The new year and chiropractic Medicare changes

Chiropractic Medicare changes in 2020 come in the form of imaging orders, MBIs and other documentation

It is hard to believe that the end of another year is just around the corner. This is a busy time in health care, and it is important to ensure your chiropractic practice is ready for two key changes. The first impacts the process of ordering advanced imaging studies, and the second may impact the timeliness of your reimbursement from traditional Medicare claims. 

Ordering advanced imaging studies

Imaging studies can play an important part in the patient’s treatment plan. Imaging studies, particularly advanced imaging studies (CT/MR/Nuclear/PET), also play a key role in a payor’s compliance plan. These advanced studies are under careful scrutiny by payors for “appropriate use.”

Does the patient’s condition as defined by the ICD10-CM codes support that level and/or frequency of imaging? Would it be possible to provide the same level of care with a more cost-effective study? Using third-party radiology benefit managers, commercial insurance companies have required pre-authorization for an MRI or CT for decades. Beginning Jan. 1, 2020, Medicare will follow this trend proven to manage imaging costs. 

For Centers for Medicare & Medicaid Services (CMS), imaging costs will be managed under the Appropriate Use Criteria (AUC or also known as Clinical Decision Support). The name and program guidelines have been in place for several years — some practices participated in a voluntary status, but all ordering providers will be involved effective Jan. 1, 2020. 

AUC changes the way in which an order is placed for advanced imaging for a Medicare patient. If you place an order for an MRI, CT, nuclear medicine study or PET for a Medicare patient, an additional step will be required to complete the order. This applies to those orders for imaging to be done in an outside facility (hospital/imaging center) and imaging that is performed within your own chiropractic practice. 

Process for ordering advance imaging post-January 2020

1. Enter the patient’s information (age/presenting problem) into a separate software system referred to in the guidelines as a “Clinical Decision Support Mechanism (CDSM).”

2. Using an algorithm developed with input from a variety of medical specialties, the CDSM will return a list of the most appropriate imaging studies for that condition.

Each recommended imaging study will include a score rating the appropriateness. For example, an MRI with contrast may be listed as ‘appropriate,’ but with a score of 7. An MRI without contrast may also be in the list as ‘appropriate,’ but with a score of 9. A provider may still request or select the imaging study they originally felt was best; however, the total score for all imaging ordered within the calendar year will be tracked by CMS. Ordering advanced imaging that is viewed as less appropriate may impact the ordering provider’s reimbursement in future years.

The facility reporting the technical component of the imaging study to Medicare will require two additional pieces of information from the ordering provider. When the imaging study is selected within the system, the CDSM will generate a result such as “adhered,” “didn’t adhere” or “didn’t apply.” This result will translate into a modifier that will be attached to the claim form by the entity reporting the technical component of the imaging study.  

This information will frequently need to be communicated by the ordering provider to the facility. The second piece of information will be the name of the CDSM that was consulted. This information will be translated into a G code and entered as a separate line item on the claim form by the entity reporting the technical component of the study.   

It is important to consider the dynamics between your practice and any outside imaging center.  For some, the facility may have a portal that can be used for meeting this requirement. Other chiropractic centers may need to consult a separate software system (CDSM) to complete the process.

CMS has approved multiple CDSMs. The list is available here: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/CDSM.html.

We recommend that you contact the facility where your patients will receive their imaging study, speak with the radiology department manager and learn their new process. 

Medicare Beneficiary Identifiers (MBIs)

It is not uncommon to receive a denial for “invalid insurance identification.” A group number or even policy number may change without the patient alerting the front office. The year 2020 will ring in with potentially more denials if the practice isn’t proactive with its Medicare patient population.

Medicare has been in a transition period since April 1, 2018, to replace the Social Security number as a patient identifier. This transition ends Dec. 31, 2019, and effective Jan. 1, 2020, the individual identification number, known as the MBI (Medicare Beneficiary Identifier) will replace the Social Security numbers used for decades. This will increase the security for patients but may require extra attention for those at the front desk who schedule and check-in patients.

The MBI will be an 11-character alpha-numeric identifier that has been randomly generated.  This is similar to the Health Insurance Claim Number (HICN) and will not contain dashes as the SSNs have in the past. Each patient, including spouses or dependents will receive their own MBI. 

During this transition period, Medicare has included the new MBI number for each patient on each ERA sent to the practice. It is recommended that DCs reach out to their billing team (internal or external) to determine if they’ve taken advantage of this resource.  

Past ERAs may not cover every patient within a practice before they present for care on Jan. 4. If the patient doesn’t have their new card or isn’t aware of this new process, you can use your Medicare Administrative Contractor’s (MAC’s) secure MBI look-up tool. You will need to sign-up for the MAC portal, and have the patient’s SSN to use this tool, but even if your patients are in a Medicare Advantage Plan, you can find their MBIs.  

Exceptions

Effective Jan. 1, 2020, the MBI must be submitted on all claims with the following exceptions:

• Appeals – you may file an appeal with either the HICN or the MBI
• Claim status query – you may use either the HICN or MBI to check the status of claims with a DOS prior to Jan. 1, 2020
• Adjustments – the HICN can be used indefinitely for Drug Data Processing, Risk Adjustment Processing, and Encounter Data
• Reports coming into/out of CMS – Quality Reporting, ACO reports, Provider Statistical & Reimbursement report, etc.

Other exceptions can be reviewed here: www.cms.gov/Medicare/New-Medicare-Card/index.

Karna Morrow, CPC, RCC, CCS-P, is an implementation manager for Practice EHR.