The “End of Flexibility” for ICD 10

Unspecified Codes Now Result in Non-payment.

When ICD-10 implementation began in October 2015, most payers accepted any diagnosis code in the correct family of codes.

As of October 2016, diagnoses must be coded to the highest level of specificity. This means unspecified codes will be rejected and the claims not paid. If a code does not exist, always use the diagnosis code with ‘other’ rather than ‘unspecified’ in the description.

Deleted & Added Codes to Help with Specificity

Many are applicable to Chiropractic; most deletions and additions were related to cardiology.

  • TMJ – deleted 3 codes (M26.6X), added 12 codes in the new family M26.6XX.
  • Added 20+ codes for cervical disc disorder and degeneration, all in the M50.0XX, M50.1XX, 50.2XX, M50.8XX family.
  • Added sprain of jaw codes, S03.41XX, S03.42XX

PQRS: It Doesn’t Have to be Painful

There are a few topics that consistently return the most questions in my Continuing Education classes, and one of them is PQRS (Physician Quality Reporting System).  Mainly, why do we have to do this and why are they reducing my Medicare payments if I do not?

What is PQRS?

The Physician Quality Reporting System (PQRS) is a voluntary Centers for Medicare & Medicaid (CMS) program, with the stated purpose of “encouraging health care professionals and group practices to report information on health care practices.” Their goal through this is to lead to better care for Medicare patients.

As a provider, you participate either through Individual or Group Measures. There are hundreds of available measures (download from CMS as an Excel spreadsheet here), and you can chose applicable measures for your office. One of the most widely applicable measures is Medication Documented (Measure #130). There are also measures for Pain Assessment and Follow Up (Measure #131), Functional Outcome Assessments (Measure #182), and many more.

Why Participate?

CMS hopes that participating in these quality measures will lead to better patient care, and more informed care for the patient. On top of that, as an added “incentive” to participate, CMS imposed a 2% fee schedule reduction for providers who do not participate in the program. If you do not participate, you likely already see this on your Medicare Remittance Advices:



If your Medicare patient volume is high enough, it could cause a noticeable decrease in reimbursement. It is a technically voluntary program, so you can decide whether or not your practice should participate based on the administrative load it would require and the decrease in payments you face for not participating.

How to Participate?

Many Electronic Health Record (EHR) programs compile the PQRS relevant information from the patient’s chart and send on for you. This is the most efficient way to participate, and should take the least administrative time for the office. They may also suggest some measures you did not realize your practice would be eligible to report.

If you are not using a full EHR program or if your EHR system does not have PQRS capability, you can report the measures on claims. The measures can be reported using dedicated “G” codes. Each applicable “G” code is added as a line item to your claims. These codes hold no value with Medicare and no reimbursement for them will be made.

Another option is to use a PQRS program. There are many PQRS alternatives to EHR that you can purchase. You must enter all of the information into their system, but they compile it for you and send it on to CMS on your behalf. They can also identify deficiencies and suggest new measures if applicable.

How Many Measures?

CMS suggests each practice report 9 individual measures.  If there are not 9 applicable measures to your practice you can, however, still avoid the reduction. A good example of this is with Chiropractic practices. Reporting on 2-3 measures for a Chiropractic office is usually enough to avoid your 2% reduction in fee schedule.


If any of our clients need PQRS guidance, email to find out if you’re already reporting or how to get started.

ICD-10: Quick Reminders!

When to Start Using ICD-10

Use ICD-10 codes on all dates of service 10/1/15 and later. Dates of service prior to 10/1/15 should be submitted with ICD-9 codes no matter the claim submission date.

In short: date of service dictates the code set used, not date of submission.

Can You Dual Submit?

Dual processing is when a company will accept either code set or both to give leeway to providers that may be a bit behind in readiness. Medicare is however not allowing this, and most private payers are not allowing this either.

In short: adherence to the 10/1/15 transition date is the safest way to ensure no delay in reimbursements to your practice. Dual code submission will not be time saving or beneficial.

Are There Exceptions?

Workers Compensation and Personal Injury carriers are not federally mandated to switch to ICD-10. In California it appears that all or most all WC carriers are honoring the 10/1/15 transition, however we are still checking with each company prior to submitting first claims. We are also checking with all Personal Injury carriers (Medpay, etc.) to be sure.

In short: Most are honoring the 10/1/15 transition date, but you may want to check with WC and PI carriers to be certain.


Happy Coding! If you are an In Charge Office Solutions client, call or email with any specific questions you may have. We are here to help and make the transition as smooth as possible, and can set up training meetings if you are in the Bay Area.

2015 Brings Changes to Modifier 59

Modifier -59 is one of the most well known and used modifiers, because it has the potential to have a large impact on your reimbursement from health insurance companies. Because of its popularity (and often misuse), CMS has rolled out 4 new modifiers that essentially replace modifier 59.

What is Modifier 59?

It is defined in the CPT manual as a “Distinct Procedural Service.” It allows the provider to indicate that a procedure or service should be considered separate from another during the same encounter. This is only necessary on codes that are usually considered bundled services. For example:

CPT code 97140 (manual therapy) is usually bundled with CPT code 98940 (CMT, spinal).  When the manual therapy is performed as a separate service for a separate issue (diagnosis), then it can be shown by appending modifier -59 to the CPT code 97140.

This makes both codes payable rather than just the one. This also, of course, needs to be supported by the medical record.

What are the Changes?

CMS has created 4 new modifiers as subsets to modifier -59 that are intended to ultimately take the place of modifier -59. They are more specific, and allow the provider to more specifically indicate why the service is separately identifiable from another.

  1. XE – Separate Encounter
  2. XS – Separate Organ/Structure
  3. XP – Separate Practitioner
  4. XU – Unusual Non-Overlapping Service

How to Implement

The modifiers became effective January 1, 2015, and CMS is encouraging immediate use but is also still accepting modifier -59. It is also important to note that private insurance carriers may not yet be accepting them. Anthem Blue Cross has stated they will accept them for dates of service 1/1/15 and later, but they will not be accepted until the system update in February. It is important to check with your contracted carriers before making the switch, but equally as important to ensure a plan is in place.

BREAKING: Senate Passes Bill Delaying ICD-10

stopsignOn 3/31/14, the Senate passed a bill that includes delay of ICD-10 implementation to October 1, 2015 – an entire year extension. It states “The Secretary of Health and Human Services may not, prior to October 1, 2015, adopt ICD–10 code sets as the standard for code sets under section 1173(c) of the Social Security Act (42 U.S.C. 1320d–2(c)) and section 162.1002of title 45, Code of Federal Regulations.”

This puts many feet in mouths, including my own.

While on the surface this may seem like a relief, the amount of time, money, and energy spent to transition on October 1st of this year is immeasurable. To delay another year puts the brakes on something that all of us in the healthcare industry have prepared for. Software vendors have upgraded their systems, clearinghouses have begun ICD-10 testing, and coding educational institutions have begun teaching the new code set.

Delay also does not help to convince people that ICD-10 is a good thing, which is the point of the whole transition. More effective reporting, advanced specificity, and accuracy in claims reporting; these are all good things.

Our current plan is to continue with preparation as we were. Our clearinghouse is also moving forward with ICD-10 testing, even with the delay. Sign up for our newsletter to receive updates, or email if you have any specific questions: .


ICD-10 for the Chiropractic Office

Chiropractic Symbol - GoldWith so much anticipation of looming ICD-10 transition, I’m getting more and more calls from Healthcare Professionals wondering what they should be doing to prepare. Luckily, there are a lot of resources out there and I am happy to be one of them.

There is an abundance of information for medical practices, but it is more difficult to find resources for the chiropractic office. The following link is a quick PDF file that was created in order to address some commonly used ICD-9 codes and what they will look like as ICD-10 codes:  ICD-10 for the Chiropractic Office

I hope that you find it helpful, and expect more resources to be posted as we get closer to the transition (October 1, 2014).

2014 ACA Implementation: One Month In

Happy New Year!

With 2014 came the roll out of the “ACA compliant” health insurance plans. The Covered Ca website is up and running with enrollment far exceeding projections; the most recent figures released  show enrollment of 500,108 in 2013.

The new plans’ high deductibles and co-payments have been the focus of much discussion, but it looks as if the real issue may be low enrollment rate of Healthcare Providers in the networks. The combination of low provider enrollment with no out-of-network benefits leaves little option for the 500,000+ enrollees when it comes to their healthcare.

Why Not Join?

Providers are reluctant to join the networks for many reasons. When insurance plans shift more out of pocket responsibility to the patient, it becomes more difficult to recoup payment for services. Patients may not understand their benefits and why they have to pay out of pocket, and resistance is met. This is already common in the business of healthcare, but higher deductibles and co-payments will only exacerbate the issue. Putting too much focus on payment with the patient can make some providers feel the focus shift too far from care to business. It is a delicate balance.

In the same vein, many providers are reluctant to join because fee schedules are either unclear or unacceptable. Typically, PPO fee schedules hover near and slightly above Medicare, but many Covered California plans reimburse slightly above Medi-Cal rates. Medi-Cal rates are unsustainable for many practices in California, and many providers have opted out of Medi-Cal participation for years. Why then, would those same providers join networks reimbursing near the same? Without a large enough Provider Network, many patients will find themselves having to switch providers or wait long hours for care.

Affordable Care Act: It’s Here, Now What?

Lately it seems difficult for people to discuss the Affordable Care Act (ACA) without things turning political, but that is what we are going to try to do here. Like it or not, changes are coming and some have already taken place

Insurance companies have had to create new plans that align with the provisions of the ACA, and with those new plans come new provider networks. These networks are generally EPOs – Exclusive Provider Organizations – which carry no out-of-network benefits.  Blue Shield of California recently sent out a “Q&A” about their ACA compliant EPO highlighting the fact that any services provided by a non EPO provider will receive no benefit. If the percentage of EPO plans increases greatly, it will be more important than ever to check a patient’s benefits before they are seen and make sure your practice is a part of their network. Get new patient insurance information over the phone at the time the initial appointment is made, and make it a routine part of your office processes.

Since  many practices are also small businesses, the reform will affect them in multiple ways.  Many of my clients have already received notice that their employee’s health plans will need to be changed to comply with the ACA, and with those new plans come higher premiums. A higher bill is the last thing any business wants, BUT, if there are truly more insured patients (and that is the plan), the increase in patient flow may make up for the increase in cost to your business.

With so much information thrown at those of us in the healthcare industry, it is important to sift through it and stay informed. There will be parts of the ACA that necessitate a change in how your practice is run. Only time will tell how many of these changes will ultimately effect business, and more importantly, patient care.

Wound Care Clinic Reimbursement in 2013


Wound Care Clinic Reimbursement

Diving so far into outpatient Wound Care reimbursement today, I may drown in MediHoney!  Corny joke aside (sorry), very interesting area of healthcare right now. Wound Care Clinics are a huge asset to any community, help lower E.R. visits and hospital admissions, and are profitable. Policy changes everywhere; continuing education a must! Vegas isn’t a bad location for a conference either.

Windows XP Losing HIPAA Compliance

PHI FolderSince its implementation in 1996, HIPAA has shaped much of how medical care is given, recorded, and how those records are protected. Because so much personal health information (PHI) is stored on desktop or laptop computers, the operating system (OS) must be secure to meet HIPAA standards. This means receiving security updates and patches when they are released, and if you’re running Windows, Microsoft takes care of that for you.

Bad News for XP Users

Beginning April 8, 2014 Microsoft will no longer support their Windows XP Operating System. This means they will no longer release those security updates and patches necessary to keep the OS in HIPAA compliance.  Although ending support is a normal part of the operating system “life cycle,” the fact is that Windows XP was a popular OS and is still used on an estimated 37.74% of active PCs, second only to Windows 7.  Healthcare providers and their businesses are sure to be a part of that statistic, and April 2014 will be here before you know it.

What to Do?

Bite the bullet and upgrade. Windows 7 is a good option and is a relatively easy transition for most users. Microsoft will  be supporting  Windows 7 through 2020, keeping the OS HIPAA compliant for the next 7 years. It may seem like a large undertaking, especially if your office uses multiple PCs and licenses, but the security and compliance justify the switch. If you are an In Charge Office Solutions client, we can assist with the transition (ask us how).