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Hey, greetings, friends and colleagues. It’s Sam Collins, the coding and billing expert for chiropractic, ChiroSecure, and of course, just the profession in general. I’m gonna give a little bit of an update. A couple months ago we did some information on the VA and their recoupment and so forth, and I want to give a little bit of an update of some changes that have occurred.
So let’s go and go to the slides. Let’s talk about what’s going on with recoupment, what’s happening there, and what’s going on with the standard episode of care, what we call the SEOC. So let’s get into it a little bit. A couple of things have come up about can you just dispute, like for instance, as we talked about last time, there are requests for care that they’re asking for back because of the multi therapy dispute.
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Now, part of it will be, hey, could we argue it based on statute of limitations? And that’s one of the things I had thought we possibly had because a standard STA statute of limitations for a year or for a recoupment is one year. So as that statute of limitations apply to the va. It turns out upon research, it is not one year.
The statute of limitations for the VA is actually six, so we’re not gonna win that one. It’s not gonna be from six years ago. So if you’re getting a dispute coming back saying they’re wanting a recoupment, first of all, make sure it’s correct, make sure the dates fit, but generally it’s gonna be for multi therapy reductions, which means.
The primary therapy is gonna be paid a hundred percent, but then subsequent therapy is about 80%. That is a standard, and that’s something they should have been doing and haven’t, but it should not equal very much money. It should be probably two to $3, $5 a code if you’re billing three or four codes, maybe 15 a visit.
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Now, obviously I don’t like returning any money once it’s already been paid, but at least it’s not something significant. And again, it’s based on the multi procedure provider reduction, where again, primary procedure is paid a little bit higher. Now where we’ve run into some recent issues though, and this has become a much bigger deal.
It’s not so much a recoupment, but just a non-payment, if you will, of exams. So you’ll see here this is literally a letter we just received. So you can see it’s dated July 23rd from TriWest. Realize this is going to apply if you’re in the east coast, whether it’s with Optum or Tris. ’cause they use the same.
And here’s what it says. They received a claim and a request for reconsideration because we’ve noticed recently they’re not paying. For exams and it says evaluation manage procedure codes are not payable for this rendering provider specialty. It says, please review billing and resubmit a collect your corrected claim.
Now, the pushback I’ve had on this is it is part of the standard episode of care. So when you look at the standard episode of care, when it comes to chiropractic, you’ll notice it does list each and every time e and m codes. Now, this supposedly has been updated and what I’m hearing is it updated in April.
I’ve not seen anything official, but I’ve seen enough of this to go through and I believe what is gonna occur is they’re gonna pay non-physician providers. So that’s gonna mean chiropractors. Physical therapists, massage therapists, acupuncturists, for that matter, are not gonna be paid for exams. Now, I think from a federal level, that’s probably against federal rule in the sense of equality, but at the same token, it’s the VA and they do what they want.
So what I think is going to occur is you’re gonna notice that we’re not going to be getting paid for exams. Now that’s frustrating, but I will say it’s not gonna stop me necessarily because obviously an exam is something necessary and we will still need to do. They’re just saying they’re not gonna cover it.
It’s something I think we’re gonna need to dispute from our state and national associations, but nonetheless, at this point, I think that’s what’s gonna happen. Now, I will still go ahead and bill for it. If they deny it, so be it, but I’m not gonna take away all the other services I get paid for. Remember, by the time you do an adjustment and several therapies, you could well be getting over a hundred dollars per visit on a VA patient, though I prefer they pay for the exam still, certainly that reimbursement’s still good enough.
However, here’s gonna be my pushback if you’re getting a request that the dates of service were pre-AP April. Then I’m gonna push back that it was covered, and here’s where I think we’re gonna push back on it. Please take special note. Your authorization and you will notice on the authorization, it will still likely have this standard episode of care, and if it has it in there, that’s my dispute.
You authorized it with that standard episode. Now the next one likely is gonna remove it. I’m waiting to see it published. But until it gets published, I’m still gonna argue that it should be there. But the latest thing that I’ve read, they said non-physician providers, which chiropractic fits under are not gonna be paid.
That maybe is the whittling away. It’s the cost cuts of government. I guess this is where DOGE is probably affecting us a little bit. But does it mean I would overall take the patient? No. I still think it’s worthwhile on the overall, when you consider, you’re generally gonna start with 12 visits and get up to eight visits at each time for a request.
Okay? I do wanna make clear though, please do not use the codes 9 7 0 3 9 or 1 3 9 for any purposes, whether you’re trying to do it for laser or otherwise. Of course, we had a recoupment for many of you who were billing laser under the S code. Remember the S code for laser was removed in 2021, and even if they inadvertently paid it, they may come back with a recoupment.
So please do not use that. The other thing I want you to be careful of, and this is something I’ve just been seeing in about the last month, if you are using the general pain index, which I think is very common, it’s one the VA recommends. They’ve come out and have said that they require at least a seven point change to be click considered.
Clinically significant. So in other words, as the patient gets better, the number gets lower, that number needs to be seven. Now if you’re doing it only monthly, it hopefully better be like more than 10. But what I had is someone the other day that the patient had a five point difference, which the form says that, but the VA said no.
So really focus in on not just the points. ’cause if the points don’t hit seven, they’re gonna say no, but give me something else in the sense of their function. If you are using a pain scale, I. It’s gotta be three points or more. So going from a seven to a six, while I’ll argue that’s a little better, it’s not enough better for them to really be considered significant.
So make sure if you’re using a general pain scale. It’s gotta be three points or more, where I will say the greatest emphasis should be on functional change. Focus more on that. What activities can that veteran do now that they couldn’t do before, whether it’s home or work or their ability to maintain it.
These will continue to be good patients, regardless of them taking away e and m codes, though we’re gonna dispute. The same token. I think the reimbursement is decent enough to be worthwhile realize if you’re requesting care, they’re gonna require that we’re showing the patient getting better. So remember, seven point or three point is going to be necessary as we go along.
I’ll update you once that standard episode of care comes out. If you’re a network member with me or coming to our seminar next month, we will have the updates there as well. Otherwise, until next time, my friends, this is Sam at HJ Ross saying I wish you well. And if you want that day-to-day help come and be part of the network.
Talk to you soon.
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