Coding compliance is an important issue for chiropractors today, with Medicare and other payers cracking down on fraudulent and non-compliant coding practices.
As a result, chiropractic offices are facing increased scrutiny as many practices struggle to stay compliant and avoid violations.
The environment that chiropractors practice in has certainly changed. More than a few doctors have committed fraudulent billing, bringing negative attention to chiropractic care. New technology has made the process of investigating noncompliance cases easier as electronic healthcare record (EHR) software facilitates the review of patient records and histories.
The Office of Inspector General (OIG) is diligently working to protect the taxpayer dollars in the Medicare Trust Funds and is increasingly concerned with uncovering cases of fraud. Because of the OIG’s greater observation and closer investigation of chiropractic billing and coding practices, it’s arguably more important than ever for chiropractic clinics to invest more effort in compliance.
How can your practice achieve and maintain standards of excellence that are beyond reproach? Taking insurers’ concerns seriously, practicing careful documentation, coding correctly and seeking solid justification through medical necessity can help.
For the conscientious doctor of chiropractic, correct coding can seem like a minefield—chiropractors are often viewed with suspicion by insurers because of the small number of bad actors who’ve given the entire profession a compromised reputation. Other doctors have struggled to keep their compliance up to speed as health care regulations have changed and coding standards have evolved.
How did we get here? The answer, unfortunately, is rampant fraud on the one hand and innocent misunderstandings on the other. Even though many chiropractors are deliberately trying to avoid compliance mistakes, the game itself has become more complicated.
Scott Munsterman, DC, CEO of Best Practices Academy, points out that payers are watching chiropractors closely for coding errors. Clinicians of every profession, he adds, struggle to properly code and risk making mistakes in the process.
“We have to always keep in mind, our small chiropractic businesses are subject to the very same laws that encumber health systems, hospitals, and medical clinics,” Munsterman says.
Without the same resources to strategically address compliance issues, chiropractic clinics face daunting odds in their attempt to consistently keep up with the changing compliance landscape. It’s easy for errors to happen when you’re tasked with focusing on so many different aspects of running your clinic at once. Without some kind of compliance strategy, doctors can quickly become lost.
The documentation dilemma
Mark Sanna, DC, president and CEO of Breakthrough Coaching, notes that individual chiropractors can have a documentation error rate almost of 95 percent, which has now caused the OIG to subject physicians with error rates above 85 percent to added scrutiny. Starting in January 2019, these providers will be subject to pre-authorization reviews of their treatment plans before they can actively treat each patient. Chiropractors impacted by this change will need to be adequately prepared, but ultimately this also means that every chiropractor should be vigilant about proper documentation and avoiding errors. “At its most recent meeting, the Chiropractic Summit, an organization composed of the leadership of 38 national and state organizations, said that bringing down chiropractic’s error rate was designated the profession’s highest priority,” Sanna says. He is a member of the Chiropractic Summit and a board member of the Foundation for Chiropractic Progress.
Every chiropractor, according to Sanna, should know what their Medicare status is and continually check their Comparative Billing Report. This can help you stay ahead of the game and know how you’re doing with your documentation.
And Medicare is highly specific about the kind of chiropractic care that’s covered and how it should be documented. Acute care is covered; maintenance care is not. So anything billed to Medicare must have the Acute Treatment (AT) modifier, and it must also appropriately justify this with the right documentation. Anything else is considered to be maintenance care and will be rejected.
Medical necessity requires that a specific and identifiable diagnosis can be made and that the injury or illness actually does cause a loss of function for the patient. Documenting that is essential to having your claim accepted and paid by Medicare and other payers.
“Many chiropractors remain confused about the documentation process,” Sanna adds. “The crux of the chiropractic documentation dilemma lies within the fact that Medicare has never clearly defined the point of transition of patient care from acute to maintenance care.”
That, he says, is where the errors start. It only adds to the confusion chiropractors have when they go to document and bill for the care they already provided to patients.
Documentation—along with proper coding and billing—is critical in the quest of achieving compliance, says Diane Barton, DC, of Medical Compliance Specialists. She points to Medicare’s Comprehensive Error Rate Testing (CERT) program, which takes a statistically valid, random sample of claims from providers to assess whether they were reimbursed properly under Medicare rules.
“Based on errors found during CERT review audits, chiropractors continually demonstrate major issues with improper or lacking documentation, medically unnecessary services, improper coding and billing, and lacking proper signatures. These results are nothing new,” Barton says.
Practicing due diligence is one important way for chiropractors to stay ahead. Medicare Administrative Contractors (MACs) are payment processors who also audit for compliance in the claims they process, meaning that payments are being closely scrutinized for errors. CERT contractors and MACs collaborate to strive for low error rates. Chiropractic claims are being actively audited and so it’s essential for practices to document thoroughly—even if their coding and billing is done perfectly from the start.
“Proper and thorough documentation is there to demonstrate medical necessity of care, it documents the doctor’s treatment and care provided to the patient for claim reimbursements and it sets the line of defense if ever audited, investigated or sued,” Barton adds.
Without this documentation, it is arguable that there’s little that can be done later to defend the chiropractor from a lawsuit. It’s a position all too many DCs find themselves in, where it’s simply too late to go back and fix documentation after the fact.
Creating a compliance program
A chiropractic compliance program can help you stay on track and demonstrate that you’re a chiropractor who’s interested in coding, billing, and documenting correctly. Unfortunately, as mentioned, the compliance environment is constantly changing and can be difficult to keep up with. It takes a consistent and prepared approach to recognize and adapt to these changes.
Barton says every compliance program should have specific coverage to keep your clinic protected. “The requirements for a Medicare, OIG, and HIPAA compliance program are quite different, but these seven elements are the foundation to build practice-specific programs upon.”
These facets of a compliance program are absolutely essential, according to Barton:
- Written policies and procedures
- A designated compliance officer to oversee your practice’s compliance
- Open lines of communication with your compliance officer
- Training and education provided to your team
- Ongoing self-audits for compliance
- Guidelines that enforce standards for maintaining compliance
- Appropriate responses to offences
If you ignore the compliance needs of your practice, you’re taking an unnecessary risk, Barton adds. “Areas of danger when dealing with compliance matters are the lack of correct knowledge of the requirements of compliance programs, sticking your head in the sand pretending your practice is compliant when it’s not, no or improper documentation, and taking the wrong advice.”
Munsterman agrees that understanding compliance is a vital first step. All too often, he notes, chiropractors fail to integrate what they know about compliance issues into their daily practice.
Beyond understanding and acknowledging the importance of compliance, practices also need to take proactive steps by reworking their operations to make compliance easier. Without that specific information documented, you could have a more difficult case explaining the rationale behind your treatment choices. This is your opportunity to explain and establish the details supporting your work.
“Just as important is acting upon these requirements, building the procedures you need into your daily workflows, and constructing encounter-specific documentation in your EHR that addresses mechanism of injury, diagnosis, treatment plan, treatment effectiveness, etc.,” Munsterman says. “Know what is required in an initial visit and subsequent visits for an episode of care. Focus on your patient’s functional ability, adopt patient-specific goals, and record the specific activities of daily living interfered with by pain and that are being improved with care.”
As Sanna notes, it’s also vital to know how your documentation compares to that of your peers. If you’re not consistently documenting at a level that’s considered to be an appropriate norm, that may be a red flag to auditors. Educating yourself proactively about documentation can help you know where you stand in relation to other doctors.
Once you put your own compliance program in place, don’t assume you’re completely and eternally protected. Make reasonable efforts to verify your program’s validity and keep it updated regularly. Because regulations can change, it’s important to continually improve that program and make sure it meets current standards. For a busy chiropractor, this can be a lot of added responsibility and effort.
If needed, you can designate a team member or colleague as your compliance officer to share the burden. Doing this doesn’t mean you’re completely off the hook, however. Check in regularly with your compliance officer to ensure the entire practice is meeting appropriate standards.
Making a difference
As a profession, chiropractic may very well be at a crucial point where individual doctors have a chance to positively change health care. Chiropractic care can be done efficiently and can make a substantial difference for patient health, but it has to be seen making an impact.
Too many regulators believe chiropractic is a haven for fraudsters—perhaps because chiropractors often have few opportunities to legitimately bill for their services and are looking for ways to boost revenue and find more patients. This creates opportunities for vendors to market equipment, and convince doctors to use codes incorrectly.
“Please understand that there is nothing wrong with equipment, but many times we find chiropractors are led to believe they can bill for equipment use, when in reality they are being advised to use incorrect or improper codes,” Barton observes.
She adds that she’s seen this when talking with chiropractors at conventions and conferences. Advocating for correct billing isn’t always high on the list of priorities for some vendors.
Having a compliance program can help protect your practice and also turn the tide against the bad reputation chiropractic may have with some payers and regulators. It’s worth it to be proactive, especially in an age of compliance challenges.
Kaitlin Morrison is a freelance writer in Washington, and she specializes in healthcare and technology issues. A frequent contributor to this magazine, she can be contacted at firstname.lastname@example.org, or through kaitlinmorrison.com.