Mario Fucinari, DC, CCSP, CPCO, MCS-P, MCS-I

Mario Fucinari, DC, CCSP, CPCO, MCS-P, MCS-I

Under the direction of the Medicare Access and Chip Re-Authorization Act of 2015 (MACRA), the Centers for Medicare and Medicaid services has made plans to implement a quality payment program that pays healthcare providers for the quality of their work, not the quantity.

As Alternative Payment Models (APMs) take effect in 2017, further changes in the ICD-10 coding system will coincide, thus providing methods for data to be accumulated and policies to take shape. When improperly used, ICD-10 codes will reveal inferior healthcare practices, leading to increased denials. It is in the best interest of every practice to learn how to properly code conditions and raise their practice profile to new levels. Those who fail to do so will see increased claim rejections.

As our population becomes older, chronic conditions elevate the costs of medical care. The top 10 conditions affecting health care costs include diabetes, heart conditions and cancer. Back pain also ranks among the top 10 conditions, costing billions of dollars in health care. Patients with multiple chronic conditions complicate healthcare recovery even more. When you code the patient’s condition, it is important to include the complicating factors on your claim form that will slow the recovery of your patient. Chiropractic is poised to make an impact on the reduction of health care costs – if we report it properly.

Some policy changes have already been introduced. As forewarned, one of the largest reasons for claim rejections since October 2015 has been the use of unspecified codes.   Physicians need to get away from the use of unspecified codes in ICD-10. Proper use of the more specific ICD-10 codes will lead to improved policies. New policies go into effect January 2017 pertaining to quality measures.  Medicare is releasing new national and local carrier policies further restricting the use of unspecified codes.

Recently, I utilized my contacts to perform an update analysis of a sample of Blue Cross claims. In that analysis, we analyzed data to obtain a ranking of the most commonly used diagnoses by chiropractors in the first eight months of 2016. We then compared the ranking of the codes to the ranking of like claims in the same subset of chiropractors analyzed in 2015. Astoundingly, we found that the top 10 codes used by chiropractors in Blue Cross were still unspecified codes. Other than subluxation codes, the most common codes were, and still are, lumbalgia, cervicalgia and dorsalgia – not good.

Payment based on quality of care takes into account initially the diagnosis of the patient. The primary communication with the carrier is through your claim. Even practices who claim to be cash practices still are profiled, since the patient usually files the information with the carrier, thus creating a paper trail. Documentation audits then ensue. It is required that the diagnosis be supported by evidence such as an examination and possibly imaging, such as MRI, that demonstrates a herniated disc. If the physician renders a short-term unspecified diagnosis such as lumbalgia, then this will adversely affect the rating of their quality care.  High-quality care is both evidence-based and delivered in and efficient manner.

By comparing benchmarked achievable results in other comparable populations of patients, you are judged and the measured quality of care you are providing will affect your reimbursement. In other words, the fee-for-service that we are used to, will be highly variable. In other words, there will no longer be a set fee for manipulation of the spine, fee for service will be based on your own personal value-based modifier. This modifier will reflect the rating of your quality of care to your specific population of patients.

In addition to documentation, examination and a proper diagnosis, we also depend on patient compliance.  Patients must be engaged in their own healthcare. This is accomplished through improved patient education.  Non-compliant patients will adversely affect our outcomes and ultimately our reimbursement rates.  Non-compliance must be documented and appropriate codes used on the claim form whenever possible.  There are now Z-codes that can be used to indicate non-compliance. If the payor sees that the patient is noncompliant, they may do an intervention with the patient to assure better outcomes.

As of October 1, 2016, the honeymoon period for coding leniency is officially over.  1943 new ICD-10 codes have gone into effect as of October 1, 2016. There were also 422 revisions and 305 deleted codes. Many of the deleted codes were not totally deleted, but rather were revised or incorporated into other categories or combination codes. It is important that each of us stays educated and well informed of the proper usage of these codes.

We must also track and monitor the codes we use in our office. Physicians must work to improve their documentation of chronic conditions as we make the transition to these advanced payment models.  If physicians do not change their diagnosis coding practices to the most specific codes by the end of 2016, then by 2019 we will see lower revenue in our practice.

In 2015, Congress passed the Sustainable Growth Rate (SGR) fix. Although many breathed a sigh of relief, further study of the regulations revealed that to make up for the 21% “fix,” CMS is to control costs through quality measures. To aid in the promulgation of payment models, Medicare and other carriers have announced increased audits this fall.  These audits include meaningful use audits, PQRS audits and documentation audits. The claim form is your first line of defense in your practice.

Run a practice management report on the utilization of your diagnosis codes. You may be using more unspecified codes than you even realize!  Look at what codes are preferred and familiarize yourself with the required examination findings or indicators for the more specific diagnosis codes.  Different sources will give you this type of information such as seminars and webinars offered by the state associations, post-graduate classes at the chiropractic universities, WebMD, and the National Institute of Health.

In conclusion, it is imperative that we code to the highest level of specificity.  Alternative Payment Models will ensure success to those who are informed and remember to code and document specifically.

Dr. Fucinari is a Certified Medical Compliance Specialist and a Certified Professional Compliance Officer. He serves on the Medicare Carrier Advisory Committee. Dr. Fucinari is the author of several books and other resources, including his latest DVD, Documentation for the Chiropractic Office available at For further information on classes, compliance audits, books or record reviews, please contact Dr. Fucinari at