Steven Conway DC, Esq .

1. Steven Conway DC, Esq.

2. Show of hands Love the Medicare system and are extremely Happy that we only get paid for adjustments.

3. Show of hands Frustrated with the entire system and if given the chance would opt out and just do cash

4. Show of Hands Would actually be willing to remain in Medicare system if the following is possible: Actually understand what documentation is required to justify service provided to the patient. Get paid for all services that you provide.

5. Problem is the Chiropractic Error Ratio The historic chiropractic error ratio has hovered in the 80-90% range. The rest of the healing profession is in the 5-15%

6. Dr. Jacklitch

7. The solution Fully understanding the required documentation to support the care provided Universal Agreement with the MACs creating standardized criteria and level playing field Trained the MAC reviewers

8. The Solution 99% of the issue and 99% of the solution is associated with the chiropractic TREATMENT PLAN. The second key element is the MECHANISM OF INJURY OR TRAUMA.

9. Medicare Compliance • Case #1: chiropractor midwest office receives a letter from Medicare • Excluded from Medicare for 3 years and request for all $ for past 3 years.

10. Medicare Compliance • OIG Exclusion Website • https://exclusions.oig.hhs.gov • Search for: • All new employees before hiring • All existing employees quarterly • All Business Associates before hiring and quarterly

11. Medicare Compliance • Case #3 U.S. Department of Justice vs chiropractor • I. M. Friendly, D.C., from nice town, Iowa, and his clinic, Friendly Chiropractic, P.C., have agreed to pay $79,919 to resolve allegations Friendly violated the False Claims Act by improperly billing Medicare and Medicaid for chiropractic adjustments after providing free electrical stimulation to beneficiaries to influence those beneficiaries to receive chiropractic adjustments from Dr. Friendly. The government alleged that this conduct violated the Anti-Kickback Statute and, in turn, the False Claims Act. The claims at issue were submitted between January 1, 2012, and September 30, 2016.

12. Medicare Compliance • U.S. Department of Justice vs Dr. Friendly • Source of complaint was unknown • Allegations • Inducement by providing free services to Medicare patients • Included both AT and Maintenance care in the complaint • Coded all maintenance patients as 98940

13. Medicare Compliance • Compliance fail point related to internal Medicare procedures. • Medicare prohibits any actions that would be considered an inducement to a potential or existing patient • Medicare prohibits upcoming or downcoding procedures. Correct coding for services performed has to coordinate with the adjustment of medically necessary vertebrae.

14. Medicare Compliance • What can we learn from the DOJ vs. Friendly case? • Can not offer or provide free services to Medicare patients including examinations, therapies or treatments. Do NOT include Medicare/ Medicaid patients in any coupons, groupon or other type of advertising system for new patients. • Do not downcode or upcode services.

15. Medicare Compliance • The false belief that chiropractors can opt out of Medicare-you can’t • You are either in and following the rules or you are 100% out. • Can not be “off the radar” and treat Medicare patients for cash • Can not be a “maintenance” practice and force a patient to sign box 2 of the ABN to be a patient. • Can not creatively code to have only non-covered services.

16. Goals for Today • Understand Medicare documentation requirements • Initial visit requirements associated with Treatment Plans • New Subsequent visit concepts • REMOVE THE FEAR OF MEDICARE AUDITS!

17. “No matter what the “experts” say, you can’t modify or interpret the Medicare rules in a way to fit your desired office policies and procedures that result in a system that is detrimental to the Medicare beneficiary or Medicare Trust Fund.” • -Steven Conway DC, Esq.

18. “ You can’t 100% macro Medicare Documentation.” • -Steven Conway DC, Esq.

19. What are the rules for documentation? Medicare Benefits Policy Manual Chapter 15, Section 240

20. What are they looking for?

21. What are some DCs doing?

22. What are some DCs doing?

23. What are some DCs doing?

24. Future Audits will be based on “Episode of Care.”

25. Initial Visit Requirements • History • Description of the present illness • Evaluation of musculoskeletal/nervous system through physical examination. • Diagnosis • Treatment Plan • Date of the initial treatment

26. Initial Visit Requirements • History • Description of the present illness • Evaluation of musculoskeletal/nervous system through physical examination. • Diagnosis (new LCDs allowing all DX) • Treatment Plan • Date of the initial treatment

27. Initial visit: History • Symptoms causing the patient to seek treatment • Family history if relevant • Past health history • Mechanism of trauma • Quality and character of symptoms/problem • Onset, duration, intensity, frequency, location and radiation of symptoms • Aggravating or relieving factors • Prior intervention, treatment, medications and secondary complaints.

28. Initial visit: History • Symptoms causing the patient to seek treatment • Family history if relevant • Past health history • Mechanism of trauma • Quality and character of symptoms/problem • Onset, duration, intensity, frequency, location and radiation of symptoms • Aggravating or relieving factors • Prior intervention, treatment, medications and secondary complaints.

29. Initial visit: History • Symptoms causing patient to seek treatment • Document ALL of the symptoms • Symptoms need to be neuromusculoskeletal conditionsk • MUST correlate to a specific vertebrae • Mechanism of Trauma • Document the cause of the patient’s injury • Correlate to patient’s condition • List the specific mechanism of trauma in your notes for each initial onset and any subsequent new injury. • Insidious onset rules. • Do not simply change area of pain or diagnosis and start a new series of treatment without considering the mechanism of trauma.

30. Initial visit: History • Onset, duration, intensity, frequency, location and radiation of symptoms. • Where applicable, use numeric rating of the quantifying factor! • VAS of 3 rather than mild pain • Establish initial severity of the condition to assist with developing a correct treatment plan.

31. Initial visit: Treatment Plan • Treatment Plan • Frequency • Duration • Specific measurable goals • Establish objective targets that can be measured to know if you actually achieved your goals.

32. List of commonly used chiropractic goals • Reduce Pain

33. List of commonly used chiropractic goals • Reduce Pain • Increase Function

34. List of commonly used chiropractic goals • Reduce Pain • Increase Function • Increase Range of Motion

35. List of commonly used chiropractic goals • Reduce Pain • Increase Function • Increase Range of Motion • Increase segmental motion and flexibility

36. List of commonly used chiropractic goals • Reduce Pain • Increase Function • Increase Range of Motion • Increase segmental motion and flexibility • Improve the % noted on Oswestry form

37. Resulting chiropractic “Macro” • Goal of treatment will be to decrease inflammation and pain, increase range of motion, segmental motion and flexibility as well as increasing the quality of life of the patient. • Improve patient’s overall symptoms and complaints noted on Oswestry by 20%

38. Initial visit: Treatment Plan Goals • Specific Goals vs Generic Goals • Reduce pain vs achieve a reduction in pain from 8 to 4 on the VAS pain scale rating. • Use of Meaningful Goals vs “lets see what is worst on the Oswestry form.” • Use goals that correlate to the mechanism of trauma and patient’s symptoms. • Goals that can be measured and verify you achieved them. • Compare to Workers Compensation goals.

39. What Goals should I include? • NO specific goal requirements are listed by Medicare. • Highly recommend, but NOT required goals include: • Activities of Daily Living (ADL) goals • Goals associated with Oswestry or other OAT forms. • Quantifiable, measurable goals using numbers • Pain level • Range of motion

40. Initial visit: Treatment Plan • Change the way you determine your treatment plan • Current model starts with visit FREQUENCY • _______ X a week

41. Initial visit: Treatment Plan • Change the way you determine your treatment plan • Current model starts with visit FREQUENCY • _______ X a week • Then you add in DURATION • 3 times a week for _______ weeks.

42. Initial visit: Treatment Plan • Change the way you determine your treatment plan • Current model starts with visit FREQUENCY • _______ X a week • Then you add in DURATION • 3 times a week for _______ weeks. • Then you add in a generalized Goal: • 3 times a week for 4 weeks to reduce pain and increase function.

43. Initial visit: Treatment Plan • New Model-START WITH THE GOAL FIRST! • Initiate the treatment plan process by determining the specific measurable goal. • Start with a goal that can be measured. • Correlate the goal to the mechanism of trauma. • Use ADL and other measurable goals. • Decrease VAS from 8 to 3 • Increase cervical rotation to the right from 25 to 40 degrees • Increase ability to sleep from current 2 hours to 6 hours.

44. Initial visit: Treatment Plan • NEXT-Focus on DURATION • Determine how long it will take to obtain the specific measurable goals and return the patient to pre-trauma status. • There are no limitations set by Medicare for duration • Average for acute is 3-4 months • Average for chronic can be longer • The DURATION decision will create the actual ZONE for the pre-determined release of care (red box) • Actual release date may change, but this system will give you and the MACs a predicted ZONE for release.

45. Initial visit: Treatment Plan • NEXT (and last) -Focus on FREQUENCY • The only limitation on frequency is “reasonable.” The MACs have released the screens and limitations on Frequency. • Do not simply chose 12 or 20 visits based on fear or unknown. • Simply determine how many visits you will need to achieve the specific measurable goals within the already determined DURATION. • Please note that the final frequency determination will be used on all subsequent visit documentation.

46. Initial visit: Treatment Plan • OLD Treatment Plan • Patient will be seen 3 times a week for 4 weeks to decrease pain, increase range of motion and segmental function. • NEW Treatment Plan • Specific Measurable goals: • Increase ability to sleep without waking up from pain from current 1 hour to previous 5 hours. • Decrease low back pain rated at 8 on VAS to 4. • Increase lumbar flexion from current 10 degrees to previous 60 degrees. • Duration to achieve goals: • 1 month. • Frequency: • 12 visits.

47. Subsequent Visit • History: • Review of chief complaint • CHANGES SINCE LAST VISIT • Use VAS information in this section • Physical Exam • Examination of area of spine involved in diagnosis • Assessment of change in patient condition since last visit. • Evaluation of treatment effectiveness (Functional Goal Improvement) • PART is NOT required on each subsequent visit. • Documentation of treatment given on the day of visit. • You are REQUIRED to list the specific vertebrae adjusted. • LIST THE VISIT NUMBER COMPARED TO TREATMENT PLAN ESTIMATE. FOR EXAMPLE 7 OF 15

48. Subsequent Visit: Key Points • Primarily considered a therapeutic visit. • Importance of each visit is now less with the new emphasis on the “episode of care.” • Always compare to the previous visit. • They are monitoring any level of change, but also realize that changes from Monday to Wednesday will not be dramatic. • Always review and monitor your specific measurable goals on each visit.

49. Signature: • Big Deal to Medicare • Medicare requires a signature that is either hand written or electronic. NO stamps • Signature Log • If your signature is poor, then include a Signature Log when submitting any requested documentation. • Signature Attestation • Providers can submit an attestation form if required.

50. ABN: Advanced Beneficiary Notice • Mandatory for Covered Services • Voluntary for non-covered services • Specific times to provide ABN • AT to Maintenance • Good for 1 year or a new onset date occurance • CAN NOT be used routinely on first visit to require a patient to be “maintenance.”