Keep up with new code documentation changes and put these procedures in place to stay out of the auditor’s web
The office of inspector general (OIG) and “me too” private insurers love to go after fraudulent practitioners for code documentation violations 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 U.S. federal government and other third-party payers up to a cool $1 million per audit.
Code documentation: errors and ignorance
Most DCs aren’t deliberately and knowingly breaking the law. They make documentation errors not with the cold intent to defraud, but from sheer ignorance or overwhelm. But just because you may not be one of the “big offenders” that auditors are looking for doesn’t mean you can breathe a big sigh of relief and ignore required elements of code documentation.
The Office of Inspector General (OIG) has estimated over the years that anywhere from 80-94% of chiropractic documentation is incomplete and/or incorrect, and you can get caught in the same net they’re using to sweep for the big fish. They will not throw you in prison if your code documentation is simply sloppy and spotty as opposed to criminally misleading, but they can still make your life extremely difficult and demand enough in recouped reimbursements to put you out of business.
So job one is to get your documentation in impeccable shape. It takes time to put procedures in place, but once you’ve got the steps down, it’s actually 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. Here are some ideas to get you started.
New coding and staying updated
Make sure you’re using the most current version of the CPT, HCPCS and ICD codes. And make sure you stay up to date by reviewing ICD-10 changes that are effective on a fiscal year of Oct. 1, and CPT changes that go into effect on the calendar year of Jan. 1 on an annual basis.
For example, the new Evaluation and Management (E/M) coding rules that went into effect in January 2021 had big changes for practitioners. Missteps related to the changes or simply ignoring the new guidelines are the recipe for a fiasco.
Likewise, learn to speak fluent modifier. If you’re not using the correct modifier, you’re not going to get reimbursed. It’s as simple as that.
Modifiers have a job to do. With Medicare, for example, use of the AT (active treatment) modifier indicates that your code documentation represents active treatment that meets their definition of medical necessity. Billing with the AT modifier and expecting reimbursement, but without the necessary elements of medical necessity in the documentation, is an example of waste and abuse.
Understand medical review policy, and what it means to you
Don’t make unnecessary errors by failing to know the rules of the game you’re sitting down to play with your $200,000 chiropractic license as an ante.
Familiarize yourself with your carriers’ medical review policies, most of which can be found online. If the insurers with which you participate have specific rules and you’re not following them, you’re in violation of the agreements you signed. Worse, they are stingy with the information, and often make it difficult to find it. But as a participating provider or one who bills out of network, on behalf of a patient, you are obligated to ensure that coded and billed services match the documentation in the health record.
For example, if kinesiology taping is considered experimental, investigational and unproven, as it is with most insurance payers, and you bill it with a code that might be covered, such as a strapping code, the coding doesn’t match the documentation. And you can see how that might be considered sneaky — a workaround — even when you may have simply not known any better. But a cursory review of medical review policy would have indicated that it is not a billable service.
The definition of medically necessary care varies based on the payer type. Some may follow Medicare’s guidelines and require a documented spinal subluxation that is causing a neuromusculoskeletal condition while others may allow doctors to diagnose and treat patients based on their scope of practice. The patient must have a significant health condition necessitating treatment with a reasonable expectation of recovery. The ability to improve the patient’s function through treatment is also a requirement.
The best way to prove medical necessity is through the provider’s documentation which includes the initial intake, history, exams, daily treatment notes, a treatment plan with measurable, functional goals, and imaging when appropriate. When medical necessity is established, this is called active care. When this criterion is not met, the patient will be under maintenance care. Many third-party payers only reimburse for active care.
Necessity vs. maintenance care
Get clear on medically necessary care versus clinically appropriate care. Yes, yes and yes, everyone with a spine deserves ongoing wellness care. But that doesn’t mean third parties will (or should) 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 hip feel better, but they won’t be considered medically necessary without documented functional improvement, and Medicare isn’t going to pay for them. Likewise, third-party payers expect there to be documentation of progress day to day.
We suggest using the functional goals from the treatment plan to guide the questions in your subjective portion of the SOAP note on an encounter-to-encounter basis. This allows for a clear “story” of the patient’s progression through active treatment, through to therapeutic withdrawal, and then to discharge.
All along the way, the return to function (or the lack thereof) is well-documented and aligns beautifully with the projected duration. If there are hiccups in the treatment plan, or the patient fails to progress, the encounter notes explain that and continue the story.
Since no two patients are alike, each patient’s documentation should be individualized for the treatment they need. Some examples of how medical necessity can be established in a patient’s chart include the following:
|Patient consultation and history data||· What is the mechanism of injury?|
· Has the patient ever had this problem before?
· Does the patient have other health problems that will impact treatment?
|Physical examination findings, tests, and measurements||· Orthopedic/Neurologic tests|
· Palpation of involved structures to evaluate for pain, swelling, hypertonic/hypotonic muscles
· Range of motion
· Imaging and lab tests
|Subjective complaints mentioned by the patient||· Quality and severity of pain|
· Activities of Daily Living (ADLs) that are affected by the complaint
· What relieves the pain, provokes the pain
|Diagnosis/Diagnoses||· Be as specific as possible with the diagnosis|
· Only report diagnoses that can be confirmed
· Use signs and symptoms codes sparingly when possible
|Treatment Plan(s)||· Frequency and duration of the recommended treatment|
· Short term and long-term functional goals that are specific and measurable
· Treatment services with a rationale that is consistent with the patient’s condition
|Achievable functional goals as the result of your care||· Reassess the patient every 30 days or a reasonable interval for any changes in their condition|
· Complete Outcome Assessment Tools (OATs) to help determine progress
· Provide an explanation if improvement is not seen as expected and make necessary changes to the treatment plan
Use NCQA guidelines
Defining and implementing these standards for medical records documentation in your practice is also a critical part of building a strong compliance program. NCQA guidelines for medical record documentation contain 21 different commonly accepted components.
The National Committee for Quality Assurance (NCQA) is an organization dedicated to improving health care quality. It has helped build consensus for important health care quality issues through its work with large employers, policymakers, doctors, patients and health plans. They determine what’s important, how to measure it and how to promote improvement. The use of NCQA guidelines sends a powerful message: Quality matters.
Defining and implementing these standards for medical records documentation in your practice is also a critical part of building a strong compliance program. NCQA guidelines for medical record documentation contain 21 different commonly accepted components. These guidelines transcend provider type, so a practice should use these components to develop and define its own standards for medical record documentation.
I think the most important guidelines to implement for quality documentation are these 12. Those in bold are the six that NCQA states are the most core guidelines, as applicable to a practice.
- The patient’s name or ID number must appear on each page
- Author’s identification in the form of a handwritten signature, unique electronic identifier or initials
- Must be legible to someone other than the author
- Significant illnesses and medical conditions must appear on the problem list
- Medication allergies and adverse reactions OR if none, the absence of allergies or a history of adverse reactions are prominently noted in the record
- Past medical history (for patients seen three or more times) is easily identified and includes serious accidents, operations and For children and adolescents (18 years and younger), past medical history relates to prenatal care, birth, operations and childhood illnesses
- The history and physical examination identify appropriate subjective and objective information pertinent to the patient’s presenting complaints
- Working diagnoses are consistent with findings
- Treatment plans are consistent with diagnoses
- If a consultation is requested, a note from the consultant is included in the record
- There is no evidence that the patient is subject to inappropriate risk by a diagnostic or therapeutic procedure
This is not an all-inclusive list, but to be on par with accepted input and code documentation standards, this is a great place to start.
Red flags to watch for
Auditors look for under- and over-coding, because billing too much or too little puts your practice outside the norms. They also watch for what appear to be cloned records, i.e., when all your documentation looks the same. Make sure each visit and documentation is encounter-specific. Overuse of a code, or too many notes that say something like “same as last visit” make your documentation stand out. You don’t want your documentation to stand out.
Don’t submit records requests with incomplete documentation. That would be documentation that lacks all the correct dates, code documentation, modifiers, treatment plans, notes, progress reports, time for timed codes, and the practitioner’s signature. An unbelievable amount of chiropractic documentation is missing some or all of these details.
When it’s real you must appeal
Feeling confident about your documentation but still getting rejected claims? Time for your next step: Appeal them. Every last one of them.
Here’s an insider secret that comes courtesy of a former insurance claims adjuster: Up to 30% of all claims submitted to insurance carriers are denied on the initial submission whether they are correct or not. Why? Because only about 25% of chiropractic practices spend the time and energy to appealing rejected claims. In other words, it’s profitable for insurers to randomly reject
claims, because they know most DCs won’t push back.
Just as it’s “worth it” to third-party payers to randomly reject claims because statistics tell them you won’t bother to put up a fight, it’s more than worth your time to write standard operating procedure for appealing rejections and follow it faithfully. Some DCs and their staff worry that appealing claims will result in more rejected ones, but this simply isn’t true. You won’t be punished for submitting appeals. And you stand to win with increased reimbursements and a far more robust bottom line.
The OIG estimates recent annual recoveries from audits recouped health care reimbursements at $4.9 billion. So 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. Claim your rightful reimbursements.
KATHY (KMC) WEIDNER, better known professionally as Kathy Mills Chang, is a Certified Medical Compliance Specialist (MCSP) 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. Kathy 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-TEAMKMC or info@KMCUniversity.com.