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OIG report suggests 82 percent of chiropractic claims were ‘medically unnecessary.’
No area of reimbursement is more confounding to chiropractors than Medicare.
“A major reason for the confusion is the wide variety of opinions versus facts regarding Medicare compliance,” says Kathy Mills Chang, a certified medical compliance specialist and certified professional chiropractic coder (MCS-P and CPCC). “A recent report by the U.S. Department of Health and Human Services’ Office of the Inspector General estimates that 82 percent of Medicare payments made to chiropractors in 2013 were unallowable—which amplifies the extent of the misunderstandings. This amounts to Medicare paying $358.8 million for care that it deems ‘unnecessary.’ But the question remains, was the care indeed unnecessary?”
The report suggests that the root of the problem stems from chiropractors inappropriately using the AT (active treatment) modifier when billing Medicare for covered adjustments.
Medicare and the AT modifier
Let’s take a look at what we know at this time:
• The AT modifier appended to the chiropractic manipulative treatment (CMT) code indicates that the care is deemed “medically necessary” and the provider expects Medicare to consider the treatment for payment.
• Medicare will only cover spinal adjustments that are billed with the AT modifier. Without the AT, a Medicare Administrative Contractor (MAC) should deny the visit.
• Providers who believe the care is medically necessary and meets Medicare’s definition should submit the billing with the AT modifier or it won’t be paid.
In order to warrant medical necessity and bill Medicare, a diagnosis must include subluxation along with a secondary, neuro-musculoskeletal diagnosis presented in tandem. In addition, the patient’s record must include appropriate documentation, e.g., that the subluxation is capable of causing the associated neuro-musculoskeletal condition.
“Chiropractors can locate and correct a subluxation, but that is not always reimbursable,” Chang says. “If the subluxation is not causing a secondary, covered condition, then it’s deemed ‘clinically appropriate’ treatment and might not meet Medicare’s definition of medical necessity.” Of course, the patient could still opt to have the treatment, but they would have to pay for it out of pocket.
Chang says oftentimes the problem is not due to the appropriateness or validity of the care provided, but rather the lack of painting a clear picture throughout the medical record of the necessity of care. “If a Medicare auditor considers a bill submitted with the AT modifier as unnecessary, it’s usually because the requested documentation doesn’t meet what’s required under the definitions of acute or chronic care,” she says.
Documentation is key
The bottom line is, whether the episode of care consists of a few visits over a short time period or a lot of visits over a few months, the documentation must show—on a continuous basis, and with periodic reevaluation—how the care is working and why the patient needs additional care. This establishes the necessity for this period of treatment.
Appropriate documentation of an active episode of care should outline the treatment’s effectiveness throughout the treatment period.
“It should begin with a history of the present concern for each area of the spine necessitating treatment along with objective examination findings that quantify the patient’s reported complaints,” Chang says. “Then, the provider must outline the diagnosis for each region to be treated, along with a treatment plan that includes frequency, duration, functional goals, and how the care will be evaluated for effectiveness.”
Once the chiropractor lays this foundation, the documentation of each visit will outline the treatment plan’s execution until the patient is ready for discharge.
“Discharge is noted in the record as the end of an active episode of care; any subsequent care for that condition may be considered maintenance and therefore is the patient’s financial responsibility,” Chang says. “If the condition returns or another active condition begins, another active episode can be started with the steps documented in order again.”
Returning to the original question: Did the report’s assertion that care was “unnecessary” really hold true? “Not in my opinion,” Chang says. “The better definition might be that it was ‘not medically necessary’ and therefore it doesn’t qualify for Medicare reimbursement and is the patient’s financial responsibility. All chiropractic care within the scope of a chiropractor’s practice can be defined as ‘clinically appropriate,’ while the smaller subset of care that meets Medicare’s definition of medical necessity would qualify for reimbursement.”
Kathy Mills Chang is a Certified Medical Compliance Specialist (MCS-P) and Certified Chiropractic Professional Coder (CCPC), and since 1983 has been providing chiropractors with reimbursement and compliance training, advice, and tools to improve the financial performance of their practices. She leads a team of 16 at KMC University and is known as one of the profession’s foremost experts on Medicare. She or any of her team members can be reached at 855-832-6562, at kmcuniversity.com, or by emailing firstname.lastname@example.org.
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