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Noridian Update 10-28-2015

Noridian Medicare has updated their LCD for chiropractic and has also corrected the error for denied claims in Jurisdiction E (California and Nevada)

The site has been updated to reflect the changes.

There was an addition of codes M43.01 to M43.09 for spondylolysis, M50.91 unspecified disc disorder high cervical and M60.89 other myositis multiple regions

Noridian ICD-10 Update 10-27-2015

The Network has received information from several offices that they have received their first payments on the improperly denied claims by Noridian Medicare Jurisdiction E. Medicare has not officially published any notice but with these payments being reported it a appears to be corrected and back on track.

HIPAA Compliance Audits on the Horison

Recently the Office of Inspector General (OIG) for the Dept of Health and Human Services (HHS) did a study and found that the Office of Civil Rights (OCR), which has responsibility for HIPAA compliance, is not doing enough to ensure covered entities (CEs), including healthcare providers and insurers, are effectively following HIPAA requirements. They found that most activities were reactive, not proactive. The OCR agreed with report's recommendations and that they need to do more oversight actvities.

Look for more HIPAA compliance audits and enforcement activities in the coming months as funding for these activities is provided to the OCR.

Have you gotten all your compliance requirements met? This includes: establishing your policies and procedures; implementing them within your practice; ensuring everyone has taken training; ensuring all your business associates have signed a BA Agreement and have security controls in place; and performing a risk assessment; just to name the major requirements.

Make plans in the near term to address all HIPAA compliance requirements.

NOTE: All the 50 State Attorneys General office are also ramping up to do their own HIPAA compliance audits and enforcement, in addition to the OCR's activities.
See the full report at

Noridian ICD-10 Update

10/19/2015 Update:

Noridian Medicare Part B for Jurisdiction E which are for the states of CA, HI, NV, American Samoa, Guam and Northern Mariana Islands has an error that they are incorrectly denying chiropractic. The LCD is being updated to contain the appropriate diagnosis codes. Once complete, Noridian will identify the claims denied incorrectly and adjust them. No action is required on the provider end at this time. These denials all indicated CO50 = medical necessity

This has not affected other states managed by Medicare or specifically Jurisdiction F Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah Washington and Wyoming.

ICD10 Important Noridian Medicare Update

Noridian Medicare ICD10
Currently, AS OF 9:30AM PST October 15, 2015, Noridian Medicare which handles Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, North Dakota, Oregon, South Dakota, Washington, Utah, & Wyoming are having problems with their system and are incorrectly rejecting Medicare claims that are correctly coded. They are requesting to not send claims in at this time as they will be rejected and await until the system is corrected. We will be monitoring and provide notice when the system is back up and running.

1500 Claim Form Diagnosis Reporting & ICD10- No Decimals

Reporting Diagnosis on the 1500 with ICD10 should NOT have decimals as they are implied. When reporting diagnosis in block 21 of the 1500 there is a 7 character limit and the use of a decimal will drop the final character of a 7 digit code. Therefore diagnosis on the 1500 should be reported without a decimal and simply the characters with no spacing.

Note the following examples of 3, 4, 5, 6, and 7 character codes.

R51, M545, M9900, M25511, MS134XXA

Below is the Medicare manual reference to the non-use of decimals as well as the NUCC 1500 instruction manual reference

Medicare Claims Processing Manual Chapter 26 - Completing and Processing Form CMS-1500 Data Set 

Item 21 - Enter the patient's diagnosis/condition.

For form version 02/12, it may be appropriate to report either ICD-9-CM or ICD-10-CM codes depending upon the dates of service (i.e., according to the effective dates of the given code set).

• The “ICD Indicator” identifies the ICD code set being reported.

Enter the applicable ICD indicator according to the following:

ICD-9-CM diagnosis enter “9”

ICD-10-CM diagnosis enter “0”

Enter the indicator as a single digit between the vertical, dotted lines.

• Do not report both ICD-9-CM and ICD-10-CM codes on the same claim form

• Enter up to 12 diagnosis codes

  • Do not insert a period in the ICD-9-CM or ICD-10-CM code.

For chiropractic claims-

Primary diagnosis must be segmental somatic dysfunction M9900 to M9905 however the secondary must be a neuromusculoskeletal diagnosis and form the approved list for your state.

NUCC 1500 Claim Form Manual



TITLE: Diagnosis or Nature of Illness or Injury


Enter the indicator between the vertical, dotted lines in the upper right-hand portion of the field.

Enter the codes left justified on each line to identify the patient’s diagnosis and/or condition. Do not include the decimal point in the diagnosis code, because it is implied. List no more than 12 ICD-9-CM or ICD-10-CM diagnosis codes. Relate lines A - L to the lines of service in 24E by the letter of the line. Use the greatest level of specificity. Do not provide narrative description in this field.

Workers’ Compensation and ICD10

Workers compensation claims systems in about half the states are ready for the switch on October 1, while half are not, according to Workgroup for Electronic Data Interchange, (WEDI).

WEDI has released data on worker's compensation readiness by state. Twenty-one states have adopted ICD-10 billing for physicians, hospital inpatients and outpatients, according to WEDI.

They are: Alabama, California, Florida, Georgia, Hawaii, Idaho, Illinois, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Mexico, New York, North Carolina, Ohio, Oregon, South Dakota, Texas and Washington.

Three states have adopted ICD-10 codes for hospital inpatient billing only: Indiana, Maine and South Carolina.

This leaves 26 states that have no plans for adopting ICD-10 for workers comp claims, unless there's a pending ICD-10 regulation: Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, Iowa, Kansas, Kentucky, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, North Dakota, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Utah, Vermont, Virginia, Wisconsin and Wyoming.

Ask the Expert: Multiple Fee Schedules and Waiving Co Pays…Am I acting Legally?

Question: I am afraid I may doing something illegal. I have heard I cannot have different fees for the same service. I have several different fees for many types of patients, as I do belong to a lot of plans, and I am concerned that I can be audited for illegal practices by having dual or actually multiple fees for the same code. Is what I am doing correct or against the rules? I also want to understand my rights and whether it is legal to waive co-pays and deductibles. I have so many patients now who have plans with very large deductibles and co-pays.

Expert Answer: In reality what you experiencing and questioning is common in today’s healthcare environment. Due to the myriad of healthcare plans including, PPO’s, HMO’s, EPO’s, Medicare, Medicaid, workers’ compensation et al there are fees or allowances that are agreed or mandated based on contracts between the provider and the insurance or are mandated by law.

In fact there is one “insurance” fee but that would be the fee for plans to which you are not contracted with and is likely your highest fee. However, the fee for plans you are contracted with will be different and lesser than your regular fee. This would include contracts with Blue Cross Blue Shield, American Specialty Health, Optum Health (United Health Care), Aetna, CIGNA etc. As I am sure you are aware and likely experienced with, your regular fee is often reduced for the patient where you are a member of their insurance plan. This reduced fee is an agreement between the insurance and you, as a member provider, to accept and collect a lesser amount then your regular fee. The trade-off of this lesser amount is a likely or anticipated increase in the volume of patients. This managed care contract is what legally allows you to have differing fees from your “regular or non-contracted” rate. I believe these plans are better understood when we call them managed cost instead of managed care.

For instance your regular fee is $50 for a particular service and your contracted or allowed rate with plan one is $26.00, plan two $41.50 and Medicare $34.90. These different allowances or fees does not violate or create an illegal fee schedule but simply contracted fees between the provider and the plan. These allowances will vary between plans and are independent, with one not affecting the other. This also applies to mandated fees such as Medicare, Medicaid, & workers’ compensation.

It would be a sound business practice and a potential marketing tool to be sure patients are aware when seeking care with you, and you are part of these plans, that they are receiving a discount or reduced fee by using a contracted provider. Patients do choose care based on their expenses and are more likely to seek t necessary care when they are aware of the value and affordability when seeking services with you.

However, non contracted fees would or should be the same for all and not vary as there is no contract or mandated fees. If you were to have varied fees for non-contracted insurance plans from patient to patient or insurance to insurance this would constitute a dual fee and is an improper billing practice. Note case by case hardships would be an exception.

I must also address, though not directly inquired about “prompt pay” or cash and whether there can be any discounts. States like California has a law that allows a discounted rate for those patients who are not insured or have no insurance reimbursement for a service. This fee can be discounted and that rate does not affect the regular or insurance rate. Specifically this law is Business and Professions Code 657, and only applies in California.

But in deference to this is California law, Washington state law states the following:


WAC 246-808-545   Improper billing practices.  The following acts shall constitute grounds for which disciplinary action may be taken:

(1) Rebating or offering to rebate to an insured any payment to the licensee by the third-party payor of the insured for services or treatments rendered under the insured's policy.
(2) Submitting to any third-party payor a claim for a service or treatment at a greater or an inflated fee or charge than the usual fee the licensee charges for that service or treatment when rendered without third-party reimbursement.

Before offering any discounts for cash or prompt pay providers should inquire with their state licensing board, department of insurance or attorney about the legality of offering such discounts.

But there is direction from the Office of Inspector General (OIG) that has made an opinion on the offering of discounts for prompt pay. In the OIG Advisory Opinion No. 08-03 it states that a 5-15% reduced rate, from prompt payment, is reasonable. This, in my opinion, is fair and reasonable, considering the actual bookkeeping savings by eliminating the administrative and clerical work associated with billing insurance, not to mention the waiting period for payments.


The OIG opinion while valid does not supersede you state laws however and each provider is responsible to be within the laws of their state and should take the time to verify what is allowed and understand any specific regulations unique to your practice area.

As far as the waiving of co-pays and deductibles there is no vagueness here. If a physician’s office routinely fails to collect the patient’s portion of the care, it is considered a violation of both the Anti-Kickback Statute (AKS) and the False Claims Act. OIG and the Department of Justice recognize that there are cases of financial hardship and make allowances for those unable to pay. They also recognize when a physician makes a reasonable effort to collect from a patient, but does not receive payment. It is the routine waiver of the patient responsibility that can cause serious consequences.

If you are providing any discount for services be sure the receipt or billing reflects this lesser amount and the regular fee should not be reflected on the billing but simply the amount charged. Do not allow the patient to have a billing whether 1500, superbill or some other receipt that reflects an amount higher than what they paid. They should not receive any benefits (deductibles) or payments from an insurance above an amount they have actually paid or are expected to pay.

Patients must be made acutely aware of their personal responsibility for their services via a financial agreement. This includes deductibles (even when large) and all non paid amounts when not contracted. When you are not a contracted provider the patient is liable for all fees not paid by the plan. This often may be confusing to the patient as they believe their plan will pay 80%. Not understanding this 80% is not always (nor often) 80% of what was billed but 80% of what the plan allows and they owe any and all amounts not covered.

For instance you are not contracted and bill $100 for services. The plan “states” they pay 80% but it was not clarified as to 80% of what. This “what” is their allowed amount not necessarily your billed amount. In this example the billed amount is $100 but the plan allows only $50 and pays $40 which is 80%. When you are not contracted with this plan your obligation is to collect $60 as that is the amount not paid and the liability, of the patient. Hence why many patients seek care from “in network” providers to avoid paying above the allowed amount for services.

The waiving of or non collection of this amount would be considered a kick back as the insurance was billed and made payments or allowances based on a billed amount of $100 and when there was no intent to collect the billed amount but accept the insurance payment as payment in full or simply waiving collecting the full amount. My guidance to offices who do this routinely, is to join these plans and avoid any legal issues as you are giving the PPO discount anyway and might as well also get the benefit of having your name available to all plan members who may more likely seek care with you. Do not place yourself in a situation wherein you mistakenly put yourself in an illegal situation with the intent or belief that the benefit to the patient supersedes the law.

For this reason never set your regular fee based on the your highest allowed plan as patients who do not have plans with as high an allowance will have to pay much more out of pocket and less likely to continue or seek care. Hence why some are enticed to waive or forgive fees on those lower allowed plans but still collect the higher on others. That method of collection however would be the illegal factor you intimated.

ASK THE EXPERT: ICD10 for Cash Practices and the Effect to Personal Injury and Workers’ Compensation


Q. I am a ‘cash only’ practice and do not contract with any payers. Do I still need to use ICD-10?
A. While technically you do not have to do so under the HIPAA federal regulations, it is still a good idea to include ICD-10 codes on the bill you provide to your patient. The reason for this is that some patients may submit claims to their insurance company on their own behalf and if the codes are not the current and correct ICD10 the patient will not receive any reimbursement.

Q. What benefits are there for Non-covered Entities (this includes workers’ compensation and personal injury claims) to transition to ICD-10?

A. According to AHIMA, there are several benefits for non-covered entities and notes that CMS plans to work with these organizations to encourage ICD-10 use.
Benefits: The increased detail in ICD-10 provides significant value to non-covered entities. For example, the expanded injury codes will be useful to automobile insurance and workers' compensation programs. Non-covered entities stand to achieve the same benefits of using more detailed, up-to-date code sets as covered entities, including better data for:
• Measuring the quality, safety, and efficacy of care
• Designing payment systems and processing claims for reimbursement
• Conducting research, epidemiological studies, and clinical trials
• Setting health policy
• Operational and strategic planning and designing healthcare delivery systems
• Monitoring resource utilization
• Improving clinical, financial, and administrative performance
• Preventing and detecting healthcare fraud and abuse
• Tracking public health and risks
In addition, ICD-9-CM will no longer be maintained once ICD-10 is implemented; meaning the usefulness of the ICD-9-CM code set will rapidly decline. ICD-9-CM products and resources also will become increasingly difficult to obtain. Those non-covered entities that continue to use ICD-9-CM after the ICD-10 compliance date will compromise their ability to compare data with covered entities.

Q. What will happen if our clinic does not switch to ICD-10?
A. Claims that are submitted by HIPAA covered entities (all claims except cash, PI and WC), without ICD-10 diagnosis after October 1, 2015 will not be processed.

With a wealth of information at your disposal included in your Digital Coding subscription, we have complied an extended demonstration on how to navigate each portal and use the tools available to members with ease.

In this how-to video meet HJ Ross' principal coding expert, Dr. Sam Collins, and take a tour of the only online chiropractic specific coding & billing resource of its kind.

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