(Medicare Claims Processing Manual)

For claims with dates of service prior to January 1, 2000, and for claims with dates of service on or after October 1, 2000, for which an x-ray is still used to show subluxation, the following instructions on documentation apply:  An x -ray film (including the date of the film) is available for your review demonstrating the existence of a subluxation at the specified level of the spine.  If the beneficiary refuses to have the x -ray, the chiropractor must submit one of the appropriate HCPCS codes for chiropractic manipulation in addition to modifier GX (service not covered by Medicare), and the claim will be denied as a technical denial.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.  Group Code: PR CARC: 96  RARC: M111  MSN: 3.1  NOTE:  The refusal of the beneficiary to have an x -ray taken will no longer need to be coded for claims with dates of service on or after January 1, 2000.   D.   Claims Processing   Edits and suggested MSN and RA messages.   1. Do not pay for manual manipulation of the spine in treating conditions other than those indicated in Pub. 100- 02, Benefits Policy Manual, Chapter 15, Section 240.1.3.  The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 3.   Group Code: CO  CARC: 50  RARC: N/A  MSN: 15.4  1. Deny claims for treatment of any condition not reasonably related to a subluxation involving vertebrae at the spinal level specified.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  The CARC below is not included in the CAQH CORE Business Scenarios.  Group Code: CO  CARC: B22  RARC: N/A  MSN: 15.4  2. Edit to verify that the date of the initial visit or the date of exacerbation of the existing condition is entered.   The following reflects the remittance advice messages and associated codes that will appear when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario 2.   Group Code: CO  CARC: 16  RARC: MA122  MSN: 9.2  E.   X -ray Review  Effective for claims with dates of service on and after January 1, 2000, the x -ray is no longer required.  However, effective for claims with dates of service on or after October 1, 2000, should the chiropractor choose to use the x- ray to show subluxation, the x -ray review process is still required as outlined below minus the requirement in the last sentence of number 2. For claims with dates of service prior to January 1, 2000, all aspects of the following instructions still apply.   1. Carriers should conduct post -payment reviews of x -rays on a sample basis.  Prepayment review should be undertaken in all questionable cases.  2. It is the responsibility of the treating chiropractor to make the documenting x-ray(s) available to the carrier's review staff.  If x -rays are not made available, or suggest a pattern in failing to demonstrate subluxation for any reason, including unaccept able technical quality, the carrier should conduct prepayment review of x-rays in 100 percent of the subsequent claims for treatments by the practitioner involved until satisfied that the deficiency will no longer occur.  Where there is no x-ray documentat ion of subluxation on prepayment review, the claims, of course, should be denied.  (The last sentence of this paragraph only refers to claims with dates of service prior to January 1, 2000.)   3. The x -ray film(s) must have been taken at a time reasonably proximate to the initiation of the course of treatment and must demonstrate a subluxation at the level of the spine specified by the treating chiropractor on the claim.  (See Pub. 100-02, Benef its Policy Manual, Chapter 15, Section 240.1.2.)   4. An x -ray obtained by the chiropractor for his own diagnostic purposes before commencing treatment should suffice for claims documentation purposes. However, when subluxation was for treatment purposes diagnosed by some other means and x -rays are taken t o satisfy Medicare's documentation requirement, carriers should ask chiropractors to hone in on the site of the subluxation in producing x- rays.  Such a practice would not only minimize the exposure of the patient but also should result in a film more clea rly portraying the subluxation.  5. An x -ray will be considered of acceptable technical quality if any individual trained in the reading of x- rays could recognize a subluxation if present.   6. When claims have been denied because the x -ray(s) initially offered failed to document the existence of a subluxation requiring treatment, no review of these decisions should be undertaken on the basis of x -ray(s) subsequently taken.  Permitting such re views could be an inducement to excessive exposure of patients to radiation in cases where the decision to treat was made despite x -rays that did not show a subluxation.   230 - Primary Care Incentive Payment Program (PCIP)  (Rev. 2152, Issued: 02- 11-11, Effective: 07 -01-11, Implementation: 07- 05-11)  Section 5501(a) of the Affordable Care Act revises section 1833 of the Social Security Act (the Act) by adding a new paragraph, (x), Incentive Payments for Primary Care Services.  Section 1833(x) of the Act states that in the case of primary care services furnished on or after January 1, 2011, and before January 1, 2016, there shall be a 10 percent incentive payment for such services under Part B when furnished by a primary care practitioner.   Information regarding Primary Care Incentive Payment Program (PCIP) payments made to critical access hospitals (CAHs) paid under the optional method can be found in Pub. 100-04, Chapter 4, 250.12 of this manual.  230.1 - Definition of Primary Care Practitioners and Primary Care Services  (Rev. 2152, Issued: 02- 11-11, Effective: 07 -01-11, Implementation: 07- 05-11)  Primary care practitioner is defined as:   1. A physician who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine for whom primary care services accounted for at least 60 percent of the allowed charges under the PFS (excluding hospital i npatient care and emergency department visits) for the practitioner in a prior period as determined appropriate by the Secretary; or   2. A nurse practitioner, clinical nurse specialist, or physician assistant for whom primary care services accounted for at least 60 percent of the allowed charges under the PFS (excluding hospital inpatient care and emergency department visits) for the practitioner in a prior period as determined appropriate by the Secretary.   Primary care services are defined as HCPCS Codes:   1. 99201 through 99215 for new and established patient office or outpatient evaluation and management (E/M) visits;   2. 99304 through 99340 for initial, subsequent, discharge, and other nursing facility E/M services; new and established patient domiciliary, rest home or custodial care E/M services; and domiciliary, rest home or home care plan oversight services; and  3. 99341 through 99350 for new and established patient home E/M visits.   Practitioner Identification   Primary care practitioners will be identified using the National Provider Identifier (NPI) number of the rendering practitioner on claims.  If the claim is submitted by a practitioners group practice, the rendering practitioners NPI must be included on t he line-item for the primary care service and reflect an eligible HCPCS as identified.  In order to be eligible for the PCIP, physician assistants, clinical nurse specialists, and nurse practitioners must be billing for their services under their own NPI a nd not furnishing services incident to physicians services.  Regardless of the specialty area in which they may be practicing, the specific nonphysician practitioners are eligible for the PCIP based on their profession and historical percentage of allowed charges as primary care services that equals or exceeds the 60 percent threshold.   The claims data  used for the primary care percentage calculations depend on the potential primary care practitioners date of enrollment in Medicare.  We will use Medicare claims data 2 years prior to the PCIP payment year to determine PCIP eligibility fo r those potential primary care practitioners who were enrolled in Medicare in that year.  For example, for CY 2011, we will use Medicare claims data from CY 2009 for practitioners who were already enrolled in Medicare in CY 2009. We will use claims data fr om the year immediately preceding the PCIP payment year in order to determine PCIP eligibility for potential primary care practitioners who newly enroll in Medicare in the year immediately preceding the PCIP payment year.  For example, for CY 2011, we will use the available Medicare claims data from CY 2010 only for potential primary care practitioners who newly enrolled in Medicare in CY 2010.  Eligible practitioners for PCIP payments in a given calendar year who were enrolled in Medicare 2 years earlier will be listed by eligible NPI in the Primary Care Incentive Payment Program Eligibility File, available after January 31 of the PCIP payment ye ar on their A/B MAC (B)s website.  Eligible practitioners for PCIP payments in a given calendar year who were newly enrolled in Medicare in the year immediate preceding the PCIP payment year will be identified in the PCIP Payment  for New Providers Enroll ed in Medicare File, available after October 1 of the PCIP payment year.  Practitioners should contact their A/B MAC (B) with any questions regarding their eligibility for the PCIP.   230.2 - Coordination with Other Payments (Rev. 2152, Issued: 02- 11-11, Effective: 07 -01-11, Implementation: 07- 05-11)  Section 5501(a)(3) of the Affordable Care Act authorizes payment under the PCIP as an additional payment amount for specified primary care services without regard to any additional payment for the service under Section 1833(m) of the Act.  Therefore, an eligible primary care physic ian furnishing a primary care service in a health professional shortage area (HPSA) may receive both a HPSA physician bonus payment (as described in the Medicare Claims Processing Manual, Pub. 100- 04, Chapter 12, 90.4) under the HPSA physician bonus progr am and a PCIP incentive payment under the new program beginning in CY 2011.   230.3 - Claims Processing and Payment  (Rev. 2152, Issued: 02- 11-11, Effective: 07 -01-11, Implementation: 07- 05-11)  A. General Overview   Incentive payments will be made on a quarterly basis and shall be equal to 10 percent of the amount paid for such services under the Medicare Physician Fee Schedule (PFS) for those services furnished during the incentive payment year. PCIP payments for new ly enrolled practitioners will be delayed due to the lag in their eligibility determination.  Newly enrolled primary care practitioners will receive a single cumulative PCIP payment, retroactive for primary care services furnished from the beginning of the  PCIP payment year, following the fourth quarter of the PCIP payment year after the primary care practitioner is deemed eligible.  Quarterly payments will be made for subsequent incentive payments.   For information on PCIP payments to CAHs paid under the optional method, see the Medicare Claims Processing Manual, Pub. 100- 04, Chapter 4, 250.12.   On an annual basis A/B MACs (B) shall receive a Primary Care Incentive Payment Program Eligibility File and PCIP Payment for New Providers Enrolled in Medicare File that they shall post to their websites.  The files will list the NPIs of all practitioners who are eligible to receive PCIP payments for the PCIP payment year.   B. Method of Payment    Calculate and pay qualifying primary care practitioners an additional 10 percent incentive payment.    Calculate the payment based on the amount actually paid for the services, not the Medicare approved amount.    Combine the PCIP incentive payments, when appropriate, with other incentive payments, including the HPSA physician bonus payment, and the HPSA Surgical Incentive Payment Program (HSIP) payment;    Provide a special remittance form that is forwarded with the incentive payment so that physicians and practitioners can identify which type of incentive payment (HPSA physician and/or PCIP) was paid for which services.    Practitioners should contact their A/B MAC (B) with any questions regarding PCIP payments.   C. Changes for Contractor Systems