Chiropractic HJR Newsletter Winter 2015


Medicare 2016

Medicare deductible increases for 2016 to $166. Note deductible is met with care by any provider in the Medicare system.
Medicare fees for 2016 will be adjusted slightly upward or downward depending on your region. Network providers can request your Medicare fees directly from the Network, send an e mail request to Sam at
If you did not register with Medicare for meaningful use of electronic health records Medicare will reduce your reimbursement by 2%.
If you did not successfully report PQRS measures in 2014 this will too reduce the Medicare rate an additional 2%.
Note these reductions will be automatically deducted from your Medicare payment when you accept assignment and these reductions are not billable to due by the patient. If you are registered as “Non Par” and not accepting assignment you will need to adjust your fee 2-4% depending on your reporting.
Medicare registered providers should have received a letter from CMS in November indicating whether you did or did not successfully meet the PQRS requirements. If you feel this was in error you may appeal this decision by December 16, 2015.

Medicare Audits 2016

The sky is not falling but it is imperative to understand what the latest Medicare OIG study found. In calendar years 2012 and 2013, Medicare allowed payment of approximately $1.4 billion for chiropractic services provided to Medicare beneficiaries nationwide. A previous Office of Inspector General review found that, in 2006, Medicare inappropriately paid an estimated $178 million (of the $466 million reviewed) for chiropractic services that were medically unnecessary, incorrectly coded, or undocumented.
None of the 100 sampled chiropractic services were allowable in accordance with Medicare requirements. Specifically, 56 services were medically unnecessary, 23 were insufficiently documented, and 21 were not documented. This is a small sample size however Medicare will be reviewing chiropractic in 2016.
Medicare documentation is not hard or unusual but simply specific. Before sending any notes to Medicare for an audit or an appeal be sure the notes contain the nuances required for Medicare. Our 2016 seminars will have an emphasis on documentation and our HJ Ross Digital Coding manual has complete Medicare documentation primer with examples. Of course Network members may also call Sam to discuss and learn what is required too.

ICD10 Coding Primer

With the plethora of new codes available in ICD10 some of the language can be overwhelming or at best confusing to decipher. Here are some basic rules to consider when choosing ICD10 codes.
When using codes that state “other” or “unspecified” note these have special meanings. Codes titled “other” or “other specified” are for use when the information in the medical record provides detail for which a specific code does not exist. For instance you may have a patient where the history and exam findings lead you to a diagnosis of facet syndrome. When you search there is no specific code that states “facet syndrome.” In this case you would use the codes M53.80 to M53.88 which are noted as “other specified dorsopathies” including regions from the occipito-atlanto-axial region to the sacral and sacrococcygeal region.
These codes are used as you are specifying it as “facet syndrome” and therefore fits as “other specified dorsopathies.” In basic terms this type of code is used when you can indicate or describe the specific diagnosis or causation of condition but there is no specific code that indicates that diagnosis language directly.

Optum Health Per Diem with United Health Care

Optum Health and United Health care have begun a “per diem” payment for chiropractic services. This means United Health Care plans affiliated with Optum Health will pay only one fee per visit. This payment is $60 and is inclusive of any copayment. This payment includes all services such as exams, x-rays, chiropractic manipulation and physical medicine services.
Providers should bill their normal fees, if a claim is sent for less than $60 the lesser billed amount will be paid.
This began October 1, 2015 in California, Oklahoma, Texas and Wisconsin. Other states to follow in quarter 4 GA, KY, OH, CO, IL, IN, & KY. In quarter 1 for 2016 AR, MI, RI, UT, OK, AL, DC, DE, IA, MD, VA, WI, LA, MS, NM, NV, & TN. Quarter 2 for 2016 ID, NC, NH, SC, VT, AZ, & PA. And in quarter 3 for 2016 CT, NJ, & NY.
75% of Optum Provider Network is on a per diem reimbursement schedule including all physical therapists. This move should reduce the need for authorization even though Optum will retain a 3 tier level of providers most will be in Tier 1 advantage which will require any UR process. Tier 2 will require minimal UR according to Optum and Tier 3 will maintain a comprehensive UR process. As with all carriers who implement a tier system high visit utilization on regular basis will lead to a lower tier and more scrutiny of services.

VA Benefits for Chiropractic and Acupuncture Services

21st Century Veterans Benefits Delivery Act has language increasing the number of facilities where veterans can access a DC and making chiropractic a standard benefit in the VA health care system. Creating greater access to services provided by DCs.
The U.S. Senate has approved this legislation that would improve the delivery of health benefits to America’s veterans, bringing them one step closer to gaining further access to the essential services provided by doctors of chiropractic (DCs) at major Department of Veterans Affairs (VA) medical centers. S. 1203, the 21st Century Veterans Benefits Delivery Act, passed under unanimous consent in the Senate and has been referred to the House of Representatives, where it awaits action. Read more.
Additionally there has been an increase in referrals and allowances for chiropractic and acupuncture care for Veterans. To access the benefits the Veteran must have a referral from the primary and/or authorization from Tri-West. Billing for these claims is the same standard as any other however when physical medicine services are authorized those services must be billed with modifier GP. There is no requirement for a modifiers for chiropractic manipulation or acupuncture codes.


Deductibles will start over at the New Year however verify as some plans may allow a rollover for deductibles for services within the last quarter of the year prior.
Acupuncture and Blood Pressure study


Background: Acupuncture at specific acupoints has experimentally been found to reduce chronically elevated blood pressure.


Objective: To examine effectiveness of electroacupuncture (EA) at select acupoints to reduce systolic blood pressure (SBP) and diastolic blood pressures (DBP) in hypertensive patients.


Results: After 8 weeks, 33 patients treated with EA at PC 5-6+ST 36-37 had decreased peak and average SBP and DBP, compared with 32 patients treated with EA at LI 6-7+GB 37-39 control acupoints. Changes in blood pressures significantly differed between the two patient groups. In 14 patients, a long-lasting blood pressure–lowering acupuncture effect was observed for an additional 4 weeks of EA at PC 5-6+ST 36-37. After treatment, the plasma concentration of norepinephrine, which was initially elevated, was decreased by 41%; likewise, renin was decreased by 67% and aldosterone by 22%.


Conclusions: EA at select acupoints reduces blood pressure. Sympathetic and renin-aldosterone systems were likely related to the long-lasting EA actions.
Link to the full report


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