HIPAA Title II: What you need to know.


HIPAA is the Health Insurance Portability and Accountability Act, put into place in 1996. Title II specifically deals with privacy and is something to be taken very seriously in today’s age of electronic workplace management.

Title II of HIPAA has enforced the establishment of a set of standards regarding electronic transactions of health care related information, this includes requiring national identifiers being assigned to all providers, health plans, and employers.

HIPAA is designed to protect the privacy of individually identifiable health information, or PHI, which is often transmitted electronically to health care plans and used to process claims and issue payment by a “covered entity”, i.e. health care provider, clearinghouse, and health plan. PHI is any information that identifies a patient, such as demographic information, or any information relating to a patient’s condition or care. It is the responsibility of covered entity to follow all rules and regulations to ensure confidentiality and integrity of this information. Covered entities must also have in place procedures to maintain compliance at all times, such as identifying risks, creating a compliance plan, assigning a security officer to oversee compliance and to perform internal audits, and having a business associate agreement with any outside contracted employees.

Simply put, as a health care provider, you must be familiar with all requirements and stay active in keeping your staff trained and aware of HIPAA compliance. Have technical and physical security measures in place to protect PHI. Limit communications of PHI to secure areas such as EHRs, and Practice Management software which are password protected. Never email or text any patient information or identifiers, and make patient privacy a top priority in your practice. Your patients will love you for it!

Refer to HHS.gov for information on how you can stay compliant.

Time-Based Therapy Billing: How to Calculate Number of Units

Are you utilizing timed codes properly?

There are certain CPT codes used in providing therapy services that are billed based on 15 minute intervals, or units. These services include procedure codes 97032, 97033, 97035, 97110, 97140, 97112, 97116, and 97530.time-430625_640

In order for a provider to bill out 1 unit of these codes, he or she must provide a minimum of 8 minutes of direct patient care. This is called the 8 Minute Rule. But providers often spend much more than this on patients with greater needs of specialized care and attention. In these situations, multiple units can be billed.

See the chart below for a quick guide to how much time is required to support billing multiple units:

8 – 22 minutes 1 unit
23 – 37 minutes 2 units
38 – 52 minutes 3 units
53 – 67 minutes 4 units
68 – 82 minutes 5 units
83 minutes 6 units

According to Medicare guidelines, instances where time spent on multiple services that individually do not equal 8 minutes but together do equal 8, one unit of service can be billed using the higher total time service. This is good to know, but keep in mind that not all payers will follow along in these guidelines.

Always be sure your documentation supports your billing, and be specific regarding time spent providing services. Many payers will request medical notes to support time based billing.

So make the most of your time and remember, if it isn’t documented, it didn’t happen!

ICD-10 and Facet Syndrome: What Chiropractors need to know.

There many questions surrounding the coding of facet syndrome using ICD-10. The confusion stems from the lack of a direct crossover from the ICD-9 code that was previously used. Chiropractors will need to aware of a few things before choosing the most ICD-10 accurate code.

Facet syndrome occurs when the zygapophaysial joints, located at the posterior of the spine, become inflamed. The ICD-9 code used for this was 724.8, Other symptoms referable to back. Mapping tools will leads us to ICD-10 code M54.08, Panniculitis affecting region of neck and back, sacrococcygeal region, which, being an inflammation of subcutaneous tissue, does not accurately describe facet syndrome. Therefore, chiropractors are forced to investigate and choose a more accurate code.

One can use  ICD-10 code M53.8-, Other specified dorsopathies, to report facet syndrome, but be aware, this being an “other” code, documentation must accurately describe the present condition as payers may request medical notes prior to approval of the claim.

Another option is the M47- series, “degeneration of facet joints“, this also requires consideration as the term degeneration implies a chronic condition, and facet syndrome could most certainly be an acute condition as well.

What we are left with is nothing short of the fact that code mapping may not always produce the most accurate code and choosing the correct code may take a little investigation into the options available. Again, always be sure your documentation supports your choice and be prepared to supply notes to payers if necessary. Get to know your ICD-10 coding manual, stay educated, and always choose the code that most accurately describes your patient’s condition.

Happy Coding!



Patient billing: when is it illegal to balance bill.

Many providers are unsure as to what balance billing actually means.

Balance billing, simply put, is billing a patient for an amount not paid by the insurance plan, the difference between the billed amount and the amount allowed for a covered service by the patient’s plan.

Guidelines state that if a provider has entered into a contract with an insurance plan, then he/she would not legally be able to bill a patient for any amount not allowed on a covered service. The provider may certainly collect from the patient co-pays, co-insurance, and deductible amounts. A provider cannot bill a patient for any amount not specifically stated by the patient’s insurance plan as being their responsibility.

If a provider does not have a contract in place with a patient’s plan, then it is perfectly legal to bill the patient according to the practice’s fee schedule or rates. Also, a provider may bill a patient for any non-covered services or in the event that the patient chooses to opt-out of insurance billing and has chosen the self-pay route.

Be in the know and and always be sure to follow CMS guidelines.  Discuss the options with your patients up front and maximize your revenue!