Chiropractic Medicare Changes in 2020 come in the form of imaging assignments, MBIs, and other documentation

It’s hard to believe that another year is just around the corner. This is a busy time in healthcare, and it’s important to make sure your chiropractic practice is ready for two important changes. The first affects the ordering process for advanced imaging studies, and the second can affect the timeliness of your reimbursement of traditional Medicare claims.

Order advanced imaging studies

Imaging studies can play an important role in the patient’s treatment plan. Imaging studies, especially advanced imaging studies (CT / MR / Nuclear / PET), also play a key role in a payer’s compliance plan. These advanced studies are carefully checked for “appropriate use” by the payers.

Does the patient’s condition as defined by the ICD10-CM codes support this imaging level and / or frequency? Would it be possible to provide the same level of care with a cheaper study? Commercial insurance companies have required pre-approval for an MRI or CT scan for decades by using outside radiology performance managers. Beginning January 1, 2020, Medicare will follow this trend, which has been shown to have the cost of imaging under control.

For Centers for Medicare & Medicaid Services (CMS), imaging costs are managed according to Appropriate Use Criteria (AUC, also known as Clinical Decision Support). The naming and program guidelines have been in place for several years – some practices have participated in voluntary status, but all ordering providers will be involved from January 1, 2020.

AUC is changing the way an advanced imaging order is placed for a Medicare patient. When ordering an MRI, CT, nuclear medicine, or PET study for a Medicare patient, an additional step is required to complete the order. This applies to imaging assignments in an external facility (hospital / imaging center) and imaging performed in your own chiropractic practice.

Advance Imaging order process after January 2020

1. Enter the patient information (age / present problem) into a separate software system called the Clinical Decision Support Mechanism (CDSM) in the guidelines.

2. Using an algorithm developed with input from various medical specialties, the CDSM returns a list of the most appropriate imaging studies for this condition.

Each recommended imaging study includes an adequacy assessment. For example, a contrast MRI may be listed as “appropriate” but with a score of 7. A non-contrast MRI may also be listed as “adequate” but with a score of 9. A doctor may still request or select the imaging study which they originally thought was best; However, the total score for all imaging orders within the calendar year will be tracked by CMS. Ordering advanced imaging that is deemed less suitable may affect reimbursement from the ordering provider in future years.

The facility reporting the technical component of the imaging study to Medicare requires two additional pieces of information from the ordering provider. When the imaging study is selected within the system, the CDSM generates a result such as “corresponds”, “does not match” or “does not apply”. This result is translated into a modifier that is attached to the application form by the entity reporting the technical component of the imaging study.

This information often has to be transmitted to the institution by the ordering provider. The second piece of information is the name of the CDSM that was consulted. This information is translated into a G-code and entered as a separate item in the application form by the entity reporting the technical component of the study.

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

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

We encourage you to contact the facility where your patients are receiving their imaging study, speak to the head of the radiology department, and learn about their new procedure.

Medicare Beneficiary Identifiers (MBIs)

It is not uncommon for an “invalid insurance certificate” to be rejected. A group number or even a policy number can change without the patient notifying the front office. 2020 is likely to usher in more rejections if the practice isn’t proactive with its Medicare patient population.

Medicare has been in a transition phase since April 1, 2018 to replace the social security number as a patient identification number. This transition ends on December 31, 2019 and from January 1, 2020, the individual identification number, known as the MBI (Medicare Beneficiary Identifier), will replace the social security numbers that have been used for decades. This increases patient safety, but may require extra attention from those at the front desk planning and checking patients in.

The MBI is an 11-digit alphanumeric identifier that was generated randomly. This is similar to the Health Insurance Application Number (HICN) and does not contain dashes, as was the case with SSNs in the past. Each patient, including spouses or relatives, receives their own MBI.

During this transition period, Medicare included the new MBI number for each patient in every ERA sent to the practice. It is recommended that DCs contact their billing team (internal or external) to determine if they have used this resource.

Previous ERAs may not cover every patient in a practice before they present for treatment on January 4th. If the patient does not have their new card or is unaware of this new procedure, they can use their Medicare Administrative Contractor (MAC). secure MBI search tool. You need to sign up for the MAC portal and have the patient’s SSN to use this tool, but even if your patients have a Medicare Advantage plan, you can find their MBIs.

Exceptions

From 01/01/2020, the MBI must be submitted for all claims with the following exceptions:

  • complaints – You can lodge an objection either with the HICN or the MBI
  • Claim status query – You can use either the HICN or the MBI to check the status of claims with a DOS before January 1st, 2020
  • Adjustments – the HICN can be used indefinitely for processing drug data, processing risk adjustments and encounter data
  • Reports going in and out of the CMS – Quality reports, ACO reports, provider statistics and reimbursement reports, etc.

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

Karna Morrow, CPC, RCC, CCS-P, is implementation manager for the practice EHR.