Editor’s Note: This article is the second in a new column by the National Association of Chiropractic Attorneys (NACA), featuring legal updates as they relate to DCs. Both of the following updates were submitted by Jeffrey Randolph, Esq., general counsel for the Association of New Jersey Chiropractors (ANJC). Jeff also operates a private practice in Glen Rock, N.J., specializing in health care law.
Repercussions for DCs Billing Osteopathic Manipulation Codes
ACTUAL ADVERTISEMENT: “Certain parts of the Affordable Care Act allow me, as a chiropractor, to bill and get paid for Osteopathic Manipulation, as long as I am properly qualified. Many of my clinic procedures are the same, and you know what.. .. I’m getting paid a LOT more for my visits than I used to ... like 3-4X. Here’s the other cool thing ... my overhead is that same! I have the same overhead from billing chiropractic adjustments (98940-98943), so that makes my practice more profitable! Here’s a special offer for you – I’m putting together a one-day seminar to qualify chiropractors to bill for osteopathic manipulations. If you want to learn more, call us...”
When something is too good to be true, it usually is. If you follow the advice of this advertisement and start billing osteopathic adjustment codes as a chiropractor, make sure that you look good in an orange jumpsuit.
When it comes to osteopathic manipulation CPT codes, these codes are divided by body regions. The range of codes starts from 98925 for 1-2 body regions and moves to 98929 for 9-10 body regions. In contrast, chiropractic manipulative CPT codes are broken down into up to five body regions, beginning with 1-2 regions (CPT 989941) to five regions (CPT 98942).
The fact that there are distinct CPT codes created and assigned by the AMA provides the first clue that they are specialty-specific and that chiropractors cannot bill an OMT code, and vice versa.
Our second clue focuses on the way the AMA creates the CPT code and assigns a value to each code. Each CPT code has a Relative Value Unit (RVU) assigned to it, which when multiplied by the conversion factor (CF) and a geographical adjustment (GPCI), creates the compensation level for a particular service.
RVUs capture three components of patient care: 1) physician work RVU; 2) practice expense RVU; and 3) malpractice RVU. Physician work RVU addresses the relative level of time, skill, training and intensity to provide a given service. A code with a higher RVU work takes more time, more intensity or some combination of these two.
Practice expense RVU addresses the costs of maintaining a practice including rent, equipment, supplies and nonphysician staff costs. Malpractice RVUs address payment for the professional liability expenses.
Geographic practice cost indices account for the geographic differences in the cost of practice across the country. CMS calculates an individual GPCI for each of the RVU components – physician work, practice expense and malpractice. The conversion factor converts the relative value units into an actual dollar amount. The dollar multiplier (CF) is updated on an annual basis according to a formula specified by statute.
Typically, osteopathic RVUs are higher than chiropractic RVUs, which equates to higher reimbursement to doctors of osteopathy (“DOs”) for osteopathic manipulative codes. For example, physician work RVUs for DOs are higher, as they have to attend four years of medical school, residency, internship and possible fellowship and board certification.
Their average higher-education costs and student loans are higher than DCs, resulting in a higher osteopathic RVU.
Practice expense RVUs may also be higher, as expenses to hire other plenary licensed doctors, nurses, and physician assistants, and the costs of medical waste disposal and compliance, are higher than that of a chiropractic office.
Finally, malpractice RVUs are higher for DOs than DCs because their average malpractice premiums are higher, as DOs can prescribe scheduled drugs and perform surgery, which provides a greater underwriting risk and higher malpractice premium.
Thus, under our scenario in the advertisement above, a DC would be billing OMT codes with the express intent of getting 3-4 times increased reimbursement compared to what they would otherwise be paid for chiropractic manipulative codes. They would be doing this even though “being qualified” to bill OMT codes does not result in higher work values for any of the three core RVUs addressed above.
This fits the classic definition of upcoding insurance fraud, in my opinion: intentionally billing a higher code for higher reimbursement with no justification for the upcoding.
Should you come across an advertisement such as this that claims you can obtain 3-4 times higher reimbursement by attending a one-day seminar, run, don’t walk away! I advise that you run any such program or claim by your health care attorney before spending money on it and exposing yourself to civil and potential criminal liability.
New Corporate Reporting Requirements Enacted
The federal government recently passed the Corporate Transparency Act (CTA), which imposes new reporting requirements for any Limited Liability Company (“LLC”), Professional Corporations (“PC”) and other privately held corporations in the United States.
The law was enacted with the goal of transparency and requiring the ownership of these entities, which many times have shell ownership and multiple layers of holding companies, to be fully disclosed to the federal government. The penalties for failure to comply with these requirements potentially include a felony conviction, a $500 daily penalty up to $10,000, and up to two years of prison.
If you operate your practice as an LLC or PC, or intend to form an LLC or PC in the future, the following reporting requirements apply to you:
- Covered entities created or registered before 2024 must file their initial reports by Jan. 1, 2025.
- Covered entities created or registered in 2024 must file within 90 days of creation or registration.
- Covered entities created or registered on or after Jan. 1, 2025, must file within 30 days of creation or registration.
The requirements apply to privately held LLCs, corporations and other entities formed or registered to do business in any U.S. state for any purpose. The beneficial ownership information will be reported to the Department of Treasury; the information will be accessible to authorized government entities, but will not be part of any publicly accessible database.
There are exceptions under the law and application to each entity is fact specific. I highly encourage that you consult with your attorney or financial advisor to determine the applicability and reporting requirements for your specific situation.
Note: The information provided is for general guidance on matters of interest only and may not take into account particular facts relevant to your individual situation. The application and impact of laws and health care can vary widely based on the specific facts involved. Given the changing nature of laws, rules and regulations, there may be omissions or inaccuracies in information contained in these materials. Accordingly, the information you receive is provided with the understanding that the author is not herein engaged in rendering legal, accounting, tax, health care or other professional advice and services; nor is he providing specific advice with regard to your practice, the treatment of any specific illness, disease, deformity or condition, or any other matter that affects trade, commerce, or legal rights of others. As such, this article should not be used as a substitute for consultation with professional accounting, tax, legal, health care, or other competent advisers. Before making any decision or taking any action, you should consult an appropriately trained professional.
