let’s take a look at another processing method. I refer to this one
as the maximum carrier allowed
amount processing method. In this
example, the patient’s policy has
a restriction in the guidelines that
limits the out of network allowed
amount. In these types of policies,
the percentile is not based on R&C,
but is based on something else,
such as the Medicare fee schedule. So for example the policy may
specify they only allow charges up to
130% of the Medicare fee schedule.
Let’s again use the example above
and apply this processing method.
The $150 billed charges may be reduced to $98.37 and then processed
at the 80% benefit for an insurance
payment of $78.69. In this instance
the patient is responsible for the
20% and the difference between
the billed charges and the allowed
amount—$71.31. Again, this shifts
more financial responsibility to the
patient and less to the carrier.
Of course, out of network providers are also subject to the processing method of silent PPO reductions.
However, when a PPO reduction is
applied to the provider’s out of network reimbursement, the patient is
not responsible for the difference
between the billed charges and the
allowed charges. In this case, the
provider has no recourse in that reduction other than to evaluate the
PPO contract for the future.
I have spent most of this article talking about the processing
methods applied to out of network
reimbursement, so I wanted to at
least give a brief mention to the
participating provider. For the participating provider, it is slightly easier
to police your EOBs in regard to the
processing method. Obviously participating providers are subject to
the fee schedule as dictated in the
signed contract. I would suggest all
providers have their fee schedules
available to make sure it is being
properly applied on the EOB. The fee
schedule of each carrier should be
easy information to obtain. You can
either obtain it online, or contact the
insurance carrier or managed care
network to obtain a copy. However,
make no mistake, although it is easier than the nonparticipating provider,
there is still some policing to do. The
insurance carrier or managed care
company does not always apply the
fee schedule correctly.
In closing, I would like to impress
upon all readers that I chose to
write about this topic because providers and their support staff need
to have a better understanding of
these processing methods. They
need to use this information when
they are evaluating the financial
picture for both the provider and
the patient. They need to use this
information when evaluating EOBs,
to reduce unnecessary wasted time
and effort. Be knowledgeable about
what is insurance responsibility and
what is not—and what is patient responsibility and what is not. I often
observe offices leaving claims open
because it is assumed they are paid
wrong, when it really may not be
paid wrong at all. I see many statements being sent to the patients
that remain uncollected because
the patients don’t understand what
they are being billed for. And lastly,
I see providers writing off these
balances as un-collectable from
either the insurance or the patient.
It would be one thing if that was
a conscious decision made based
on all relevant information, but it
is more often a decision made because of a lack of understanding. I
am hoping that changes after reading this article.
One other point to consider: if you
have not collected these amounts
from the patients, consider creating
a process (maybe an adjustment
code in your billing system) that
allows you to track how much revenue this amounts too. Remember,
informed decisions about such matters will always allow you to keep
that finger on the pulse of your practice and make changes when necessary.
–––––––
Lynette Contreni Bernier is the
founder and President of CB&C, Inc.,
a billing, collection, and consulting
company specializing in chiropractic
and multidisciplinary practices. She
can be reached at [email protected] or 973-827-3544.
ache, pain, or other symptom is merely
a form of body-to-brain communication.
A limit has been reached. Change is
necessary.
Naturally, if you allow patients to
think their problem is their ache or
pain, then you can easily find yourself
in a fearful state. Especially with little
more than chiropractic adjustments in
your pain treatment arsenal.
If all a patient wants is pain relief,
you’d probably best refer them to a
medical doctor for a prescription for Vicodin or Oxycotin. They’re much faster,
more convenient, and less expensive.
Thankfully, if you dig a bit deeper
you’ll discover that patients want
something more than pain relief. As in,
“I want pain relief without the side effects of drugs.” Or, “I want pain relief
through natural methods.” Or, “I want
pain relief without becoming dependent
on a drug or a doctor.”
Okay, they’ve considered a medical
solution and they prefer what you’re
serving up. Great!
Now, simply because patients want
pain relief, doesn’t mean you must
agree to deliver it. Accepting a patient
on the grounds that you deliver pain
relief, whether implicitly or explicitly,
besides being the practice of medicine,
is a promise you cannot deliver with
anything near the certainty of drug
treatment. Again, fail to make this distinction with patients and you set yourself up for needless misunderstanding
or disappointment. This is the missing
component of the initial pre-care interview. Far too many chiropractors are
simply thankful to have someone in
front of them who wants to be helped
to be mindful to explain that chiropractic adjustments don’t treat pain.
Granted, this is a communication
challenge. But not an insurmountable one. Before you can powerfully
and confidently communicate with
patients, you must have laser-sharp
boundaries, clarity about your limitations, and certainty about what your
chiropractic intervention is actually
doing. For starters, it’s not treating a
patient’s symptoms!
Instead, it’s reviving the life force in
their body, remember? You’re helping
reduce nervous system interference
so brain-to-body and body-to-brain
communications can work more faithfully. Relief of the patient’s symptoms
often seems to follow when this is
successfully accomplished, but it’s an
indirect effect. And its timing, if it occurs, is unpredictable.
Being in the pain relief business
is fraught with still other challenges.
Is the patient willing to become an
active partner? Will they drink more
water? Will they start walking and
getting more exercise? Will they get
more than five hours of fitful sleep?
Will they reduce their consumption of
alcohol or tobacco? Lose the weight?
You know the list. The point is, if patients expect you to do all the heavy
lifting, and they are no more engaged
than when they’re having their car’s
oil changed or getting a haircut, the
chance of this resolving as you’ve implicitly promised is risky indeed.
Just to operationalize what this
might sound like at your consultation,
before you formally accept them as a
new patient you might say: “Based on
what you’ve shared with me it sounds
like you’re a good case for chiropractic
care. In fact, we’ve helped a lot of patients with problems just like yours. It’s
practically routine around here.
You mentioned that your headaches
are what has brought you to our prac-
tice. Just to be clear, we don’t treat
headaches. That would be the practice
of medicine. Have you tried a medical
approach to this problem?”
Of course they have. But you’d want
to understand why they’re in your practice and why their allopathic approach
was seemingly unsatisfactory.
“Now that’s not to say we haven’t
helped people with headaches! We’ve
helped hundreds. Maybe thousands.
But we do it by reviving your body’s
ability to work the way it’s supposed
to. Headache relief usually comes
after your nervous system is working properly—the speed of which is
something you control, not me. Plus,
it’s dependent on what you’re willing to
do between visits, such as improving
your diet, getting more exercise, better
sleep, that sort of thing. Is that what
you’re looking for?”
If you really want to make sure your
new patient understands, you must ask
them a couple of follow up questions.
So, take on a lighter tone and ask!
“Okay, now before we accept you
as a new patient, a quick pop quiz.
Ready?”
What choice do they have? After
completing your paperwork, waiting
to see you, and telling you their story
they’re unlikely to leave in a huff. (If
they do, this individual shouldn’t be in
your practice anyway!)
“First question. Are you in the right
place?”
“I think so.”
“Correct! Second question. Do we
practice medicine?”
“No.”
“Correct! And now the biggie. Question three: Do we treat headaches?”
“It sounds like you help people who
have headaches, but you don’t treat
headaches.”
“Bingo! Yahtzee! Welcome to our
practice! Shall we get started?”
Okay, that might be a bit over the
top, but dial it back a notch or two. The
point is, with or without the quiz you
have an obligation to clarify what makes
chiropractic different, explain what you
do, and affirm that it is a partnership.
Anything less and you’re accepting their
expectation of pain relief without lifting
a finger or making any other changes in
their life. Accepting the patient without
resolving this distinction risks far more
than potentially disappointing them.
You needlessly put your self-confidence,
certainty, and financial investment in
becoming a chiropractor on the line.
Risky business, this notion of treating symptoms.
–––––––
William Esteb is the creative director of
Patient Media, Inc., a patient education
and practice success resource for the
chiropractic profession. He is the author
of 10 books describing the doctor/
patient relationship from the patient’s
point of view, provides a free weekly
email, Monday Morning Motivation, and
regularly conducts The Conversation.
Learn more at www.patientmedia.com.
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26
How to Determine Who Is a Business
Associate and What to Do?
PPACA Sec. 2706, the NonDiscrimination Clause—in Jeopardy?
By Wiks Moffat
By Matt Minnella – ANJC Director of Insurance
A
t this moment it seems everyone is scrambling to understand—in a concise way—who
is a Business Associate (BA) and how
to manage them. Certainly a daunting
and time consuming challenge. This
is a valid concern as this regulation
carries with it extensive liability and
large fines. The regulation requires
that the Covered Entity (CE), which
is the chiropractic practice, update
their business associate agreements
(BAAs) and get validation from all
their BAs that they are compliant.
In short, the BA is required to have
written HIPAA-HITECH policies and
procedures that comply with the updated regulations. Conduct a security
risk audit. Train their employees and
have a mechanism in place to maintain compliance. Bottom line: a BA
needs to implement and maintain the
same compliance program that the
chiropractic practice is also required
to have.
So who is a BA?
Definition: A “business associate”
is a person or entity that performs
certain functions or activities that
involve the use or disclosure of protected health information on behalf
of, or provide services to, a covered
entity.
Hint: A good way to figure this out
is to look at your accounts payable
and ask yourself: “Based on what I
have hired them to do, do they need
access to PHI in order to perform
those functions?” From there, you
need to make sure they have policies
and procedures to prevent and identify a breach, a training program for
their employees, and have completed
an IT security risk assessment. In
other words, the BA needs to have
a program just like a chiropractic
practice. Finally, make certain that
all BAs have been given your updated
Business Associate Agreement and
have returned it to you with signatures. This needs to be done each
time you contract with a new BA. Review it annually.
Examples of who is a BA:
• IT service organizations
• A CPA firm whose accounting
services to a healthcare pro-
Welcome New Members!
Dr. Paul L. Friedman
Dr. Wendy Menneg
Dr. Perry Metzger
Dr. Mitchell Pernal
Dr. Gina Poletti-Leckburg
vider involve access to protected
health information
An attorney whose legal services
involve access to protected
health information
Consultants that perform coding
and chart audits
Healthcare clearinghouses
Shredding services
Transcription services
Billing companies
Collection agencies
the audit of your BAs and most importantly document their response that
they have attested back to you that
they have a program in place.
In summary, pulling together your
BA program is not terribly difficult,
just a bit time consuming and another one of the unfunded mandates the
government has burdened all medical
practices with.
How do you audit your BAs? After
you have compiled your list of BAs,
based on the list above, you will need
to contact all of them and ask the
three basic questions.
• Have you written individualized
policies and procedures to comply with HIPAA-HITECH?
• Have you trained your
employees?
• Do you have a mechanism in
place to maintain compliance?
Wiks Moffat is a pioneer in the
Healthcare Compliance industry and
has over 23 years of experience and
expertise. In this capacity, he has
done compliance assessments in over
1,000 medical practices of all sizes.
He is also a sought-after speaker to
both national and state associations.
In his current role, he is a principal and
founder of MedSafe, which has served
over 5,000 chiropractic practices in
implementing regulatory compliance
plans for HIPAA-HITECH, Corporate
Compliance/Fraud, Waste and Abuse,
billing compliance and code auditing,
and OSHA safety.
•
•
•
•
•
•
•
This is best accomplished by email, simply because you will have
documentation that you have done
–––––––
Dr. Zachary Voyce
Dr. Bibo Zhang
The New Jersey Chiropractor is a bimonthly publication of the Association of New Jersey Chiropractors. To assist with the many challenges of everyday practice, it is filled with updates and extraordinary
ideas from our profession’s best and brightest minds and serves as a leading information resource for
the more than 3000 chiropractors located throughout the Garden State. We hope you enjoy ANJC’s
latest effort to keep you updated and informed. The Association of New Jersey Chiropractors - The kind
of association you’ve been aching for!
S
ec. 2706 of the Patient Protection and Affordable Care
Act (PPACA) is known as the
non-discrimination provision of the
law. This part of the law states that
carriers, “shall not discriminate with
respect to participation under the
plan or coverage against any health
care provider who is acting within
the scope of that providers license
or certification under applicable
State law.” The law makes clear that
carriers are not obligated to contract
with any provider willing to abide by
the carrier’s terms. The section also
notes that the carriers are allowed
to vary reimbursement “based on
quality or performance measures.”
The great hope for this part of the
law was that it would once and for
all prevent carriers from writing out
certain types of essential care from
plans, especially chiropractic. This
provision has been in effect since
January 1, 2014. Unfortunately,
since then we have seen disappointing interpretations of this law by carriers and regulatory agencies alike.
There are many issues related
to the non-discrimination clause
and the erroneous interpretations
thereof. The two issues I wish to
focus on here are participation and
reimbursement. As you just read, the
statute notes that carriers are not
to discriminate with respect to participation under a plan for a provider
acting within their state-specific
scope of practice. PPACA law mandates that 10 essential health benefits (EHBs) be included in all health
insurance plans starting in 2014.
Among these EHBs is Rehabilitative
Services. One could draw the conclusion that as rehabilitative services
EXECUTIVE DIRECTOR
• Dr. Sigmund Miller
ASST. EXECUTIVE DIRECTOR
• Diane Philipbar-Fetzer
ANJC APPOINTED OFFICIALS
• Dr. Richard Healy
Treasurer
IMMEDIATE PAST PRESIDENT
• Dr. Steven Clarke
ANJC STAFF
• Matt Minnella
Director of Insurance
• Susan Cully
Events and Member
Services
• Jennifer Makuna
Administrative Assistant
and Operations
• Clara Campbell
Financial Operations
Associate
ANJC STATE BOARD MEMBERS
Central
Dr. Robert Blozen
Dr. Joseph D’Angiolillo
Dr. Kostantinos Linardakis
Dr. Alfonso Manforti (Alt.)
Northwest
Dr. Don DeFabio
Dr. Dave Graber
Dr. Jerry Szych
Dr. Jeannine Baer (Alt.)
South
Dr. Rick Brown
Dr. Dan Fuzer
Dr. Michael Kirk
Northeast
Dr. Steven Clarke
Dr. Ed Cohen
Dr. Tom D’Elia
Dr. Bob Haley (Alt.)
Council
Dr. Alan Vargas
Dr. Lenny Siskin (Alt.)
scope of practice. They noted that a
carrier or plan should clearly identify
what services are or are not covered
in descriptions of their plans. In effect this bulletin stated that it was
okay to exclude chiropractic services
but it was not okay to exclude services provided by a chiropractor. A
chiropractor could perform services
such as physical therapy modalities, which are covered by the plan
when performed by a PT, and are
permitted within the chiropractor’s
scope of practice. In my view, as
the statute states that a carrier
cannot discriminate with respect to
participation, excluding chiropractic
services entirely would seem to be a
violation.
Another key issue here is that of
reimbursement. As established previously, a chiropractor can perform
services within their scope of practice that are covered under the plan
when performed by other providers
(PTs for example). If a chiropractor
does so, must the reimbursement
be the same as another provider
performing the same service? The
statute bars discrimination but does
note that reimbursement can vary
based on quality or performance
measures. Part of the goal of PPACA
was to reduce medical costs across
the board. One could argue that this
language allowing reimbursement
variances to account for quality and
performance measures was to encourage incentives for better patient
outcomes. It could also be argued
that the intent here was not to allow
a carrier to reimburse two different
provider types at different rates for
performing the exact same services.
Unfortunately, the Center for Con-
sumer Information and Insurance
Oversight (CCIIO), a division of CMS,
issued a set of FAQs further confusing this issue. In the FAQs issued on
April 29, 2013, the CCIIO stated that
reimbursements could vary by quality and performance but also added
the phrase “or market standards and
considerations.” This language was
not expressly included nor implied
in the original statutory language
of Sec. 2706 and clearly changes
the potential interpretations of the
statement.
The Senate Appropriations Committee took issue with several parts of
the CCIIO’s FAQ release and requested that the agency correct the FAQ to
reflect the law and congressional intent. Since that time the Department
of Health and Human Services, which
houses CMS and the CCIIO, has
released a request for information
from the public regarding the intent
and implementation of Sec. 2706.
Through the coordinating efforts of
COCSA and the ACA, many chiropractic state associations submitted comments in support of the original and
proper intent of Sec. 2706. The comment period concluded on June 10,
2014. At the time of writing the Dept.
of HHS had not released any changes
or analysis of the comments.
It appears probable that the proper
interpretations of Sec. 2706 will
eventually be argued in court. In the
meantime, the ACA, COCSA, and
many state associations are monitoring the situation and doing what they
can to protect the non-discrimination
provision and ensure it is properly
interpreted. The ANJC has and will
continue to support these efforts in
any way we can.
How to Get Paid for Physical Performance Tests on the Same Day as CMT
ANJC LEADERSHIP
ANJC ELECTED OFFICIALS
• Dr. Joseph D’Angiolillo
President
• Dr. Michael Kirk
Vice President
• Dr. Tom D’Elia
2nd Vice President
are mandated to be part of every
health insurance plan, chiropractic
services are a form of rehabilitative treatment, and a carrier cannot
discriminate against a provider acting in their scope of practice—that
chiropractic care should be allowed
under all plans going forward. Early
analysis show this not to be the
case. Regarding reimbursement, the
law states reimbursements can vary
specifically based on quality and
performance measures. As this is
a brand new law, with no published
court cases as precedent, the exact
execution of the law is susceptible
to a broad range of interpretations
by various parties. We are beginning
to see some of these play out.
A prime example of the issues
with Sec. 2706 is evolving in Colorado. Each state was required to
choose a benchmark plan for the
exchange to be run in their state,
whether it would be operated by
the federal government or the state
itself. The benchmark plan would
then serve as the standard of minimum coverage to be included in any
plan sold on that state’s exchange.
Colorado chose a Kaiser Permanente
plan that specifically excluded chiropractic services and services of
chiropractors. As the implementation
of Sec. 2706 in 2014 approached,
Colorado’s Division of Insurance did
revise this part of the benchmark
plan. However, they did not recognize
that chiropractic services must be
included as a form of rehabilitative
services. Rather, they issued a bulletin announcing that a carrier could
exclude a category of services, in
this case chiropractic, but not a category of provider acting within their
27
COMMITTEE CHAIRS  ADVISORS  CONSULTANTS
• Dr. Joe D’Angiolillo
Legal Advisory
• Dr. Robert Blozen
COCSA Rep
Medicare Consultant
• Dr. Steven Clarke
Legislative
• Dr. John Cerf
Hospital Protocol
• Dr. Mark Spratford
Communications
• Dr. Tom D’Elia
Insurance
• Dr. Barry Coniglio
Rules and
Regulations
• Dr. Joseph Garolis
NJ Board of
Examiners
• Dr. Christopher Bump
Nutrition
• Dr. Frank Zaccaria
College Liason
• Dr. Mark Magos
Senior Advisory
Finance
• Dr. Joseph D’Angiolillo
Executive Committee
• Dr. Kostantinos
Linardakis
HQ Committee
• Dr. Mike Kirk
PR Committee
• Dr. Richard Fellows
PAC Committee
• Jon Bombardieri
Lobbyist
• Lynette Contreni
Insurance Consultant
• Dave Klein, CPC, CHC
• Dr. Mike Goione
• Anthony Rosner, PhD
Research Consultant
• Jeffrey Randolph, Esq
Legal Counsel
• Dr. David Graber
Council on Technique
& Clinical Excellence
• Dr. David Graber
ED Committee
• Dr. Don DeFabio
Council on Physical
Rehab & Performance
• Katherine Lusk
Editorial Assistant
ANJC VISION & MISSION
Vision: To position Doctors of Chiropractic as providers of first choice for New Jersey families to obtain
optimal health and wellness, while improving the quality of their lives.
Mission: To improve the health of patients, families and communities by promoting high standards of
professionalism and patient care through chiropractic methods, education, advocacy and accountability.
ASSOCIATION OF NEW JERSEY CHIROPRACTORS
3121 Route 22 East, Suite 302 • Branchburg, New Jersey 08876
908.722.5678 • 908.722.5677 – fax
www.anjc.info • [email protected]
sociated with the procedure. The E/M
service may be caused or prompted
by the same symptoms or condition
the CMT service was provided for.
As such, different diagnoses are not
required for the reporting of the CMT
and E/M service on the same date.
For purposes of CMT, the five spinal regions referred to are: cervical
region (includes atlanto-occipital
joint); thoracic region (includes costovertebral and costotransverse joints);
lumbar region; sacral region, and;
pelvic (sacro-iliac joint) region. The
five extraspinal regions referred to
are: head (including temporomandibular joint, excluding altanto-occipital)
region; lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints),
and; abdomen.
The complete service of CMT
requires a certain amount of pre-,
intra- and post-service work that is
included as part of the service. This
pre-, intra- and post-service work is
necessary to determine what specific
manipulative work will be necessary
and also to determine the effectiveness of the service being provided.
It is inclusive in the CMT and is not
separately reported as an E/M service. The pre-service work includes
review of previously gathered clinical
data (including an initial or interim
history, reviewing the problem list,
pertinent correspondence or reports,
and other important findings and prior
care); review of prior imaging and
other test results; test interpretation,
and; care planning. The intra-service
work includes an interactive patient
reassessment—determining the current status, determining indications
or contraindications, assessing the
change in condition, evaluating any
new complaints, correlating physical
findings, and coordinating and modifying the current treatment plan. Also
included in the intra-service work
is a number of manipulations and
post-adjustment assessments that
Continued on Next Page
are necessary in order to adequately
treat the presenting problem. This
work is inherently included as part
of the CMT service and would not be
reported separately.
According to the CMS the term
“physician” under Part B includes a
chiropractor who meets the specified qualifying requirements only
for treatment by means of manual
manipulation of the spine to correct
a subluxation. Subluxation is defined
as a motion segment, in which alignment, movement integrity, and/or
physiological function of the spine
are altered although contact between
joint surfaces remains intact.
The following are some common
examples of acceptable descriptive
terms for the nature of the abnormalities: off-centered, misalignment,
malpositioning, abnormal spacing,
incomplete dislocation, rotation, listhesis, limited motion, hypermobility,
and hypomobility.
Again, the concern for many doctors of chiropractic is what constitutes a separate procedure and why
do carriers deny reimbursement for
code 97750 and CMT when performed on the same day? The separate procedures we are referring to
here are chiropractic manipulation and
a physical performance test or measurement. The purpose of the performance test is to evaluate a patient’s
capacity to perform routine activities
such as bending, lifting, and getting
in and out of a car. The purpose of
a chiropractic spinal manipulation is
to correct a subluxation/misaligned
vertebra. Both procedures should be
reimbursed because there are inherent differences between them.
The testing described by code
97750 is not included in any CMT
code (98940-98943) and represents
separate and distinct evaluative testing. Code 97750 should be reported
when a provider needs to determine
a patient’s functional capacity to perform activities of daily living.
When modifier -59 is appended to
97750, it is reporting that a separate
and distinct procedural service was
provided. In this case, separate from
the CMT codes. Under certain circumstances, a provider may need to indicate that a procedure or service was
distinct or independent from other
services performed on the same day.
Modifier -59 is used to identify procedures/services that are not normally
reported together, but are appropriate
under the circumstances. This may
represent a different session, patient
encounter, different procedure, or
separate injury not ordinarily encountered or performed on the same day
by the same physician.
Additionally, a carrier should not
consider code 97750 part of another
service, such as CMT. This is incorrect bundling of codes according to
the National Correct Coding Initiative
Edits (NCCI edits). The Centers for
Medicare & Medicaid Services (CMS)
developed the NCCI edits to promote
national correct coding methodologies and to control improper coding
leading to inappropriate payment in
Part B claims.
The CMS developed its coding policies based on coding conventions
defined in the American Medical Association’s CPT manual, national and
local policies and edits, coding guidelines developed by national societies,
analysis of standard medical and surgical practices, and a review of current coding practices. The purpose of
the NCCI edits is to prevent improper
payment when incorrect code combinations are reported. The NCCI edits
(effective January 1, 2013) do not
list code 97750 and codes 98940-
98943 as being mutually exclusive.
Please note that while this information addresses a critical issue associated with code 97750, other issues
are beyond the scope of this correspondence. For example, providers
must continue to observe rules relating to documenting medical necessity,
time units, documenting time, aggregating time, and supporting the care
with appropriate diagnosis codes.
In conclusion, physical performance
testing should not be considered a
component of chiropractic spinal manipulation. These two procedures are
provided for two different reasons and
outcomes and should not be considered mutually exclusive.
–––––––
Marty Kotlar, DC, CHCC, CBCS is the
President of Target Coding. Dr. Kotlar
is Certified in CPT Coding, Certified
in Healthcare Compliance and has
been helping healthcare providers nationwide document properly, get paid
properly, and prevent insurance audits
for over 10 years. Target Coding can
be reached at 1-800-270-7044, website: www.TargetCoding.com, email:
[email protected].

Fall 2014

Transcription

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