How many times may CPT code 97035, application of modality to 1 or more areas; ultrasound, each 15 minutes, be reported if treating 3 body areas, such as neck, wrist, & knee, on same date of service?
Both the supervised modality codes (97010-97028) and the constant attendance modality codes (97032-97039) include language in their code descriptors that indicate "application of a modality to one or more areas." The constant attendance codes also have time indicated in their code descriptors (each 15 minutes). Therefore, although the number of areas of application is not a consideration in the reporting of these constant attendance codes, the amount of time the provider spent in constant attendance with the patient providing the ultrasound would need to be indciated in order to support the number of units billed. (This question was originally published in the November 2010 AMA CPT Assistant)
If a patient is fitted for orthotics on 11/13 is it okay to bill the office visit as 11/13 and then bill the orthotics as 11/14?
You should bill for services on the day they were provided. If you fitted the orthotics on the second day due to a necessary reason then that would be appropriate. However, intentionally misrepresenting dates of service in an effort to avoid bundling issues is certainly problematic and could result in an audit, recoupment, and possibly worse.
I recieved a letter from a company called Sunera that claims it is performing audits for Horizon Blue Cross Blue Shield and requests copies of patient records?
The ANJC has received numerous calls and emails on this issue. Horizon has apparently hired Sunera, Inc., to outsource its post-payment audit of doctors and is focusing on the use of modifier-25 when billing Evaluation and Management Services on the same day as a Chiropractic Manipulative Therapy (CMT), as well as the use of modifier-59 when performing manual therapy or massage on the same day as CMT. You cannot ignore the record request and it is our recommendation to those doctors who receive such a request to consult with a healthcare attorney prior to responding.
In many cases, the attorney will retain an expert coder/documentarian to review your files and highlight any issues prior to sending the records, in essence preparing for an appeal of any request for reimbursement by Sunera should it occur. If the expert is retained through the attorney, his or her findings are considered work product and/or protected from disclosure by the attorney client privilege. Thus, proceed cautiously if you receive such a request and contact your healthcare attorney or contact ANJC headquarters for a referral if you require one prior to sending in your notes.
Can a Chiropractor licensed in New Jersey hire a Nurse Practitioner to work for them?
Yes. The New Jersey Board of Chiropractic Examiners opined at their February 2013 Public Session meeting that a chiropractor licensed by them can hire a nurse practitioner but that the nurse practitioner is working under that chiropractor and their scope of practice. Thus, the nurse practitioner's duties would be limited to the chiropractic scope of practice and not the nurse practitioner scope of practice.
Do Insurance carriers generally reimburse treatment specifically for scoliosis?
Most payers will not reimburse with scoliosis as primary diagnosis; it can often be a contributing condition but if it is the only condition you are treating or listed as primary then most payers will not reimburse for this condition.
If you perform a service or use a modality knowing that it is not covered, do you have to report it as a charge to the insurance company?
It may not be necessary to report all charges that are clearly not covered. However, you should check with your provider agreement to be sure. Additionally, you should have the patient sign a benefit waiver that puts them on notice whenever a service is considered non-covered.
How long must we keep patient files?
Regulations require patient records to be kept for 7 years from the last entry in file for adults with no differentiation for the deceased. For minors, it is 7 years from the age of majority (18) or 7 years from last entry in file, whichever is later.
What is the difference between "self-funded" and "fully funded" insurance plans?
Fully funded plans work how most people understand insurance. A person or entity pays a carrier a premium and in return that carrier is responsible for the medically necessary care outlined in the agreed upon policy. These plans are under the jurisdiction of NJ State insurance laws regulated by the NJ DOBI.
Self-funded plans work differently. In a self-funded plan an entity, such as an employer or union, pays a carrier to administer a plan for them. But while the carrier is managing the plan by processing claims or perhaps reviewing treatment for medical necessity, it is the original entity that actually pays for the medical treatment. In these plans the carrier is really acting as a third party administrator. These types of plans are under the jurisdiction of federal ERISA laws regulated by the U.S. Deptartment of Labor.