Critical for compliance and your bottom line, a coding compliance audit can find red flags and increase revenue
When a chiropractor asks us to perform a proactive chart review, they are often surprised that we request a copy of the itemized statements that reflect the coding for those dates of service. Providers fail to see the link that exists from the documentation to the coding.
They are inextricably connected like the proverbial chicken and the egg. And just like that famous question of, “Which came first?” we must recognize that the documentation must always drive the coding. This applies to both CPT procedure coding and ICD diagnosis coding. Without the documentation, the coding cannot exist.
Coding compliance audit: find red flags before payers do
Being aware of your code usage is critical for compliance. It can be easy to fall into a dangerous routine of using the same code over and over again — even though it really might not be the most appropriate code to use. Remember that the codes you submit to third-party payers for reimbursement represent you as a provider. Be assured that even if you’re not looking at your code usage for red flags and outliers, the payers are. The codes you use must match the documentation that may inevitably be requested for review.
Besides direct chart reviews to confirm the coding is correct, there are other compliance-related coding audits that will provide a peek into the patterns you may be falling into. There are guidelines and estimates to be used to see what your ratios look like compared to the national averages when performing a coding compliance audit. But remember:
These guidelines are just that — not recommendations of ways to game the insurance companies or to increase reimbursement.
CPT coding audit
Your computer software can provide you with a list of CPT codes and their usage for the period you wish to use for a coding compliance audit. The report should reflect the total occurrences of each code entered into the system for each month. If you don’t use computer software, you may need to rely on paper reports. Even just monitoring the code usage from the past 30 days can give you an indication of where you stand. Use the following indicators as you evaluate your usage:
Evaluation and Management (E/M) Services (9920X and 9921X Series)
Compare the total number of New Patient E/M codes (9920X) to the total number of X-ray services provided, if you take films in your office:
- Does the total number of X-ray codes, when compared to the E/M codes, make sense? Is it within your X-ray protocol? Some providers find that they X-ray more than is recommended and others, as part of a protocol, X-ray every patient. That is a provider-specific decision and this review of the ratio sheds light on exactly what you are doing, rather than what you think you may be doing.
- Look at the total number of New Patient E/M codes (9920X) and compare to the number of Established Patient E/M codes (9921X). As a rule, established patient codes should run at least two times the number of new patient codes. The rationale is that, depending on your practice style and patient visit average (PVA), each new patient’s episode of care should have at least two re-evaluations. Even with short-term treatment, the second one is a discharge evaluation. This opens a window to whether your documentation would continue to demonstrate medical necessity through re-evaluation. It also shows patients how their progress is going and provides educational opportunities. An excellent goal is a ratio of at least two-to-one with established patient E/M codes being at least double the number of the new patient E/M codes. Remember, this calculation does not take into consideration reactivating patients, those returning with new conditions, and other reasons you may have for established patient E/M services. Therefore, doubling the number is a conservative estimate.
Chiropractic Manipulative Treatment (CMT)
The CMT code usage among the three spinal codes will vary with your practice style, your adjusting techniques and other factors. But this ratio tends to be one of the most important when it comes to evaluating code usage for a coding compliance audit.
Because it’s the main code billed to Medicare, it provides a snapshot of a provider’s tendencies with adjustment coding. While one provider may be a “full spine adjuster,” it does not mean that all the regions were medically necessary, and therefore billable services. An excellent guide is to look for a ratio of 40-60% of your code usage for each 98940 and 98941 with a very low percentage of 98942 — usually 8% or less.
For example, it may be 55% 98940 code, 40% 98941, and 5% 98943. Or, 35% 98940 code, 63% 98941, and 2% 98942. These are estimates based on CMS data for relative usage by chiropractors. If you find that 98941 or 98942 percentages are creeping up, it may be time for a proactive chart review to see how that coding compares to the documentation.
Extraspinal manipulation code usage (98943) can vary by provider. A good estimate to work with is that the total number of 98943 codes should be approximately 20-30% of the number of spinal CMT codes, if the practice treats extra spinal regions. The rationale is that approximately that many patients in each population will require additional care for extra spinal regions. Of course, when the practice contracts with certain provider networks, sometimes these are bundled and not billed separately. Everything must be taken into consideration.
Modality and procedure coding Because restoring functional deficits is key when demonstrating medical necessity, best practices are to limit the use of passive modalities in favor of more active therapy procedures. For this ratio, compare the total number of services for passive modalities to the total number of active treatment services (97530, 97112 and 97110). A two-to-one ratio in favor of active treatment is an excellent mark to strive for. Passive modalities are expected to drop off within the first month of treatment, due to the goals of those treatments being achieved relatively quickly. At this point, patients are expected to transition to active therapy.
For easy math, strive for the total number of 97110s to be equal to at least 50% of the total of CMT codes. The reason for this is that in today’s functional model of care, it’s important to deliver active care in your practice so that you can show you are delivering care aimed at functional restoration. And most active care rehab in a chiropractic practice is billed as 97110, therapeutic exercises.
If you perform muscle therapies in the practice, 97140 or 97124, compare that total number to your 98941 total. If the number seems out of range, compare the documentation to make sure the manual therapy was not performed on one of the regions adjusted on that day. These services provided in the same body region are not separately billable.
Coding audits should be performed as a baseline to your compliance program, and then at least annually. As you perform a coding compliance audit, record the findings, and the improvements, into your OIG compliance manual. Be sure to document areas of concern, create strategies to correct these problems, and detail any training that will take place to assist practitioners with corrections that are needed. This will allow you to stay on top of any potential problems with overuse of certain codes when coding ratios are out of balance with expected norms.
Kathy Mills Chang, MCS-P, CCPC, CCCA, is a Certified Medical Compliance Specialist (MCS-P), certified Chiropractic Professional Coder (CCPC), and Certified Clinical Chiropractic Assistant (CCCA). 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 in the profession, KMC University, and is known as one of our profession’s foremost experts on compliance, Medicare, documentation and CA development.