| One of the more potentially volatile risk areas for | | | | Development. |
| health care practitioners today is the delegation of | | | | The Final Rule for transactions and code sets as |
| therapeutic procedures to unlicensed assistants, | | | | part of the Health Insurance Portability and |
| and billing for those procedures as though the | | | | Accountability Act (HIPAA) identifies CPT codes |
| practitioner personally provided the procedures. | | | | and modifiers as the national standard for health |
| This practice activity is particularly prevalent and | | | | care plans and providers to electronically transmit: |
| ever-growing in chiropractic! | | | | Physician services; physical and occupational |
| Some practice consultants - with promises of | | | | therapy services; radiological procedures; clinical |
| increased income, coach chiropractors to integrate | | | | laboratory tests; other medical diagnostic |
| low-tech rehab and protocols into their practices. | | | | procedures; hearing and vision services; and |
| Chiropractors are advised that it is legally | | | | transportation services including ambulance. |
| permissible for unlicensed assistants (e.g., | | | | Does the involved payer reimburse for supervised |
| chiropractic assistants) to perform the therapeutic | | | | therapeutic procedures? |
| procedures on patients that are billed (per | | | | Payers often set their own standards for |
| "incident-to") as if personally performed by the | | | | reimbursement of health care services and |
| chiropractor, who at the same time, is providing | | | | determine what will be paid, who will be paid, and |
| services to other patients who are billed for the | | | | how much will be paid. Standards may vary from |
| chiropractor's services during the same time | | | | payer to payer, and may differ from those |
| frames as the therapeutic procedures. | | | | standards established by the provider's own |
| Does the regulatory board allow for delegation of | | | | regulatory licensing board. Accordingly, it is the |
| therapeutic procedures to unlicensed staff? | | | | responsibility of all practitioners (e.g., chiropractors) |
| Individual state health care regulatory boards | | | | to be familiar with both the payer's billing/coding |
| establish their own state's administrative practice | | | | and their state board's standards and seek to |
| standards for licensees for the purpose of | | | | abide by those standards that impose the stricter |
| protecting the public from conduct that does not | | | | requirements when seeking reimbursement! By |
| conform to their state's accepted standards of | | | | adopting a policy of compliance with the stricter |
| conduct. Such administrative regulations almost | | | | standard the provider will always ensure that he |
| always include standards relating to the delegation | | | | she is protected from claims of improper billing |
| of services to persons other than the licensed | | | | practices. |
| provider. In many states, chiropractic boards do | | | | Medicare, and other payers following Medicare |
| not allow their licensees to delegate therapeutic | | | | standards, indicates that therapeutic procedures |
| procedures to unlicensed staff, and, as such it | | | | supervised by (unqualified) unlicensed staff are not |
| would be inappropriate in any and all | | | | reimbursable! Payers with such standards do not |
| circumstances for the licensees to engage in this | | | | pay for provider services, at provider rates, when |
| conduct! | | | | such services are administered by non-providers. |
| However, some boards opine that licensees (e.g., | | | | Further, these payers do not maintain that |
| chiropractors) can delegate therapeutic | | | | practitioners can not delegate therapeutic |
| procedures to qualified and properly trained | | | | procedures to unlicensed assistants but are |
| unlicensed staff (e.g., chiropractic assistants) acting | | | | asserting that such services are not covered and, |
| under a licensee's supervision consistent with the | | | | therefore, they are not reimbursable - BILL THE |
| health and welfare of a patient so as to | | | | PATIENT! Medicare Benefits Policy Manual, Chapter |
| encourage the more effective use of the skills of | | | | 15, Sections 220 and 230 specifies: |
| licensees. It would appear prudent for | | | | Therapeutic procedures are medically necessary |
| chiropractors to gain clarification from respective | | | | only when they require the professional skills of a |
| regulatory agencies regarding the following: | | | | qualified practitioner, are designed to address |
| What are the standards that must be met by | | | | specific needs of the patient, and are part of an |
| chiropractors to ensure their unlicensed staff are | | | | active treatment plan intended to achieve a |
| "qualified and properly trained"? | | | | specific goal. |
| What level of supervision (general, direct or | | | | Medicare pays only for skilled, medically necessary |
| personnel) is required of the chiropractor relative | | | | services delivered by qualified individuals, including |
| to unlicensed staff directing therapeutic | | | | therapists or appropriately supervised therapy |
| procedures? | | | | assistants. Supervising patients who are exercising |
| What is meant by "consistent with the health and | | | | independently is not a skilled service. |
| welfare of a patient so as to encourage the more | | | | Providers can not bill and seek payment for |
| effective use of the skills of licensees"? | | | | one-on-one codes (e.g., therapeutic procedures) |
| How should the therapeutic procedures | | | | administered at the same time as other |
| (supervised) by unlicensed staff be documented in | | | | procedures were rendered to the patient, or to |
| the patient's clinical record? | | | | other patients. |
| How should the therapeutic procedures be | | | | A physician may not delegate physical therapy |
| reported to payers - especially those following | | | | services (e.g., therapeutic procedures) to |
| Medicare standards, to avoid potential allegations | | | | unlicensed persons and report them as |
| of misconduct? | | | | "incident-to" services unless that person has the |
| Is reporting therapeutic procedure codes for | | | | education and clinical experience equivalent to a |
| supervised procedures consistent with CPT? | | | | physical therapist. |
| Therapeutic procedure codes (97110-97546) | | | | Incident-to a physician's professional services are |
| identify the application of clinical skills and/or | | | | defined (Benefits Policy Manual, Chapter 15, |
| services that attempt to improve function that | | | | Section 60) as services or supplies furnished by |
| requires the physician or therapist to have direct | | | | auxiliary personnel as an integral, although |
| (one-on-one) contact with the patient. These | | | | incidental, part of the physician's personal |
| procedure codes do not indicate "supervised" | | | | professional services in the course of diagnosis or |
| services and to report them to payers in such a | | | | treatment of an injury or illness that are billed to |
| manner could result in allegations of misconduct. | | | | Part B by the physician as if they personally |
| Consequently, it is imperative for the practitioner | | | | provided them. |
| (e.g., chiropractor) to obtain prior approval for this | | | | Some within chiropractic have differing opinions as |
| billing practice from ALL involved payers | | | | to the appropriateness of the delegation and billing |
| notwithstanding the fact that this type of practice | | | | of therapeutic procedures. Illustrative of this is the |
| activity has previously been found to be | | | | following written opinion of a chiropractor to |
| consistent with state regulatory standards on | | | | whom a colleague was referred subsequent to |
| delegation. The purpose of seeking the payer's | | | | requesting assistance from a State Chiropractic |
| approval is not to enable the payer to make | | | | Association regarding the issue discussed herein: |
| determinations on what practices are legal and | | | | The auditor is confused, to say the least. As a |
| what practices are not; rather, it is to protect the | | | | doctor, you can delegate to whomever you wish |
| individual provider from a payer's unilateral referral | | | | to perform those [therapeutic procedure] |
| of the provider billing practices to law | | | | services. You simply must be in the building at the |
| enforcement authorities who may have a differing | | | | time services are rendered to supervise [sic]. You |
| interpretation of the acceptable standards of | | | | do not have to perform the treatment yourself, |
| delegation that the provider's state regulatory | | | | nor do you have to stand over them and watch. |
| board. | | | | This auditor may be confused with what some |
| Current Procedural Terminology (CPT) is a listing | | | | insurance companies are pushing for and have |
| of (a) descriptive terms and (b) identifying codes. | | | | proposed, i.e., they require the doctor to do it. |
| The foregoing is used to report medical services | | | | However, as far as I know, no insurance |
| and procedures, as well as to provide a uniform | | | | company has any policy in place to prohibit you |
| language that accurately describes medical, | | | | from delegating to staff. As far as statute goes |
| surgical, and diagnostic services. The use of CPT | | | | in Xx, if an insurance company did write that into |
| provides an effective means of reliable nationwide | | | | their policy, we would have to go to the Xx with |
| communication among providers, patients, and | | | | complaint. The P.T.'s would love to have those |
| payers. | | | | rules in place as well. Short answer is the auditor |
| The listing of a service or procedure and its code | | | | is wrong. Maybe some other state he/she is |
| number in a specific section is not restricted to | | | | familiar with has that as a rule. Not here though. |
| any specific specialty group. Any procedure or | | | | The bottom-line is that due-care and good |
| service in any section may be used to designate | | | | judgment must be exercised by chiropractors in |
| services rendered by any qualified physician or | | | | this risk area, as missteps could result in |
| other qualified health care professional. CPT | | | | administrative, civil and/or criminal exposure. A |
| indicates that the terms -"Physician or Therapist" | | | | few years ago chiropractors, similarly instructed |
| and "Provider" as identified in CPT are | | | | on use of "incident-to" to increase income, billed |
| interchangeable to refer to someone licensed to | | | | for their rendered services under the license of an |
| perform health care services. | | | | associated medical doctor in MD/DC practices so |
| Select the name of the procedure or service that | | | | as to avoid limited chiropractic (insurance) |
| accurately identifies the service performed that is | | | | coverage. Several of these doctors, including a |
| adequately documented in the medical record. Do | | | | highly prominent chiropractic consultant who |
| not select a CPT code that merely approximates | | | | advised them on the use of "incident to" billing, are |
| the service provided, and that if no such | | | | now serving federal prison sentences. Many |
| procedure or service exists then report the | | | | chiropractors have learned the hard way that |
| service using the appropriate unlisted procedure or | | | | "incident-to" does not allow for the |
| service. | | | | misrepresentation of the actual service provider |
| Suggestions concerning introduction of new | | | | to facilitate reimbursement for services that |
| procedures, or the coding, deleting, or revising of | | | | would otherwise be non-covered. |
| procedures contained in CPT should be made by | | | | ORIGINALLY PUBLISHED: "Zalma Newsletter", July |
| contacting the CPT Editorial Research & | | | | 2007. |