Resource Centers:(News, information, and tools to support your practice)
March 2010
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Coding Questions: How to prevent insurance audits and refunds
By Marty Kotlar, DC, CHCC, CBCS
Q: How can I prevent an insurance company from asking me for my SOAP notes? And if they do, what can I show them that will allow me to sleep better at night?
A: Your desire to be proactive and learn how to prevent potential problems is commendable. It’s difficult to provide specific recommendations because the type of practice you manage is not known.
There are, however, basic documentation and billing items that are important for every chiropractor to know, even if you’re a cash practice.
1. Compliant documentation. When you decided to become a DC, it was probably because you wanted to help people get well through high-quality chiropractic care, not because you wanted to become an expert in documentation and coding. In today’s healthcare environment, proper documentation is extremely important and required.
In order to receive the reimbursement you rightfully deserve, you must document properly and bill compliantly. Good quality patient care involves documenting everything that occurs during every patient encounter. After all, your documentation is the only way to substantiate the care you provided was actually performed.
This is extremely important if you are ever involved in a malpractice case or insurance audit. Good documentation is also important if your files are ever asked to be reviewed by a chiropractic state board or if the patient simply asks to see their files.
2. The first visit. All new patients should complete a good, quality health history intake questionnaire. It’s important to document the following items:
• History: Make sure to comply with the guidelines. Example, CPT code 99203 requires four items documented in the history of present illness (HPI).
• Examination: Here again compliance is vital. Example, CPT code 99203 requires 12 examination findings be identified and documented in the patient chart.
• Diagnosis: List all the diagnoses, even if there are 10.
• Short-term goals: Example, improve lumbar flexion range of motion from 40 degrees to 75 degrees within four weeks.
• Services: List the services going to be rendered and the reasons why you are going to do them.
• Visit schedule: List the duration and frequency.
3. Modifiers. Many offices use modifiers too casually, which as a result can initiate an investigation. Two Office of Inspector General (OIG) reports revealed that modifiers 25 and 59 were used incorrectly nearly 40 percent of the time. Both modifiers are used to alert the payer that a second service should be paid separately, due to special circumstances.
The most common problem the OIG found with the documentation for modifier 59 was that the claims don’t specify clearly enough that the two treatments the modifier makes separately billable were performed at separate and distinct times, and for a medically necessary reason. You can clear up some of the confusion by writing down the specific times an action took place.
Modifiers allow providers to indicate that a service or procedure has been altered by some specific circumstance, but not changed in its definition or code. The careful application of modifiers prevents the necessity to supply a separate
4. Good quality SOAP notes. Make sure your notes are legible and don’t look “canned.” All SOAP notes must include the patients name, date of service, and should be initialed or signed by the person providing the service. The chart notes must identify the provider responsible for the care of the patient. This includes your CA even if she or he is applying simple modalities, such as cold packs and traction.
Do not white out your SOAP notes. If you have to make a change to your documentation, draw a single line through the item, date and initial it, and then make your correction. You cannot change, add, delete, or alter your SOAP notes once they have been entered into the patient's record. The SOAP notes should be completed and entered into the patient's record on the day that the service was rendered.
Document any phone conversations, missed appointments, missed spinal health orientation classes, and if the patient hasn’t followed your home-care instructions.
General do's and don'ts
• Do not bill 98942 on every patient on every visit.
• Incorporate re-evaluations. The doctor, patient, and insurance company (if necessary) need to be kept aware of the patient’s progress.
• Create a written treatment plan for every new patient.
• Do not waive co-pays, deductibles, or co-insurance.
• Become proficient when incorporating CPT codes 97140, 97124, and 97112. Remember, these CPT codes (according the National Correct Coding Initiative Edits), if performed on the same day as a chiropractic adjustment, must be applied to a separate anatomic site than the chiropractic adjustment.
• Become familiar with the Medicare guidelines for your state. Learn how to document the initial visit, subsequent visits, P.A.R.T. exam, maintenance care, the new ABN form, and all the Medicare modifiers, such as AT, GA, GP, GY, etc.
• Know the difference between time-based codes and nontime-based codes.
• Know how and when to code and bill for group therapy, CPT code 97150 vs. individual therapy.
• Do not bill 97140 if you’re really doing a 98940 – 98943.
• Do not bill for a report of findings.
Marty Kotlar, DC, CHCC, CBCS, is the president of Target Coding. Target Coding, in conjunction with Foot Levelers, offers continuing-education seminars on CPT coding and compliant documentation. He can be reached at 800-270-7044, drkotlar@targetcoding.com, or through www.TargetCoding.com.
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When to use a modifier
Modifiers may be used to indicate the following:
• A service or procedure was increased or reduced.
• Only part of a service was performed.
• An adjunctive service was performed.
• A service or procedure had both a professional and technical component.
• A service or procedure was performed by more than one physician and/or in more than one location.
• A service or procedure was provided more than once.
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