The New Language of Healthcare


In just under a year we are scheduled to Implement ICD-10 for all HIPAA covered transactions.  This is a significant change in how healthcare business is conducted – but it is not an insurmountable change.  With a bit of forethought, planning and education we can make the transition to ICD-10 less painful.  In the coming months you’ll find tips and tasks to keep you focused on the transition.  After all, you can only eat an elephant one bite at a time!


Learning a New Language


On October 1, 2015 the language of healthcare is changing.  This new “language” allows providers, payers and others to get a better picture of the patient and far more detail regarding the reason(s) for their visit.


Learning a new language takes time.  Communication between doctor and patient isn’t impacted by the change.  You’ll still take care of your patients with the same processes, procedures and care that you do today.  The change comes in communicating with third-party payors.  ICD-10 allows providers to paint a more thorough picture of the patient, allowing the insurance companies to “see” things that they can’t with ICD-9.  This change in communication impacts the inside of healthcare; insurance companies, software vendors, hospitals and doctors.  These new codes provide a more accurate description of the conditions encountered. 


Over the next 11 months we’ll work to keep the information we provide simple, clear and useful.  We’ll work to walk you thru how to prepare for the transition, how to speak this new language and how to find the information you need to keep your practice strong.


Your task this month is to purchase an ICD-10 book and read the introduction.  It’s important that you have access to this information.  We’ll explore the transition together over the coming months.

Increasing Audit Activity by Medicare

Recently Railroad Medicare conducted a widespread review of chiropractic services.  The results of this review were disheartening.  For the third quarter of FY 2014, Additional Documentation Requests (ADRs) were mailed for just over 14,000 services.  Chiropractic was found to have a 79.5% error rate.

Out of the 14,000 services requested – 5300 services were denied without a review of the documentation.  Doctors failed to provide any documentation for 36% of the services reviewed!  Failing to provide documentation results in an automatic denial - how many providers have a 100% fail rate just from lack of submitting records?!?!

For the records reviewed, the top three reasons for denial were:

  • Required elements of the history and examination were absent
  • The Treatment plan absent or insufficient. Treatment plans most commonly lacked specific goals with objective measures to evaluate treatment effectiveness. 
  • Missing or incomplete P.A.R.T. exam to document subluxation. 

Where does that lead?  “Railroad Medicare isn’t a big payer in my practice” – is what I hear most often from providers.   If they aren’t a major payer, why bother?  

Railroad Medicare shares its results with Mamma Medicare.  

That’s right.  That not-a-major-payer just shared your profile with “big” Medicare.

Doctors who fail to provide records automatically fail the audit.  Doctors with missing exam elements, missing treatment plans, missing PART documentation – doctors who fail to implement outcomes assessments to measure progress – don’t be surprised if Mamma Medicare sends you a note - a let’s-get-acquainted invitation in the form of a Comprehensive Error-Rate Testing (CERT) request.

Cornerstone has been contacted by doctors that are now receiving CERT review letters.  The CERT review letters are requesting documentation for specific patients and specific timeframes.  This could spell trouble for some providers.

This review evaluates a statistically valid random sample of claims to determine if they were paid properly under Medicare coverage, coding, and billing rules.  Their aim is to recover payments made improperly.  Last year, FY2013 Medicare recovered $36 billion dollars in improper payments. 

The error rate from this sample can be extrapolated across your patient base and applied to monies paid by Medicare for services rendered.  Imagine a request from Medicare for a refund of 79.5% of payments made?  If the results of a CERT review is similar to the results of the RR Medicare review  – ouch!  

Wonder where you are on the scale?  What would your error rate be if Medicare looked at your records?

We can help!  

Whether you are looking for a full compliance plan - or just a chart audit, contact our office for more information.


HIPAA Authorizations

HIPAA Authorizations

Does your office disclose patient information properly?  The following list can be used to determine if a records request meets HIPAA’s requirements for a valid authorization.

Does the authorization contain:

  •        Patient’s name
  •        Type of information to be disclosed
  •        Name of the provider from whom the information is being requested
  •        Name of the recipient of the information
  •        Purpose for the disclosure
  •        Signature of patient (or legal representative and their relationship)
  •        Date of signature
  •        Effective date and expiration date or event
  •        Statement informing the patient of their right to revoke the authorization
  •        Statement that the patient may inspect or copy the information disclosed
  •        Statement regarding any assessment of fees for providing the copy


This list may not be all-inclusive.  There may be additional elements required by state law. 


HIPAA requires that the authorization contain either an expiration date or an expiration event that relates to the individual or the purpose of the use or disclosure.  Examples provided by the Department of Health and Human Services include “one year from the date the Authorization is signed”; “upon the minor’s age of majority”.


An Authorization remains in effect until its expiration date, expiration event or until the individual revokes it in writing. 


Be aware of both incoming records requests and the forms that your office uses to request records! 


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