Consultation Definition

The Current Procedural Terminology (CPT) manual defines a consultation as a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem, or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.

To Bill or Not to Bill

It’s important to note the statement “at the request of another physician or appropriate source” in the definition. This means that you can’t bill for a consultation simply because your patient asked you to consult with them about chiropractic care.  In fact, CPT is clear when it explains that “a ‘consultation’ initiated by a patient and/or family, and not requested by a physician or other appropriate source is not reported using the consultation codes, but may be reported using the office visit codes.” A patient requesting that you render a second opinion or provide a consultation does not meet the CPT definition of a consultation code.

What is an “appropriate source?”

The consultation must be requested of you by a physician (MD, DO, DC, DPM), physician assistant, nurse practitioner, physical therapist, occupational therapist, speech-language pathologist, psychologist, social worker, lawyer, or insurance company.

Consultation Codes

In the office setting, the physician should use the appropriate office or other outpatient consultation codes.  These codes are 99241-99245 and are billed based upon the 3 key components, much like office visit E & M codes.  If after the consultation, you defer the patient back to the original source, you can bill for the consultation code if all the criteria have been met.  If the criteria for a consultation code are not met, do not bill for a consultation.  Instead select the appropriate office visit E & M.  If you take over the care of the patient, then you can bill for any subsequent treatment performed.

You Must Document!

Before a consultation takes place, there must be a written or verbal request made by the requesting physician or other appropriate source. The request and reason for the consultation must be documented in the patient’s record. The consultant’s opinion and any services that were ordered or performed must also be documented in the medical record and communicated by written report to the requesting source.  Here’s a tip: Remember the three R’s: Request, Render, and Respond.

What about Referrals?

A referral is NOT a request for a consultation but rather is a transfer of total care or a specific portion of care of a patient from one physician to another.  If a referral occurs that does not meet the criteria for a consultation, use the appropriate outpatient office visit E & M codes for either a new or established patient.

Summary

There are instances in which a chiropractor can bill for a consultation.  Just remember that a written or verbal request must have been made from an appropriate source.  As the consultant, you must perform a history and exam and render an opinion or recommendation.  And finally, your opinion as the consultant must be sent back in writing to the requesting source.  All of this must be documented in the patient record.  Any procedure performed on or subsequent to the date of initial consultation is reported separately.  A consultation initiated by the patient or the patient’s family is not a billable consultation but rather is billed with an office visit E & M code.  If after the consultation, you assume responsibility for managing all or a portion of the patient’s condition(s), then you can also bill for the procedures you performed.

We get a lot of questions regarding cash discounts from chiropractors looking for an easy and legitimate discount option for their uninsured and underinsured patients. This is one reason that OSCIPA developed the ACCLAIM program several years ago. This blog will help clarify what the ACCLAIM Card Program is and how it can help your office. Many of you and your patients are currently participating in this program. This individual discount card was developed by OSCIPA to combat the rising cost of health care and as a way for chiropractic physicians to offer their quality services at a discounted rate within an ethical and professional format. It can only be used when insurance benefits DO NOT exist or have been exhausted. Also, it only be used by the patient or enrolled family members when visiting the chiropractic physician that introduced them to the program.

The ACCLAIM card allows your office to use one fee schedule for all patients whether they have insurance or not. Your patient purchases the card for $30 and immediately receives a 25% discount off your standard fee schedule for all the chiropractic health, diagnostic or radiology services they receive. The membership is valid for one year from time of purchase, at which time the patient receives a renewal notification from OSCIPA. In addition, all family members living in the same household can be included under the same ACCLAIM card membership at no additional charge. Once the card is processed, each participating OSCIPA office will receive a cash return incentive check for each membership enrolled in this program.  Chiropractors who are not OSCIPA members can also use ACCLAIM in their office.

This program helps the patient by giving them a discount for services, helps the doctor in making his or her services more affordable for the patient, and helps OSCIPA create a small revenue stream.

If you want more information on this program or would like to receive a kit to start offering the program in your office, please feel free to call Elizabeth, Amy or myself for further discussion at 918-641-0444 or toll free at 877-940-3044. You can also request additional information by sending us an email at info@oscipa.com.

During the month of January more than 480 state lawmakers also planned to file a brief urging the Supreme Court to uphold President Obama’s healthcare law. This group includes at least one lawmaker from every state, including the 26 states whose attorney generals are suing to overturn the healthcare law’s individual insurance mandate.

At the state level the focus of attention were the development of Affordable Insurance Exchanges and developing a premium rate review system where insurers must justify the rationale for any double-digit insurance premium increase. Currently 44 states are participating in the new premium rate review system.

What is an insurance exchange? A new transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans. Affordable Insurance Exchanges will offer you a choice of health plans that meet certain benefits and cost standards.  Click here to learn more about how Exchanges work.

Twenty-eight states and the District of Columbia are on their way toward establishing their own Affordable Insurance Exchange-an essential part of the law. Oklahoma is not one of those states having returned $54,582,269 in federal grant money saying the grant would not be used. At this point Oklahoma is running the risk that on January 1, 2014 The Department of Health & Human Services (HHS) could develop a Federally-Facilitated Exchange for Oklahoma if they have not created their own State-Based Exchange. This is where the Oklahoma for Free Market Health Solutions comes into play. As a group, OSCIPA believes Oklahomans should create our own state-based, private sector driven response to federal health care reform requirements. To protect the interest of Oklahomans, we need to control our own future health and create an Oklahoma Health Insurance Marketplace (OHIM). OSCIPA members will be represented in any of these efforts as we move forward. We (OSCIPA) were there during the developing stages of the state exchange prior to the grant money being returned and will continue to be a part of this process in the future.

Another area of vital importance for the chiropractors of our state is being involved in the development of Essential Health Benefits (EHB) in the health law. The Center for Consumer Information and Insurance Oversight published the Essential Health Benefits Bulletin on December 16, 2011. Fortunately the PPACA & COCSA-of which both OSCIPA is a member-have been involved in this process since the beginning. The PPACA understood in 2010 that the health care reform legislation was not likely to include chiropractic services as a separately named essential benefit. Therefore, its strategy has been to ensure that DC’s are able to provide their services under the categories of EHB’s included in plans offered through the health exchanges.

Essential Health Benefits: A set of health care service categories that must be covered by certain plans, starting in 2014.

In the EHB Bulletin on page 9, Four Benchmark Plan Types are described for 2014 and 2015 that best reflect the statutory standards for EHB in the Patient Protection & Affordable Care Act:

1. The largest plan by enrollment in any of the three largest small group insurance products in the state’s small group market. In Oklahoma this is the BCBSOK individual & small group plan.
2. Any of the largest three State employee health benefit plans by enrollment, and the largest in Oklahoma is HealthChoice.
3. Any of the largest three national Federal Health Benefit plan options by enrollment. The largest in Oklahoma is BCBSOK FEP Standard Option.
4. The largest insured commercial non-Medicaid Health Maintenance Organization (HMO) operating in the state which is CommunityCare HMO.

This analysis was promoted and encouraged by COCSA and has been done in several states. OSCIPA has the relationship with each of these plans and the data for us to select the best plan for chiropractors if it got down to a single benchmark to serve as the standard for qualified health plans inside the Exchange operating in our state and offered in the individual and small group markets.

I hope this gives you some idea of the behind the scenes work that continues on a daily basis in the OSCIPA office regarding both national health care reform and how it will impact our state’s chiropractors. Please continue to read our Blogs and E-blasts so that you can keep current on all issues that we feel will impact you and your practice both globally and on a daily basis.

First of all, let’s address the definition of “active” care and how it is different from passive therapies.  Like the office we assisted, you may be providing active care in your office already and not even billing for it.  Active therapy is a type of care in which the patient is actively engaged in some type of physical therapy that is directed by the doctor or therapist and  requires a responsibility on the part of the patient to participate.  This could be in the form of stretching, aerobic activity, strengthening exercises, balance to improve proprioception, some type of procedure to increase range of motion, or any number of other activities.  The key is that the patient is performing the therapy rather than having the therapy performed on them.  During passive therapy, however, the patient is taking no active part in the procedure. Examples of therapies that are passive are ultrasound-97035; traction-97012, electrical muscle stimulation-97014 or 97032; and heat/ice-97010.

When choosing a code to bill for an active therapy, you should look at not only the service or type of therapy done, but also the intended therapeutic outcome or what you hope to improve in the patient.  Ask yourself, “Am I applying this service to simply improve joint mobility or strength or am I attempting to restore a specific function in the patient? Will this service be addressing one parameter only or multiple parameters?” 

Let’s take a look at active therapies that may be used in the chiropractic setting, keeping in mind that these three services are all timed therapies which means they are billed in “units” according to how much time is spent performing the therapy, not how many anatomical areas are treated.

97110    Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility¹.

The CPT® Assistant Archives give further clarification to the definition above. Therapeutic exercise incorporates one parameter (strength, endurance, range of motion or flexibility) to one or more areas of the body. Examples include treadmill (for endurance), isokinetic exercise (for range of motion), lumbar stabilization exercises (for flexibility), and gymnastic ball (for stretching or strengthening)².

97530    Therapeutic activities direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes ¹.

Additional information from CPT® Assistant further explains that dynamic activities include the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity. Examples include lifting stations, closed kinetic chain activity, hand assembly activity, transfers (chair to bed, lying to sitting, etc.), and throwing, catching, or swinging².

97112    Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities¹.

97112 is perhaps one of the most misused and misunderstood of all the active therapy codes.  Many times providers will use this code for certain types of massage or soft tissue therapy, and that is not what this was intended for.  Examples of services that may be performed to rehabilitate the patient’s neuromuscular issues include Proprioceptive Neuromuscular Facilitation (PNF), Feldenkreis, Bobath, BAP’S Boards, and desensitization techniques².

As with all procedures, there is a professional component of one on one time with a patient.  The CPT® definition specifically states “Physician or therapist required to have direct (one on one) patient contact.”  If the provider does a group therapy session, then the service should be billed as a 97150 regardless of the procedure.

There are many other active therapy codes in the physical therapy section of the CPT® code book, but these three are the most frequently used by chiropractors due to the nature of the physical therapy they provide and seem to be the ones we get the most questions about.  So in summary, 97110 is used when affecting one parameter (strength, flexibility, ROM), 97530 is for multiple parameters and to improve a functional activity, and 97112 is for reeducating or re-patterning the motor system in some way or for when there has been a loss of coordination.

For more information, refer to current CPT® coding materials and guidelines.

 Click here to read our October 31, 2011 E-Blast letting our members know what had transpired in this case up to that date.

October 19, 2011 was the day of the Supreme Court hearing when John C. McMurray presented to the Supreme Court our questioning of the constitutionality of this situation. Then on December 20, 2011 Mr. McMurray notified us that the Oklahoma Supreme Court “threw out” the insertions in the law that we felt were unconstitutional!

Read the NewsOK and Tulsa World articles that covered this story.

This was after several months of ground work, several meetings in OKC, and our financial commitment to reach this goal. Not only will chiropractors benefit but so will other non-MD/DO health care specialty areas. It was also a statement that this profession through the OSCIPA framework will not stand idle if the end result makes sense and is beneficial to all chiropractors’. This could not have been done without the financial support of our members.

OSCIPA currently has 10 carriers/network health plan contracts.  Something to keep in mind is that each of these carriers/networks has decided on their own to outsource their chiropractic benefits to OSCIPA.

Continuing Education programs was selected as the second priority. Our Board of Directors, I, and Amy Prentice our event coordinator always want to have the best CE seminars we can for all Chiropractors in a five state area to attend. Of course this includes acquiring outstanding speakers. A good example of this is in our upcoming 2012 spring seminar where we are bringing in Dr. Jeffrey Spencer who was Lance Armstrong’s personal chiropractor through his 7 Tour De France victories. This seminar is scheduled for February 25^th and February 26^th in Oklahoma City at the Oklahoma City Marriott. All Oklahoma based chiropractors should have received a brochure in the mail regarding this event. All of our seminars are approved for 16 hours of CEU’s by 5 states. Planning is done at least a year in advance for each one of these. We select above average hotels so that any amenities that we have or that attendees select are beneficial. Our registration process is fully automated through a software program called Cvent which is used by many professional organizations nationwide.

The third priority that was selected for us was legislation. Legislatively OSCIPA hired Dennis Adkins of A&A Associates as our lobbyist. Dennis served 8 years in the Oklahoma House of Representatives. He has served on many committees and has a degree in political science. Dennis along with our Board and Dr. Dan Post our Board Chairman & Legislative Chairman and Dr. Jason Westemeir our newly elected OSCIPA President will lead us through our 2012 legislative agenda. This will include being more proactive than we were last year as Dennis was learning more about our profession and specific legislative needs of chiropractors. However during the past two months OSCIPA acquired the services of the honorable John C. McMurry P.C. a constitutional attorney to represent chiropractic in an Oklahoma Supreme Court Hearing that took place on October 19, 2011 in OKC. This involved OSCIPA’s challenge of the specific sections of the recently passed Work Comp legislation that negatively affected the chiropractic profession as well as other non-MD/DO specialty areas.

We now have a monthly membership fee that is reasonable and understandable without having an initial sign up fee. Each staff member including myself has a very specific assignment and we have all been around long enough to know our jobs well. It takes a dedicated staff, Board of Directors, health plan contracts, quality and reputable business partners, and most importantly involved members to make an organization work both as an IPA and a state association. We are all up for this task with your continuing support!

Medicare has a policy called Multiple Procedure Price Reduction (MPRR).  MPPR has been applied to multiple surgical procedures and multiple diagnostic imaging services and is also being applied to therapy services.  Of course, therapies are not a covered Medicare benefit when performed by a chiropractor; however we want to make you aware of this policy because as you know, many times commercial payers adopt Medicare policies.  This would impact you as chiropractors who perform therapies as well as those of you who employ PT’s.  The MPPR works by reducing only the practice expense portion of the payment for a therapy procedure when more than one unit or more than one therapy procedure is provided to the same patient on the same date of service.  This means that MPPR applies to multiple procedures as well as multiple units of therapy.

Background:

Section 3134 of The Affordable Care Act added section 1848(c)(2)(K) of The Social Security Act, which specifies that the Secretary of Health and Human Services shall identify potentially misvalued codes by examining multiple codes that are frequently billed in conjunction with furnishing a single service. CMS determined that therapy services are misvalued when multiple therapies are provided for a patient on the same day because CMS is paying providers for duplicate clinical labor and supplies.

Details:

The MPPR policy applies to codes that are considered “Always Therapy” codes. Full payment is made for the unit or procedure with the highest PE (practice expense).  All subsequent units and/or procedures are paid with the PE portion of the RVU discounted by 20%.

To understand the impact of this policy, it helps to have an understanding of RBRVS and the Relative Value Unit (RVU) scale for CPT codes.  A CPT code is assigned an RVU based on three components: Work Expense, Practice Expense, and Professional Liability Insurance Expense.  The total RVU is multiplied by a dollar conversion factor to arrive at the Medicare allowable fee.  For example, the RVUs for 97110 and 97140 are broken down as follows:

This is an example only and may or may not reflect a real situation, but in a scenario where a commercial payer adopted the MPPR policy and used the above allowable fees, 97110 would be paid at $28.43 (100% of the allowable). 97140 (which has the lower practice expense) would be reduced to $24.31. That is 80% of the PE portion (.38 * 80% = .304) + .43 + .01 * DCF = $24.31.

Impact:

For those of you who perform multiple units of a therapy and/or multiple therapies at the same session, you could see payment for your additional units and therapy procedures reduced if payers begin to implement this Medicare policy as part of their reimbursement.  As of this publication, Aetna is currently using the MPPR policy and UnitedHealthcare will begin using it March 1, 2012.

RESOURCES:

Medicare MLN Matters Article: MPPR for Selected Therapies

Aetna Office Link Update

While we are still a little over 2 years away from the go-live date for ICD-10 implementation, it’s important to start planning for this transition now.  Hospitals, doctors’ offices, medical centers, and health plans are required to start using the new ICD-10-CM coding system on October 1, 2013.  CMS has made it clear that there will be no grace periods or implementation delays.  With that said, it’s important to keep in mind that it‘s still a little too early for ICD-10 code set training.  It’s impossible for doctors and staff to remember for two years codes that they don’t use every day.  In fact, the codes and guidelines that you learn now may not be in the final draft that will be available in 2012.  Instead, in these early stages, it’s important to gain an overall understanding of several key areas and ask yourself how this will affect your practice.

What will ICD-10 look like and how will ICD-9 translate into ICD-10?

While ICD-9 codes are 3 to 5 digits long, ICD-10 codes may be up to 7 digits and will always start with an alpha character. Characters 1-3 describe the category. Characters 4, 5, and 6 specify etiology, anatomic site, & severity or other clinical data.  Character 7 is an extension for descriptors such as initial encounter, subsequent encounter, or sequela.  There is a General Equivalence Mapping (GEM) tool that assists with understanding the conversion of ICD-9 codes to ICD-10 codes.  Some ICD-9 codes translate easily to ICD-10 in what’s called a one-to-one conversion.  But in other cases, there is no mirror image of an ICD-9 and ICD-10 code.  There may be a multitude of different mapping ratio relationships such as one-to-three, one-to-twelve, or even one-to-2,500.  Consider sciatica for example (ICD-9 code 724.3).  In the ICD-10 set there is a code for sciatica unspecified, sciatica right side, sciatic left side, lumbago with sciatica unspecified, lumbago with sciatica right side, and lumbago with sciatica left side, plus codes that describe sciatica due to intervertebral disc disorder.

How will the new system affect my administrative processes?

Your office’s administrative area will be impacted in several ways. In addition to the obvious coding and billing changes, superbills and forms may need to be updated and your information technology will need to be assessed.  Practice management software will need to be updated for the new code set. Practices may need to run dual systems during this transition, meaning you will need to have the capability to bill ICD-9 codes for dates of service prior to 10/01/13 and in case some health plans aren’t ready to accept ICD-10.  Now is a good time to talk to your business partners such as your practice management software vendor and clearinghouse to make sure that your billing processes will be updated and ready for testing and/or receiving ICD-10 data before the go-live date.  In fact, the preparation for ICD-10 also brings with it a change in the area of submitting electronic claims in the new HIPAA 5010 version.  The deadline for transitioning to HIPAA 5010 transactions is January 1, 2012.  You will need to either update your practice software or discuss translation with your clearinghouse. Regardless, it is imperative that your software be ready for ICD-10 before October 2013.

How will ICD-10 impact my clinical processes and reimbursement?

Currently reimbursement is tied to procedure codes, and it’s the diagnosis codes that support medical necessity. However, local coverage determinations and medical policies will be revised to include the new code set.  Even though the ICD-10 conversion is not intended to alter reimbursement, a change in medical policies could result in a change in reimbursement methods.  Perhaps the biggest impact to your clinical processes will be in the area of documentation.  As we get closer to the go-live date, the term Clinical Documentation Improvement (CDI) will be used more frequently. CDI refers to ensuring that your documentation is detailed enough so that the proper ICD-10 code can be selected.

How can I assess the specificity of my documentation to determine if I’m ready for the expanded ICD-10-CM Code descriptions?

It’s important to remember that the diagnosis code should be selected based on your documentation of the patient’s condition and symptoms, not the other way around.  You can begin to audit and assess your documentation now to see if there are weaknesses in this area.  The increased specificity of ICD-10 codes will require you to attain and document as many details from your patients and your exam findings as possible.  Start by running a report and determining the most frequent ICD-9 codes you currently use. Start with the top diagnosis seen in your office and pull about 5 or 10 files of patients who have that specific diagnosis.  Go through the documentation and test yourself.  Determine if you described everything needed to select that ICD-9 code. Then look up what that code might translate to in ICD-10. Determine if your current documentation would support a more specific ICD-10 code. For example, if sciatica is a common occurrence in your patients, check your documentation to see how specifically you are describing sciatica in your notes.  Ask yourself if your notes are descriptive and detailed enough to meet ICD-10 standards.

Stay educated and informed about the implementation of ICD-10. To help you, we have included some resources below that you can use to stay updated on ICD-10 implementation.

More information & References:

ICD-10 Code Translator: http://www.aapc.com/ICD-10/codes/index.aspx

ICD-9 to ICD-10 Conversion & Mapping Tutorial: http://www.aapc.com/ICD-10/conversion-mapping.aspx

ICD-10 Provider Office Changes: http://www.aapc.com/ICD-10/office-map/index.aspx

About ICD-10 & ICD-10 FAQ’s: http://www.ahima.org/icd10/about.aspx

About General Equivalence Mapping (GEMs):

http://library.ahima.org/xpedio/groups/public/documents/government/bok1_043820.pdf

https://www.cms.gov/ICD10/11b1_2011_ICD10CM_and_GEMs.asp

However the ride itself was very difficult for me as my last year’s winter training was limited due to a couple of medical setbacks. The first day I rode 58 miles in 5 hours of riding time. It started out okay but after 3 hours of riding I entered Vail, Colorado and eventually began to ride up Vail Pass. This is about a 7 mile climb after going slightly uphill for 6 miles prior to the climb. At the halfway mark of the actual climb you ride downhill under a highway and then turn sharply with a half mile climb that is very steep where many just walk their bikes up. I made it riding all the way to the top but it was not fun! Then I had 3 more miles of climbing before the descent to Copper Mountain Ski Resort where I stayed. The next day my wife road with me for a 48 mile ride but with only one climb-Swan Mountain. She did to me what a lot of wives would like to do to their husbands in that situation. She ended up waiting for me at the end as I could not keep up with her since I was still feeling the effects of Vail Pass from the day before. However life was good on the final day because I actually began feeling better and left Copper Mountain and climbed Fremont Pass up to 11,318 feet, the highest elevation on the ride. Then it was on to Leadville, the highest city in the USA at 10,800 feet. I felt good the whole ride on day three. I am not sure that I will do this again but overall it was a great experience like always!

On to another topic.  I’ve  been thinking and reading  about the country’s health care crisis taking place right now and how much money we as Americans spend on our medical needs.  Let’s look at eight reasons why our health care costs so much:

1. Our population as a whole is getting older and we are using more services.
2. Not everyone chooses a lifestyle that includes a Courage Classic so overall our lifestyles don’t help!
3. We rely on a lot of specialty medicine which is very expensive.
4. We are using some amazing technology and taking more prescriptions. Both are very costly.
5. Health care is labor intensive.
6. We pay for services, not results or value.
7. We have multiple stakeholders with different agendas and a lot of lobbyist money.
8. We are inefficient and we waste a lot of money and resources.

 A study by PricewaterhouseCoopers estimates that we waste almost half of what we spend on health care! This information came from an article entitled “Why Our System Costs So Much”. It was published in March, 2011 by Collaberation Health Care, Inc.

In Oklahoma magazine’s July 2011 edition of “The Best of the Best” on page 104 under Chiropractor several OSCIPA members are highlighted as well. Dr. Tim Cole at Integrated Physical Health, LLC where he partners with Dr. Tyler Bachman, by readers’ accounts is someone perspective patients should seek out for help. Dr. Cole and Dr. Bachman are located on Harvard. Two other Tulsa OSCIPA chiropractors were also mentioned in the same article. They were Dr. Jason Westemeir, an OSCIPA Board Member and Executive Officer. Jason practices out of South Tulsa Performance Health located on So. Mingo. Dr. Gerald Chicoine of Chicoine Chiropractic Clinic located on 11th street was also highlighted. It does not end in Tulsa, however. Edmond’s Dr. Harmony White of Harmony Chiropractic and Harrah’s Dr. Damon Coffman of Harrah Chiropractic both OSCIPA members were also highlighted in this article. Special congratulations to each of these doctors!