How long do I have to perform a timed code to bill for it?
Timed codes are billed in units of 15 minutes. To bill one unit of a timed code you must provide the service for at least 8 minutes. Before a second unit of a timed code can be billed you must first reach a full 15 minutes for the first unit and then at least an additional 8 minutes beyond that for a total of at least 23 minutes. This is true even when billing one unit of two different codes. In other words, you cannot bill a unit of 97140 for 8 minutes and then a unit of 97110 for 8 minutes because combined they only add up to 16 minutes. To bill a second unit, even of a different code, the total time must be at least 23 minutes. The same is true for billing a third unit. First, two full units equaling 30 minutes (15 minutes each) must be completed. Then at least an additional 8 minutes must be performed to reach the third unit for a total of at least 38 minutes.
For a visual aid for time based billing units see this cheat sheet:
What do I have to do when closing my practice permanently or temporarily?
If a licensee ceases to engage in practice or it is anticipated that he or she will remain
out of practice for more than three months, the licensee or a designee shall:
1) Establish a procedure by which patients can obtain patient records or acquiesce in
the transfer of those records to another licensee or health care professional who is
assuming the responsibilities of that practice;
2) If the practice is unattended by another licensee, publish a notice of the cessation
and the established procedure for the retrieval of records in a newspaper of general
circulation in the geographic location of the licensee's practice, at least once each
month for the first three months after the cessation;
3) File a notice of the established procedure for the retrieval of records with the Board
of Chiropractic Examiners; and
4) Make reasonable efforts to directly notify any patient treated during the six months
preceding the cessation in order to provide information concerning the established
procedure for the retrieval of records.
Can a Chiropractor hire other licensed healthcare providers to work for them?
Yes and no. The permissible practice structure regulations permit a doctor of chiropractic to hire a licensed provider of lower licensure that are considered "closely allied healthcare providers." Thus, a DC can hire: a physical therapist; an acupuncturist, a podiatrist, and a licensed massage therapist, for example. A DC cannot hire: a medical doctor or doctor of osteopathy, which are both defined as plenary licensed healthcare providers with higher licensure than a chiropractor.
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. Medicare Part C requires records to be kept for up to 10 years from date of service. HIPAA requires a 6 year retention but since New Jersey state law requires 7 years, providers must keep records for beyond the 6 year HIPAA requirement to 7 years. If you participate with a carrier, check your participating provider agreement which may have a different retention requirement.
What is considered part of the patient file?
The patient file consists of all clinical documents including notes, exams, diagnostic tests, consult reports as well as all billing records. This includes claim forms, EOBs, appeals, etc. Essentially, any document maintained in your patient file is part of the patient record. X-ray films, CDs of MRI, CT Scans and other imaging are also part of the patient file.
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.
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.
Can I treat Medicare patients for cash?
Doctors of Chiropractic (DC) may not opt out of Medicare. Note that opting out and being non-participating are not the same things. Chiropractors may decide to be participating or nonparticipating with regard to Medicare, but they may not opt out. Opting out refers to physicians’ ability to decide not to bill Medicare at all and then entering into private contracts with Medicare beneficiaries they treat. In this instance, you may not treat the Medicare beneficiary for cash.
However, when a provider of service believes that Medicare may not pay, the use of a valid ABN form that is properly executed does allow the provider to ask for payment at the time of the service. For example:
OPTION 1. I want the (D) listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles. This option allows the beneficiary to receive the items and/or services at issue and requires the notifier to submit a claim to Medicare. This will result in a payment decision that can be appealed. See Ch. 30, §50.15.1 of the online Medicare Claims Processing Manual for instructions on the notifier’s obligation to bill Medicare. Suppliers and providers who don’t accept Medicare assignment may make modifications to Option 1 only as specified below under “D. Additional Information.” Note: Beneficiaries who need to obtain an official Medicare decision in order to file a claim with a secondary insurance should choose Option 1.
OPTION 2. I want the (D) listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed. This option allows the beneficiary to receive the non-covered items and/or services and pay for them out of pocket. No claim will be filed and Medicare will not be billed. Thus, there are no appeal rights associated with this option.
With Option 3, the patient is directing the provider that they do not wish to receive the services, therefore they are not responsible for payment.
OPTION 3. I don’t want the (D) listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.
Please keep in mind, these options must be offered to and chosen by the patient, not the provider.
The beneficiary or his or her representative must choose only one of the three options listed in Blank (G). Under no circumstances can the notifier decide for the beneficiary which of the 3 checkboxes to select. Pre-selection of an option by the notifier invalidates the notice.
Don’t denials of Chiropractic care have to be from a New Jersey Licensed DC?
The answer is yes and no. If the plan is fully-insured it is then under NJ state law and the answer is yes, only a NJ licensed chiropractor may reduce, deny or curtail a course of chiropractic treatment per the NJ chiropractic scope of practice statute. If the plan is self-insured it is under federal ERISA (Employee Retirement Income Security Act) law and is not subject to the NJ statute. ERISA law is enforced by the Employee Benefits Security Administration (EBSA) which is housed under the U.S. Department of Labor. This department has issued an advisory opinion that denial of care should be performed by a provider of the same specialty as the requested care. In other words, denial of chiropractic care should come from a chiropractor – though not necessarily an NJ licensed chiropractor. See advisory opinion here: https://www.dol.gov/agencies/ebsa/employers-and-advisers/guidance/advisory-opinions/2005-16a
I spent 45 minutes with a new patient and billed a 99204 but the carrier said my documentation did not warrant this level of E/M code, is this right??
The level of service for evaluation and management services depends on the 3 key components, History, Examination and Medical Decision Making. For a new patient exam, in most instances, DC’s qualify for a Level 3 (99203) and not a level 4 (99204). Time is not a key component when it comes to the level of E/M service unless counseling and coordination of care dominates more than 50% of the total time spent performing the examination.
What activities can I delegate to my unlicensed assistant?
Under the current NJ Chiropractic regulations there are 10 specifically outlined tasks that can be delegated to an unlicensed assistant (CA). Per N.J.A.C. 13:44-2.7 these tasks are:
1) Completing a medical history of a patient;
2) Preparing the patient for chiropractic care;
3) Writing into the patient record subjective complaints from the patient and objective findings provided by the licensee;
4) Performing a urinary dipstick analysis;
5) Taking and recording vital signs;
6) Preparing and developing X-ray films;
7) Providing patient education activities;
8) Providing instruction in activities of daily living;
9) Administering cryotherapy, hot packs, non-fulcrum mechanical traction without restraints (such as roller tables and roller chairs) and non-invasive surface screening; and
10) Setup and preparation of the patient for the administration of physical modalities
What codes require the -59 modifier when billed with CMT?
A: The most common codes performed by a chiropractor that bundle and require a -59 modifier when billed with CMT (98940-2) would include 97140 Manual Therapy, 97124 Massage Therapy and 97112 Neuromuscular Re-education. It should also be noted that while NCCI does not bundle the same codes with extraspinal CMT 98943, many private payers will bundle them as well. Remember, documentation should support the use of the -59 modifier.
What legal and compliant ways can I offer discounts to patients in my office?
In most instances, a doctor can legally apply discounts for prompt pay, hardship or a Discount Medical Plan. It should be noted that each type of discount has specific requirements that must be followed for proper compliance with state and federal law. For more information please view article on the matter by our Coding & Compliance Consultant Dave Klein:
Where can I file a complaint about an insurance carrier?
For fully-insured commercial plans or PIP claims, you would file a complaint with the New Jersey Department of Banking and Insurance (NJDOBI). You can find the forms to file a complaint at this web address: http://www.state.nj.us/dobi/consumer.htm
For self-insured non-governmental plans, you would file a complaint with the Employee Benefits Security Administration (EBSA). You can find instructions on this at the web address: