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Medicare Demonstration ProjectProject Description The Medicare Chiropractic Demonstration Project will test expanded access to chiropractic services for America's seniors in a two year, four site project that was launched in April, 2005. A positive evaluation of the project by the Centers for Medicare and Medicaid Services (CMS) is key to the potential opportunity to increase the services for which we may be reimbursed -- in turn, making it easier for patients to benefit from chiropractic services. It is vital that all chiropractors are billing and documenting correctly so that the CMS gets an accurate and complete picture of the impact of full integration of chiropractic services into the Medicare system. The American Chiropractic Association (ACA) and VCA teamed up for a seminar in Charlottesville on April 2nd to help chiropractic offices to better understand how the demonstration will work, how it will affect their practice, what the results can mean to DCs and their patients, master proper coding procedures and bill correctly, provide the required documentation, recognize potential problems and how to avoid them, and more. Additional training will be announced soon. Seventeen central Virginia counties are affected:
A list of the affected zip codes may be found on the CMS web page. [2/16/07] Demonstration Ends March 31, 2007 As you may be aware, for the last two years a number of DCs in central
Virginia have been participating in the Medicare Chiropractic Demonstration
(mandated by Section 651 of the Medicare Prescription Drug Improvement and
Modernization Act of 2003.) This Demonstration provided for expanded coverage of
chiropractic services including the following additional services: [2/15/07] Notice from CMS: Outpatient Physical Medicine and Rehabilitation Services LCD In 1997, Congress imposed a cap on the amount of therapy services (physical
and occupational therapy and speech-language pathology services) for which
Medicare may pay for an individual patient in a given year. Each year since
then, Congress has either suspended the cap or provided some other means to
bypass the cap. The cap was based on an estimate of the amount of therapy
services the average Medicare beneficiary might need to rehabilitate from a
single injury or illness. For dates of service in Calendar Year (CY) 2006,
Change Request (CR) 4364 provided instructions for both an automatic and a
manual exception process that allowed for payment of additional reasonable and
necessary therapy services. In conjunction with the initiation of this exception
process in 2006, Trailblazer temporarily suspended its procedure to diagnosis
editing related to the Y-18 Outpatient Physical Medicine and Rehabilitation
Services Local Coverage Determination (LCD). Helpful Links CMS
Chiropractic Demo web page CMS has asked that doctors in the demo areas download, print out and provide state-specific beneficiary fact sheets to all of their Medicare patients. Click here for a copy (PDF) or visit the CMS website to download Virginia's information. For those providers wishing to participate in the demonstration project (or not), it will be an “all or nothing” situation—they will either be participating in the project or they will not. They will NOT be able to pick and choose which services are billed to the demo and which are not! If a provider chooses to participate in the demonstration, they will be required to bill all covered services provided to the demo and, obviously, will need to abide by all relative rules. This is VERY important. Again, doctors will not be allowed to submit some covered services to the demo and not submit others (with the obvious exception of spinal CMT). If the provider chooses to be part of the demonstration, and the service rendered is listed in Table 5 as a covered service, then the provider will be required to bill this service to Medicare. Where this may become an issue is with the physical medicine services. As we all know, to provide physical medicine services to a Medicare beneficiary, the technician/therapist must be either a licensed physician (DC, MD, DO, DPM) or a graduate from one of the specified APTA or AMA programs. No one else may provide these services under the demo. Therefore, if a provider chooses to render physical medicine services, and is not willing to either provide the service themselves, employ a qualified person to do it, or refer the service out, then they will not be able to participate in this project. (Of course, as we know, providers not participating in the demonstration project may still treat Medicare beneficiaries and be reimbursed for active care spinal CMT services.) Alerts(Listed in reverse chronological order) September 19, 2005: Click here for important updates including:
July, 2005: PLEASE NOTE: The ACA continues to object to the manner in which CMS is treating "incident to" services for the purposes of conducting the demonstration project. The ACA argues that, for purposes of the demonstration project, regulation 42 CFR 410.60 should be waived. The legislation mandating the demonstration project expressly grants the Secretary of HHS authority to waive any existing regulation necessary in order to carry out the demonstration project in an effective manner. However, in this instance, CMS has refused to urge the HHS Secretary to waive this regulation. If the regulation were waived, as requested by the ACA, then chiropractic assistants working under the authority of the DC would be able to provide "incident to" physical medicine services under the demonstration project and, in the opinion of the ACA, this circumstance would more accurately reflect common practice within the typical chiropractic office. The ACA will continue efforts to persuade CMS and HHS to change their current policy decision regarding how "incident to" services will be treated under the demonstration project. If the ACA is successful in effecting such change, this change may not take place until the demonstration project is already underway. In the meantime, it is very important that all doctors of chiropractic practicing in the demonstration areas be encouraged to participate in the demonstration project in spite of this restriction. If you have further questions, please call Amy Hanley at the American Chiropractic Association At 1-800-986-4636 or e-mail her via ahanley@amerchiro.org. June 10, 2005 (Denials and "Incident to" Requirements): (1) TrailBlazers Processing Error Alert!! We have learned that there were some demonstration project claims and potentially manual manipulation claims that may have been denied incorrectly by TrailBlazers, if the provider has a practice zip code within the demonstration project area. If any Virginia chiropractor believes that their claims have been denied incorrectly and they have reviewed their claim forms to make certain they were submitted correctly, the provider can fax a copy of their remittance notice to TrailBlazers and they will have their claims reopened. Providers should put an asterisk by the claims they feel have been denied incorrectly. The provider does not have to refile any claims where they were denied incorrectly. This was an internal issue at TrailBlazer and they have taken steps to correct the problem. While there may be a few claims that are still trickling through, claims processed as of May 26 th, 2005 should not be affected. Unfortunately, they are not able to conduct a mass adjustment on these claims they must be handled manually. For more details about this processing error at TrailBlazers contact: Kathy Boehm (804) 327-2134 (2) “Incident to” Requirements ACA representatives met with representatives from the Center for Medicare and Medicaid Services (CMS) on Friday morning, June 10 th, regarding the incident to requirements. It was confirmed that due to the pending litigation against CMS by National Association of Athletic Trainers ( http://www.nata.org/), all "incident to" requirements on DCs in the demo areas have been temporarily rescinded retroactive to April 1, the beginning of the demo. While we expect more information from CMS on how to file corrected claim forms in the near future, we wanted to make sure that the profession was aware of this vital information as soon as possible. It means that DCs participating in the demo are allowed to have their CAs perform "incident to" therapy services at this time. The ACA continues to raise its objection to the overall application of the incident to regulation to the demonstration project. We have received advance copy of the CMS Q&A addressing this issue which will be posted on the CMS site ( http://www.cms.hhs.gov/researchers/demos/eccs/default.asp) this upcoming Monday: “Q: Can trained office staff who are not chiropractors, such as chiropractic assistants, provide therapy services “incident to” the chiropractor? A : Due to pending litigation, CMS has agreed to delay implementation of the regulation and manual provisions governing qualifications for auxiliary personnel furnishing services billed as physical therapy and occupational therapy services incident to the services of a physician or nonphysician practitioner. We anticipate this delay to be temporary, probably less than two months. By its terms, CMS's agreement to delay implementation will expire on July 22, 2005, unless the court enters an injunction order prohibiting implementation of the qualification provisions described above. If the court rules in favor of CMS before July 22, 2005, CMS will issue instructions requiring implementation of the provisions of the regulation and manual. In light of CMS's agreement to delay implementing new Chapter 15 manual provisions and certain provisions of the regulations regarding “incident to” therapy services, chiropractic assistants, physical therapy assistants, or other trained office staff may provide therapy services incident to a chiropractor as of the beginning of the demonstration, April 1, 2005. Please note that the court has ordered that any hearing on the issue, if necessary, will take place on July 1, 2005. The incident to requirements for this demonstration will then mirror the court’s ruling regarding implementation of these manual provisions. If the court allows the CMS manual provisions to take effect, then chiropractors under the demonstration will also be subject to these requirements as of the effective date. This means that when a physical therapy service is provided “incident to” the service of a chiropractor, the person who furnishes the service must be a physical therapy qualified practitioner other than licensure (meeting the physical therapy definition at 42 CFR 484.4 other than licensure).” The ACA and VCA will continue to update you as information becomes available. If you have any questions, please feel free to visit ACA’s demo website at www.acatoday.com/demo or call the ACA at 800-986-4636 or the VCA at 540-932-3100. May 17, 2005: The VCA has just been informed that there has been another misunderstanding with CMS concerning the demonstration project. Please note that you can NOT use PTAs to provide therapy unless they are under a PT’s management. Additional details and explanation will follow later this week, as soon as the information is available. Please help to spread this alert to your colleagues in the demo project area. P.S. Reminder regarding paper claims: As of this year, if you are not filing electronically, you will receive a letter from Trailblazers asking you to demonstrate that you qualify for paper claims. If you do not respond, Trailblazers will assume that you do not qualify and all your paper claims will be denied. |