‘I think we’re probably fine’ is likely a problem waiting to happen with your chiropractic records and practice risk
MANY OF THE DOCTORS WE MEET TELL US THEY’RE NOT TOO WORRIED about their chiropractic records and documentation. “We’ve got that covered,” they say. “I think we’re probably fine.”
We wish we shared their optimism, but statistics — as well as our own practical experience — tell us that their documentation is not anything close to fine. A few years back, the HHS Office of Inspector General (OIG) reported that as many as 94% of chiropractic records are missing or inadequately present some key elements — evaluation, a treatment plan, medical necessity and/or contraindications to treatment. That statistic matches up with what we find when we proactively review someone’s documentation as a sort of “white hat” auditor: Even DCs who tell us at the outset that they think their paperwork is solid have, instead, documentation errors that put their practice at risk.
A recent new client is a splendid example. One of the blessedly open-minded, this DC came to us because of documentation concerns. But even she was horrified when we found that her Medicare documentation error rate was 100%! That means there was something seriously missing, miscoded or misstated in every single Medicare claim the practice filed. Their risk factor for an audit? Insanely high.
Chiropractic records: convert denial into dynamic documentation
As we compile the types of errors and missteps we see, there is certainly a pattern. Some of the biggest issues can easily be addressed to turn your Documentation “D”enial into “D”ynamic Documentation:
Understand the differences between chiropractic records for active treatment and documentation for maintenance care. Of course, it’s best practice to do thorough documentation on all patients, but there is a significant difference in the number of required elements when billing a third-party payer for active treatment, and what’s necessary to document a routine maintenance visit.
Create templates and macros meant to prompt you to include the most important aspects of the active treatment documentation rather than leaving it to chance.
There is a reason nearly every state requires regular continuing education that includes a certain number of hours of documentation training. Payers change their requirements. Boards update guidelines. Clarifications come out constantly. Certain compliance-related annual activities are necessary as a part of your OIG compliance program.
Keeping up on the annual duties that may include those related to documentation make changes and updates easier to manage. Stay up-to-date by remaining connected to trusted sources of documentation training, and consider having an expert proactively review a chart annually to have someone with fresh eyes and a fresh perspective provide feedback.
N-New Patient/New Episode
Speaking of templates and macros, this is a wonderful time to be sure that your initial visits, whether a new patient or a new episode of care, look and feel different from the routine visits within episodes.
Your initial visit of an episode of care is your opportunity to lay the foundation for the medical necessity of the episode or series of visits you’re prescribing. That visit anchors the beginning of the episode with the expanded details of history, exam, initial assessment, diagnosis and treatment plan. Without it, the hodge-podge of visits floating without connection to the episode make it difficult for a reviewer to understand the patient’s true condition and note their progress.
Most providers bristle at the word “audit” because it denotes a terrible thing … or something that might get one in trouble. I’ve always taken the attitude that I’d rather find a problem in and have the chance to fix it before someone looking to spank my hand finds it.
There are many good reasons to perform periodic documentation audits, and to conduct spot-check quick audits. First, compliance programs mandate self-auditing. It is only through this process that you can meet the statutory requirements and regulations associated with your compliance program. But there are also many other benefits, like system improvement, detecting and preventing fraud and abuse, and finding errors that may have resulted in your office being underpaid. Devise a plan to spot-check your chiropractic records monthly and to conduct ongoing full chart audits for continuous improvement.
M-Master Medical Necessity Definitions
Ever tried to play pin-the-tail-on-the-donkey while blindfolded? It’s hard! And it causes unnecessary angst. Trying to meet the medical necessity requirements for payers and Medicare without knowing what the definitions are can feel the same way.
Most every payer publishes this information. They publish Medical Review Policy (MRP) that outlines what’s expected for specific treatments, including chiropractic care. Doing business with a payer, on your patient’s behalf, without knowing these definitions, is like sitting down to play poker without any prior knowledge of the game, and your $250,000 chiropractic education is the chips you’re playing with. Don’t leave yourself in the dark. Know the rules if you’re playing in the third-party sandbox.
I-Initiate Correct Coding
Doctors know the treatment they give an individual patient and therefore feel justified in how they code the service —but if documentation doesn’t support the code, it’s a problem. Remember, as far as a third-party payer (or auditor) is concerned, if it isn’t in writing, it didn’t happen.
So if, for example, you bill a chiropractic manipulative treatment (CMT) code for a certain level of service, but the documentation only justifies a lower number of regions treated, you’ve just waved another red flag. Note: These kinds of mistakes usually found in post-payment audit reviews can cost a practice thousands of dollars in repayment. No complaints and findings in an area doesn’t mean you can’t address those compensatory areas. It simply means we don’t bill for them.
C-Cloned Records – A Thing of the Past
When each chiropractic visit looks the same as the last and statements like “same as last visit” pepper the daily notes, it’s difficult to ascertain the necessity of each visit. Standard guidelines dictate what must be included, and it can be quite easy to get into the trap of rushing through your daily documentation.
Most documentation software programs allow you to start with the notes from the last visit, so you can modify from there. The error here is when you get rushed or lax, you may be tempted to minimally modify and move on. Resist the impulse, and make sure each visit and your chiropractic records are “encounter-specific.”
Fortunately, as with most things, being willing to admit you may have a problem is a huge step in the right direction. Our client with the 100% error rate? Thanks to a lot of unflinching courage and a little challenging work, their practice’s Medicare claim error rate is now 8%. Now, that’s a number that justifiably inspires confidence.
So, for those of you reading who are still thinking, “Yeah, that must have been one messed-up practice, our documentation is fine” — well, you may be right. But statistics say that you have a 94% chance of being wrong.
How do you like your odds?
KATHY (KMC) WEIDNER, MCS-P, CCPC, CCCA, better known professionally as Kathy Mills Chang, is a Certified Medical Compliance Specialist (MCS-P) and a Certified Chiropractic Professional Coder. Since 1983, she has been providing chiropractors with reimbursement and compliance training, advice and tools to improve the financial performance of their practices. She leads the largest team of certified specialists under one roof in the profession, at KMC University, and is known as 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.