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MCA In Touch: July 2017
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In this issue:


Recent Changes in the Medicare Chiropractic LCD

By Lyle Coleman, DC

The Chiropractic LCD is our contractor’s (National Government Services) local rule book for Medicare. There are some recent changes that all DCs need to know about to stay compliant with regulations.

  1. There is a new requirement with documentation regarding risk of adjustment for patients with relative contraindications to manipulation. For clarity I quote the relevant portions. The current language is:

    B. Contraindications
    Dynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement. A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust, but does not rule out the use of dynamic thrust. The doctor should discuss this risk with the patient and record this in the chart. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3B)

    The following are relative contraindications to dynamic thrust:

    Articular hyper mobility and circumstances where the stability of the joint is uncertain; Severe demineralization of bone; Benign bone tumors (spine); Bleeding disorders and anticoagulant therapy; and

    Radiculopathy with progressive neurological signs. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3B) Dynamic thrust is absolutely contraindicated near the site of demonstrated subluxation and proposed manipulation in the following: Acute arthropathies characterized by acute inflammation and ligamentous laxity and anatomic subluxation or dislocation; including acute rheumatoid arthritis and ankylosing spondylitis;

    Acute fractures and dislocations or healed fractures and dislocations with signs of instability; An unstable os odontoideum; Malignancies that involve the vertebral column; Infection of bones or joints of the vertebral column;

    Signs and symptoms of myelopathy or cauda equina syndrome; For cervical spinal manipulations, vertebrobasilar insufficiency syndrome; and A significant major artery aneurysm near the proposed manipulation. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3B)

    The new language is:

    Dynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement. A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust, but does not rule out the use of dynamic thrust. The doctor must discuss this risk with the patient and record this discussion in the chart.

  2. In the “Limitations” section of the LCD, the following paragraph has been revised from:

    The five extraspinal regions referred to are: head (including, temporomandibular joint, excluding atlanto-occipital) region; lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints) and abdomen (CPT Assistant Nov 98:38). Medicare does not cover chiropractic treatments to extraspinal regions (CPT 98943).

    to:

    There are five spinal regions addressed by this LCD: cervical region (atlanto-occipital joint), thoracic region (costovertebral/costo-transverse joints), lumbar region, pelvic region (sacro-iliac joint) and sacral region (ref. CPT® Professional Edition 2017 p. 672).

    Medicare does not cover chiropractic treatments to extraspinal regions (CPT 98943). The five extraspinal regions are: head (including temporomandibular joint, excluding atlanto-occipital) region; lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints) and abdomen (CPT Assistant Nov 98:38).

  3. The following statement has been moved to the last paragraph in the “Limitations” section:

    The need for a prolonged course of treatment should be appropriate to the reported procedure code(s) and medical necessity must be documented clearly in the medical record.

  4. The language for P.A.R.T has been revised in the “Documentation: X-Ray/CT/MRI” section of the LCD and the following paragraph has been added:

    On receipt of a request for documentation, at a minimum, the practitioner must submit the Initial Visit’s (ref. CMS 1500 box 14) Treatment Plan, the Concluding/Discharge Visit and Subsequent Visits that demonstrate any change in the History, Physical Exam or Treatment Plan.

  5. The “Utilization” section has been revised to indicate that only one chiropractic manipulation service for a beneficiary can be reimbursed per day.

  6. The following statement has been removed:

    Prolonged or repeated courses of treatment are more subject to medical review and may indicate maintenance therapy. Documentation to support the medical necessity of repeated courses of treatment must be present in the patient’s plan of care.

    And replaced with:

    Prolonged or repeated courses of treatment are more likely to undergo medical review

  7. The following source has been added:

    American Chiropractic Association / Medicare Administrative Contractor Collaborative Outreach Forums on February 26, 2015, September 24, 2015 and March 16, 2017.


Legislative Update

By Dr. Chuck Sawyer, MCA Professional Officer for Legislative Affairs

Following publication of the June MCA In Touch newsletter, it seemed logical that the focus of this article should be on efforts by Washington, D.C. lawmakers to “repeal and replace” the Affordable Care Act (ACA) and the possible implications for the chiropractic profession in Minnesota.

Like many of us, I have been trying to follow this soap opera and, now that the Senate version has presumably collapsed, I’m slowly developing a sense of optimism (misguided perhaps) that Republicans and Democratics will finally find a way to work to together to fix the problems with “Obamacare.”

Rising insurance premiums, instability in the individual insurance market, narrow provider networks (e.g., “you can keep your doctor”) and the financial burdens of high-deductible plans are all high on the problem list. But the range of policy thinking regarding solutions is wide and deeply partisian. The far left prefers “Medicare-for-All” (aka, single payer) while the far right believes that the federal government should be much less – and definitely not more – involved than is currently the case under the ACA. It’s a classic question of how much (or less) reliant should we be on federal or state governments for assuring access to affordable and effective healthcare through financial subsidies, regulation and other means. And now it looks like neither side will prevail and – worse yet – no Obamacare fixes will be forthcoming in the U.S. Congress.

While the ACA was primarily individual insurance market centered, it also extended coverage to millions of low-income and working poor Americans through expansion of the federal Medicaid program. Thirty-two states (including the District of Columbia) expanded their Medicaid programs under the ACA and that resulted in sharp declines in uninsured rates across the country. Minnesota did it early and, when enrollment in our Medical Assistance Program is combined with MinnesotaCare, approximately 20% of Minnesotans (or about 1 million) are now covered by publically-funded healthcare.

As the so-called repeal and replace movement in Congress progressed – especially in the U.S. Senate – the implications of funding cuts in the Medicaid program quickly became worrisome for several Republicans whose states opted to expand coverage to low-income individuals and families under the ACA. That, coupled with opposition from their colleagues who felt the Senate bill did not go far enough to repeal the ACA ultimately caused the initiatve to stall and that might work to our advantage in Minnesota.

As you know, our legislative agenda includes efforts to address patient and provider discrimination regarding access to chiropractic services and reimbursement in both public and commercial insurance plans. While we made some headway in the 2017 legislative session when the MCA’s Medical Assistance bill (HF 1357/SF 1425) moved through the first committee in the House, our legislation also stopped moving due to concerns over cost.

Although lawmakers from both political parties in the Minnesota Legislature had good reason to be concerned about growth in Medical Assistance spending, uncertainty in Washington regrding the level of Medicaid funding that would continue to flow to the States was a factor in our legislation failing to move very far in 2017.

So, now what are the prospects for success? This legislation was the cornerstone of the MCA’s non-discrimination priorities in 2017 and it will continue to be important going forward. The federal funding question is hopefully resolved – at least in the short term – and our rationale for expanding reimbursement for chiropractic services in Minnesota’s Medical Assistance program is still strong, and our arguments did resonate with many legislators in this last session.

So we have to keep at it and your grass-roots advocacy is critical! And keep in mind that this legislation simply seeks to expand Medical Assistance and MinnesotaCare reimbursement for all the services that chiropractic doctors are trained and licensed to provide under our current scope-of-practice.
As a foundation for our efforts in 2018, and if you live or pratice in one of the following legislative districts, please take a minute to send a brief email to authors of the MCA’s Medical Assistance bill thanking them for their past support:

Sen. John Hoffman (DFL) Senate District 36 – sen.john.hoffman@senate.mn

Sen. Warren Limmer (R) Senate District 34 – sen.warren.limmer@senate.mn

Sen. Carla Nelson (R) Senate District 26 – sen.carla.nelson@senate.mn

Sen. Dan Schoen (DFL) Senate District 54 – sen.dan.schoen@senate.mn

Rep. Glen Gruenhagen (R) House District 18B – rep.glenn.gruenhagen@house.mn

Rep. Rob Ecklund (DFL) House District 3A – rep.rob.ecklund@house.mn

Rep. Debra Kiel (R) House District 1B – rep.deb.kiel@house.mn

Please also get in touch with me at csawyer@nwhealth.edu if you want the Legislative Fact Sheet for this bill that we used during the MCA Day at the Capitol event last March, or if you want to become more involved in the advocacy efforts of the Minnesota Chiropractic Association.


Avoiding Pitfalls in Your Next Office Lease Negotiation

By Ramsey Fandler, Carr Healthcare Realty

Over 80% of healthcare practices lease their office space. The location and impression their office makes on patients is a huge determining factor in patient referrals and return visits, especially in a competitive market. Additionally, the cost of rent is typically a practice’s second-highest expense after payroll. For these reasons, it is imperative that practices achieve the best possible terms during new lease and renewal negotiations in order to maximize profitability.

There are three common pitfalls many practices fall into when negotiating on their office space.

Lack of market knowledge

To achieve the best possible terms, you must be familiar with all options that exist in your area. This market knowledge includes available vacancies, recently completed transactions, and future spaces that may be coming available soon. This is critical information that a local commercial real estate professional can provide to you at no charge. It would be extremely difficult for a healthcare provider, an attorney, or an out-of-town “lease negotiator” to know this information as it is not public record, and many available spaces are not listed on online databases. Knowing about other properties that may be more appealing or offer better value will help you find the best space and ensure you are not over-paying.

Unawareness of less-common business points in a lease

Most healthcare professionals are familiar with the rental rate, length of term, and build out allowance provided by the landlord. Beyond these, there are many other important concessions available such as free or reduced rent periods, the right to transfer the lease to another practice owner in the future, options to renew the lease after the original term expires, death and disability termination options, exclusive uses and more. There are also landlord-friendly clauses such as relocation provisions, unusual expense pass-throughs, and electrical or mechanical requirements designed for general, non-healthcare users that can impair a practice’s ability to operate.

Failing to create a strong posture

The key to an effective negotiation posture is making the landlord understand that you have multiple options on the table and are willing to pursue those options. One of the first questions a landlord will ask its broker is whether the tenant has professional representation. If the answer is no, they will ask if the tenant appears to know the market and is educated on the business points they are seeking. In a renewal situation, they will ask if the tenant is seriously willing to leave. If the landlord and its broker sense any weakness in the posture created by the tenant, they will not offer terms that are truly competitive to the tenant. Many landlords also see it as a weakness if a consultant or out-of-state attorney is handling the negotiation for the tenant because there is no local market knowledge. The same is true when tenants attempts to represent themselves. It is also crucial to the posture to begin the negotiations at the proper time—ideally one year before the current lease expires. If there is insufficient time to plan and build-out a space, then the landlord will know the tenant’s options are limited, weakening the posture.

Strong posture causes the negotiation to be more favorable than merely bartering with a landlord. Leveraging a local real estate professional’s expertise and then dictating favorable terms to a landlord yields consistently more favorable terms to a tenant than simply asking for a price, and then asking for a lower price, etc. Strong posture is not about bluffing or threatening. Having multiple legitimate options and a credible willingness to choose the other property creates an environment where landlords compete to attract or retain quality tenants, and ensures they get competitive terms. Expert representation by a real estate professional is available at no cost to tenants, because their services are paid for by the landlord or seller as part of the listing agreement with the landlord’s broker.

The current commercial real estate market has fully recovered and it is more important than ever to be prepared during lease negotiations. Avoiding these pitfalls will help tenants achieve more favorable terms for their practice and their bottom line.

Carr Healthcare Realty is the nation’s leading provider of commercial real estate services for healthcare tenants and buyers. Every year, hundreds of medical, dental, veterinary, and other healthcare practices trust Carr Healthcare Realty to help them achieve the most favorable terms on their lease and purchase negotiations. By not representing landlords or sellers, Carr Healthcare Realty is able to strongly advocate for healthcare providers and avoid conflicts of interest while saving their clients hundreds of thousands of dollars. Carr Healthcare Realty’s team of experts can assist with all types of real estate transactions, including lease renewals, expansions, relocations, startup offices, purchases, and practice transitions.


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