PQRS - Time is Getting Short!


If protecting your reimbursement is important to your practice and you haven’t yet mastered PQRS for 2013, may I have your attention please!?


Medicare requires that you successfully report PQRS measures for at least 50% of all Medicare visits in 2013 or face at 1.5% fee schedule reduction. 

Even if you have reported Clinical Quality Measures via your EHR attestation, you must also successfully report PQRS measures to protect your future income!


What is PQRS?

It remains a “voluntary program” that creates financial incentives for providers to report certain quality measures for Medicare Part B services.  These incentive payments are issued separately the year following the reporting. CMS believes these quality initiatives will empower providers and consumers with information that would support the overall delivery of quality care.  Consumers will have access to provider quality measures by 2014.  Ultimately, CMS believes these quality measures will help support a new payment system based on quality rather than quantity.

While participation is voluntary, beginning this year providers who do not participate or are unsuccessful participants will see their Medicare reimbursements decrease by 1.5% in 2015 and 2% in 2016.  The Patient Protection and Affordable Care Act (PPACA or ACA) makes reporting mandatory by 2015. 

Quality Measures are developed by many organizations within the healthcare industry.  The criteria for satisfactory reporting of claims-based quality measures include: 

  • Reporting on at least 3 PQRS measure (or 1-2 if less than 3 measures apply to the provider)
  • Report each measure for at least 50% of the providers Medicare Part B patients

There are only 2 measurements open to chiropractic in 2013: pain assessment; and function outcome assessment. 

To report these measures, each provider must include the Quality Data Code (QDC code) that identifies the actions taken at this visit. 


Pain assessment (#131)

Patients aged 18 years and older with documentation of a pain assessment (including location, intensity and description) through discussion with the patient include the use of a standardized tool on each visit AND documentation of a follow-up plan.

In order to report this code, providers must determine the patient’s pain level document the rating and the tool used (i.e. “pain level 8 using visual analog scale”) and document the return visit schedule (“Patient to return in two days”). 

If these criteria are met, the appropriate QDC code is included on the claim for the CMT.


Functional Outcome Assessment (#182)

Patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool and documentation of a care plan based on identified function outcome deficiencies.

In order to report this code, providers must use a standardized outcome assessment tool to identify a functional deficiency and create a care plan to address the deficiency.  This treatment plan / care plan must be part of the documentation for your patient.  The care plan is valid for thirty days. 

This measure uses two QDC codes: one reported when the care plan is created and another to indicate days that care is delivered based upon this care plan.    


If these criteria are met, the appropriate QDC code is included on the claim for the CMT.


In short, for each 9894x code that you report to Medicare, you must include two additional codes on the same claim form.


PQRS is frequently confused with the EHR program’s Clinical Quality Measures.  Reaching Meaningful Use with your EHR does NOT equate to successful PQRS reporting. They are separate programs and failure to successfully participate in both will impact your Medicare reimbursements.

Confused?  Frustrated?  Need help in getting started? 

Attend one of our Lunch and Learn Webinar programs and see just how easy it is to get started – and become a successful reporter of PQRS measures!

Durable Medical Equipment

Adding Durable Medical Equipment (DME) to a chiropractic practice has been one avenue that offices have used as an additional revenue stream.  The National Supplier Clearinghouse, part of Palmetto GBA, is the DME section of Medicare. 

Chiropractors can apply for and be granted a supplier number to provide durable medical equipment, such as back braces, to Medicare enrollees and are able to be paid according to the Medicare approved price codes and limits.

Chiropractors desiring to add DME to their practice must do so by following a strict set of DME guidelines.  These include:

  • Written order
  • Certificate of Medical Necessity (if applicable)
  • DME Information Form
  • Proof of delivery
  • Beneficiary authorization
  • ABN, if applicable
  • Information from the treating physician concerning the patient’s diagnosis
  • Additional documentation requiremen


Chiropractic physicians know that Medicare only covers manual manipulation of the spine to correct a subluxation; any other service or item ordered by a chiropractor is statutorily excluded and will be denied.  This includes any order for durable medical equipment.


This means that DC’s dispensing durable medical equipment for Medicare will require an order, certificate of medical necessity and other documentation from an MD or other authorized provider.  The dispensation of the product must follow the DME documentation guidelines required by Medicare.


In September 2012, the National Supplier Clearinghouse (NSC) announced a change in the DME accreditation rules.  Chiropractors are eligible to enroll as DMEPOS suppliers but are no longer afforded any special enrollment exemptions extended to other physicians and non-physician practitioners identified in Section 1861(r) of the Social Security Act. Medicare coverage for a chiropractor is limited to the manual manipulation of the spine to correct a subluxation; all other services furnished or ordered by chiropractors are not covered. As such, chiropractors are not exempt from DMEPOS accreditation, surety bonds, enrollment fees, site visits or licensing requirements as required for a DMEPOS supplier in the state(s) in which they provide service.


NSC further announced that existing chiropractic DME suppliers must complete the accreditation process and obtain a surety bond to be recertified. 


DME accreditation is a moderately complex process and requires full policy, procedure, and compliance programs are in place prior to a site visit that must be conducted before the entity can be accredited. 


All of these changes do not effect your Medicare Part B provider enrollment, claims processing or current payment stream for manipulations!


For additional information on this or other billing, coding, documentation or compliance related issues – contact Cornerstone Medical Management.  We are experienced providers of DME policy, procedure and compliance plans.

Updating your Notice of Privacy Practice

If your Notice of Privacy Practice (NOPP) is updated - through regulatory or office policy changes - there are several things you must do to maintain your compliance with the HIPAA regulations.

First, you must updated the last revised date on the NOPP form.  You must post the new notice in a prominent location in your office and you must include it on your website, if you have one. 

It is not necessary to have your existing patients sign new NOPP acknowledgements nor is it necessary to give existing patients a copy of the new notice.  Publishing the changes in your office and on your website is sufficient for current HIPAA regulatory compliance. 

Be sure you are providing all new patients with a copy of your Notice of Privacy Practice and that you are getting your acknowledgment signed!