The devil is in the details of chiropractic documentation, and it’s painfully obvious when that’s missing.
The Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS) and “me too” private insurers are going after fraudulent practitioners because the government, unsurprisingly, prosecutes fraud.
But equally significant is that going after fraud is highly profitable: Fines and recoveries from big offenders can earn the Feds and other third-party payers up to a cool million per audit. It is a rare occasion that we see doctor of chiropractic emblazoned on a report from the OIG, but it happens. And as I look into the reasons these DCs made headlines, it saddens me that most of it was very preventable.
If it wasn’t documented, it didn’t happen
Most DCs aren’t deliberately and knowingly breaking the law. They make chiropractic documentation errors not with the cold intent to defraud, but from sheer ignorance or overwhelm. But just because you’re not one of the big offenders (droids) auditors are looking for doesn’t mean you can breathe a big sigh of relief and ignore your chiropractic documentation. The OIG has estimated over the years that anywhere from 80-94% of is incomplete and/or incorrect, and you can get caught in the same net they’re using to sweep for the big fish. Why? Usually because what was billed doesn’t match what is in the documentation.
They won’t knock down your door if your chiropractic documentation is simply sloppy and spotty as opposed to intentionally misleading, but they can still make your life extremely difficult and demand enough in recouped reimbursements to ruin your day, and maybe your practice. So, job one is to get your chiropractic documentation in impeccable shape. It takes time to change old habits, but once you’ve got the steps down, it’s far easier to just do it right the first time around than to deal with time-sucking records requests, or, worse, the extensive time and stress spent preparing for and recovering from an audit.
SALT may be bad for you
The documentation concept of same as last time (SALT) has claimed more bodies than the plague. Why? Because the OIG has deemed it potentially fraudulent. Many DCs simply bring forward the last note on the patient, then maybe change a thing or two, and call it done. It’s painfully obvious to an auditor when this happens. You can hold pages of chiropractic documentation up to the light and it all lines up. This is where the biggest mistakes happen. We are humans in a difficult system and mistakes are not always fraud, but the continued ignorance of these rules can swing what your pattern looks like from careless to intentional.
Each visit should be able to stand on its own. Of course, you can bring certain information forward from the last visit, but where good doctors go wrong is leaving it there. The purpose of the subjective (S) and the objective (O) section of your routine visit note is to show what’s called “changes since the last visit.” SALTing forward makes that easy, but not if you don’t make changes. And if you say the patient is better or worse, you must indicate what that means. Such as, “The patient is improving because they are sleeping longer before being awakened by the pain” or something like, “The patient’s pain levels rose from an average of five to an average of seven after two days of watching their grandkids.” Simple, elegant and not time-consuming. But the devil is in the details of chiropractic documentation, and it’s painfully obvious when that’s missing.
Billing errors are tattletales
One of the most noticeable errors we find when doing proactive chart reviews for providers is that the billing simply doesn’t match the chiropractic documentation. Some of this is because of SALTing, as noted above. Other times, it’s sheer carelessness or lack of paying attention.
Here are some of the things we see most often and what to do about them:
The diagnosis doesn’t match the coding. Commonly, we see this with chiropractic manipulative treatment (CMT) coding. The provider is billing for three to four spinal regions, but the chiropractic documentation shows complaints and documented findings in two. Why does this happen? Because many are “full-spine adjusters” and if there is a segmental dysfunction in an area, it gets addressed. But it doesn’t mean it’s billable. Or, another common occurrence is that an extra-spinal area was addressed and billed, such as a shoulder, with no diagnosis supporting that. These are easy to fix, but only if you are aware and spot checking periodically to make sure what is billed is properly documented.
Codes are billed that are assumed to be correct. Familiarize yourself with all carriers’ medical review policies (MRPs), most of which can be found online. If the insurers to whom you are submitting billing have specific rules and you’re not following them, you’re in violation and because you’re supposed to know what is in the MRP, ignoring it or running afoul of the rules looks intentional. One of the more recent examples is seeing that providers bill 97012, mechanical traction, on a billing form. A deeper look into chiropractic documentation shows that the patient was laid on a roller table type traction device. First, 97012 is not the correct code for this, and further, many MRPs specifically state that roller table traction is considered experimental, unproven and investigational.
Misunderstanding the difference between medically necessary vs. clinically appropriate care. Yes, yes and yes, everyone with a spine deserves ongoing wellness care. But that doesn’t mean third parties will pay for it. Medically necessary care is episodic care, with a clear beginning, middle and end of treatment. It’s also care undertaken with the reasonable expectation of progressive functional improvement. Weekly adjustments may well make a senior’s arthritic neck feel better, but they won’t be considered medically necessary without documented functional improvement, and Medicare isn’t going to pay for them. And private payers follow the same definitions and rules. Where do you find those? In the MRP, of course! And the issue here is not the treatment. It’s the idea of billing it for reimbursement when it doesn’t qualify. And that can look intentional.
Final thoughts on chiropractic documentation
So, yes, you are likely not one of the droids they are looking for. But that doesn’t mean you will be overlooked altogether. A small fish may make for a small meal, but a net full of many small fish can feed a village — or the coffers of a third-party payer — quite nicely. How can you avoid the net? Well, maybe you can’t avoid it, but you can withstand it. Ongoing spot-check auditing and diligence in working your in-office compliance program helps to hedge the bet. If you find the issue first, it’s fixable, and clearly not intentional. Addressing errors through your compliance program makes your office look like…not, the droids they are looking for.
KATHY (KMC) WEIDNER, MCS-P, CPCO, CCPC, CCCA, better known professionally as Kathy Mills Chang, has been providing DCs with reimbursement and compliance training, advice and tools to improve the financial performance of their practices since 1983. This year, celebrating serving this profession for 41 years, Weidner leads the largest team of certified specialists under one roof in the profession at KMC University. She is one of our profession’s foremost experts on Medicare and documentation. She or any of her team members can be reached at 855-TEAM-KMC or info@kmcuniversity.com.
