Medicare Reimbursement Overhaul Joins ICD-10 Coding Changes

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As we head into 2017, the chiropractic physician of the future has a significant opportunity to participate in programs being developed by the government to control the cost of health care. As chiropractic physicians, we have always asserted that we are instrumental in delivering quality health care at a lower cost. Now systems have been put in place to reward such actions. ICD-10 and the Merit-based Incentive System (MIPS) may just put us in the game.

On October 14, 2016, the Department of Health and Human Services (HHS) issued its final rule implementing the Quality Payment Program (QPP) that is part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). QPP improves Medicare by helping you focus on health care quality and improving patient’s health outcomes. MACRA ended the Sustainable Growth Rate (SGR) formula, which threatened clinicians participating in Medicare with potential payment reductions of up to 21%. Due to the aging of the population, Medicare has become the primary insurance for over 20% of the population. If you add in the covered “lives” of Blue Cross Blue Shield, this accounts for over half of the United States.


The Quality Payment Program’s purpose is to provide new tools and resources to help give patients the best possible, highest-value care. The Quality Payment Program policy will reform Medicare payments for more than 600,000 clinicians across the country and is a major step in improving care across the entire health care delivery system. In the 50 years since the establishment of Medicare, this is the greatest overhaul of the payment system ever seen. As a practitioner (now referred to as clinician in the law), you can choose how you want to participate in the Quality Payment Program, based on your practice size, specialty, location, or patient population.

The Merit-Based Incentive Program System (MIPS) will provide opportunities for providers, referred to as “clinicians,” to obtain a “fresh start”. New data systems will go into place as of January 1, 2017, which will replace EHR meaningful use attestation, the Value-Based Modifier system, and the Physician Quality Reporting System (PQRS).

Most chiropractors are expected to be eligible to participate in MIPS. In this budget neutral system, eligible clinicians’ data will be compared to each other. The negative tier or high utilizers will be punished with reduced payment amounts, and the money will be used to reward other clinicians as an incentive for lowered utilization costs and improved outcomes. Now providers will be rewarded if they effectively control costs by delivering quality care in a timely, cost-controlled environment.

Electronic health records, specific ICD-10 coding capabilities, and ease of data retrieval by insurance companies and agencies such as CMS, will allow clinicians to effectively report their outcomes. The data collection in 2017 will show the control of costs, giving providers the opportunity to update their profiles, thereby affecting their reimbursement rate in 2019.

On October 1, 2016, we entered the next phase of ICD-10 coding. To implement ICD-10 in the United States, all diagnosis codes were frozen from the original worldwide implementation date in 1995. Once the “thaw” occurred on October 1, 2016, the diagnosis codes were updated to facilitate new conditions, coding systems and new guideline interpretations. Of the 7,000 code changes, chiropractic physicians were faced with over 2,000 code changes that affected their practices. Numerous references books are available to guide you in the use of the new codes.

Increased specificity of the diagnosis codes is available to the clinician. These codes can be used to explain the increased co-morbidities or complicating factors that are facing the aging baby boomer population. Since care is a team effort of clinician and patient, there are now methods to indicate non-compliance on the part of the patient, through ICD-10 diagnosis codes and reporting systems. This is a method that the physician can use to perhaps avert negative payment adjustments and instead divert blame to the patient for delayed recovery. The clinician is finally able to report factors such as when a patient is not compliant in keeping appointments or completing home care.

The chiropractic physicians in practice today must learn to use the full benefit of the new ICD-10 codes and enhancements. A recent probe into claims submitted by 4,200 chiropractors to Blue Cross revealed that, of those claims, the top medical conditions diagnosed were lumbalgia, cervicalgia, and thoracic pain, in that order. These codes are considered to be unspecified, short-term diagnosis codes. The ICD-10 diagnosis rules state, “Codes that describe symptoms and signs are only acceptable if that is the highest level of diagnostic certainty documented by the doctor.” In other words, you should not report on the claim form a diagnosis that you would not want to report to the patient. You would never tell the patient that after the examination and review of findings that you have discovered that he or she has lower back pain!

All of the data that can be accumulated by insurance companies, government agencies and clinicians should help to transition our healthcare system and practices from a volume-based system to a value-based system. Using the diagnosis codes and reporting systems to accurately reflect the conditions we treat is imperative. Physicians and staff are encouraged to become active in continuing education in the coming year to survive the transition into a value-based system.

Dr. Fucinari and the ICS will be presenting several classes in the coming months to aid the doctor and staff in correct documentation and coding procedures. For an updated schedule of classes and locations, go to or Dr. Fucinari is a Certified Medical Compliance Specialist and a Certified Professional Compliance Officer. For information on the 2017 ICD-10 coding changes, the fourth edition of ICD-10 Coding of the Top 100 Conditions for the Chiropractic Office is available for purchase at For further information on DVDs, books or record reviews, please contact Dr. Fucinari at

About Author

Mario Fucinari DC, CCSP, APMP, MCS-P, CPCO

Dr. Mario Fucinari has helped train doctors and staff over the last 20 years. He received his bachelor's degree from Wayne State University in Detroit and his Doctor of Chiropractic degree from Palmer College of Chiropractic in 1986. Dr. Fucinari was the recipient of the 1998 and the 2003 President's Award from the Illinois Chiropractic Society (ICS) for his work with education and training and most recently received the 2012 Chiropractor of the Year award from the ICS. Dr. Fucinari was the first chiropractic physician to attain the Certified Medical Compliance degree. Two years later he earned his degree as a Certified Instructor for the Certified Medical Compliance Program. He is now the Chairman of the Chiropractic division of the national medical compliance program. He has produced classes and publications on HIPAA, Clinical Documentation, Medicare, and Stroke and Cervical Manipulation. He is a worldwide speaker for NCMIC, Foot Levelers, ChiroHealthUSA and several state associations and a Certified Chiropractic Sports Physician [CCSP].Online CME CoursesConnect

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