Do you know everything you need to know about documentation and coding to enable your claims to be accepted the first time?
According to the Office of Inspector General (OIG), nearly $360 million—or approximately 82 percent—of the $440 million paid by Medicare in 2013 for chiropractic services was unallowable.
After this investigation, “We, as chiropractors, have been on the OIG workplan since then,” says Diane Barton, DC, who is a certified medical compliance specialist, a certified peer reviewer, and an insurance consultant. “They are not only targeting chiropractors. OIG is going after the top 10 percent of all Medicare healthcare providers.”
But the vast majority of chiropractors are honest, professional practitioners. So why are these issues occurring?
A need to understand
“It has little to nothing to do with filling out forms,” says Kathy Mills Chang, MCS-P, the founder and CEO of KMC University. “This is about the provider understanding the difference between the definition of active treatment and maintenance care. Once the provider understands that difference, they can properly ‘report’ on the form, if necessary or directed by the patient, that it was ‘active,’ using the AT modifier or ‘maintenance,’ indicating that an Advance Beneficiary Notice was signed, using the GA modifier.
“That is the only way that the carrier can know that the provider applied proper decision-making to determining whether active care—billable and reimbursable—or maintenance care—not reimbursable from Medicare but paid by the patient, was needed. The precursor is actually a knowledge of when it’s active and when it’s maintenance.
That is the problem in our profession now … not billing it incorrectly.” Chang says that unfortunately, many providers don’t understand when a treatment is active or maintenance as well as they could (or should). Sometimes they simply bill it all with the hope that it gets paid.
Educating yourself about the criteria is absolutely vital before you file your claims. “Perhaps the provider heard that some code pays well, but they don’t bother learning the details or rules around that particular diagnosis or service,” says Evan Gwilliam, DC, CPC, executive vice president of ChiroCode, Inc. “Rules change, but sometimes the doctors don’t. Getting educated and staying up-to-date is critical if you want to do business in healthcare today.”
“Of utmost importance and value is making sure your documentation of the patient care visit, whether initial or subsequent, is meeting Medicare policy standards,” says Scott Munsterman, DC, CEO of Best Practices Academy. “According to Dr. Steve Conway, our Medicare care expert and healthcare attorney, treatment plans are 99 percent of the issue and 99 percent of the solution to all Medicare documentation.”
Munsterman adds, “There is a proposed Local Coverage Determination currently in the comment period. It is important to note that Dr. Steven Conway and Dr. Michael Jacklitch, in their efforts with the ACA, have spent three years working one-on-one with all of the Medicare Administrative Contractors (MACs) to create a universal document outlining the interpretations of what documentation is required to establish medical necessity.1
“The key changes that have been proposed will hopefully improve our standing with the OIG. The new review will focus on episodes of care rather than specific dates of services. And doctors of chiropractic now must use measurable goals in their treatment plans to make the plans effective and viable under the scrutiny of reviewers,” Munsterman says.
Until things change, however, it’s important for chiropractors to under- stand what they need to document. “By and large, doctors of chiropractic struggle with understanding the rules behind the procedure codes that they submit as they render those relevant services to patients. Getting better at coding—including the appropriate use of modifiers—begins with the doctor taking the responsibility to become knowledgeable in this aspect of the business,” Munsterman says.
Understanding if the code is time-based and how many elements are necessary to qualify for the evaluation management codes are substantial in addressing the correct code for the procedure that you have performed.
Raising your game
Barton says that recent Comprehensive Error Rate Testing (CERT) found that the three most-common areas of failure are: insufficient documentation, lack of medical necessity, and coding errors. She continues that the Palmetto GBA-Railroad Medicare audit reviewed chiropractic services for the spring of 2017. Of the 13,679 claims reviewed, 5,500 services were denied, and 8,179 services were allowed. The overall charge denial rate was approximately 40 percent based on the dollar amount billed. Approximately 3,060 services were denied due to lack of provider response to the Additional Documentation Requests (ADR).
Approximately 2,020 services were denied due to insufficient documentation, including a lack of history, examination, and treatment plan. Approximately 110 services were denied due to lack of signatures. The remaining denied claims fell into general categories.
Gwilliam says that one of the most important actions that DCs can take to make sure they get paid—and keep their reimbursement—is to improve their documentation. Again, this comes down to educating yourself. “Some sources blame documentation for up to 92 percent of the problematic chiropractic claims. Payers know that if they go to the trouble to review documentation, they will likely find something that the DC did incorrectly,” Gwilliam says. “There are many ways to get help with documentation—from attending seminars or webinars that focus on the topic to hiring a consultant to conduct a proactive audit. Doing an audit voluntarily with a credentialed expert can identify deficiencies before the payer decides to poke around and ask for their money back.”
For proper documentation, you want to begin with a thorough examination of the patient. “Though Medicare does not reimburse for the examination—it is a patient’s responsibility—it lays the foundation for treatment, medical necessity,” Barton says. “It is the first line of defense in the event of a malpractice claim or an audit.”
The evaluation should be an ongoing process. With the recent changes to many Medicare Local Carrier Determination (LCD) requirements, functions, signs, and certain symptoms must be rechecked each visit.
Barton says that the book Netters’ Orthopaedic Clinical Examination: An Evidence-Based Approach—3rd Ed., by J. Cleland and S. Koppenhaver, provides reliable tests that can narrow a diagnosis.
“Thorough documentation creates the story of the patient. It also provides medical necessity,” Barton says. “History of present complaint includes mechanism of injury, date of onset, quality of pain, radicular patterns, exacerbating factors, alleviating factors, and co-morbidities and complicating factors. Family history includes grandparents, parents, siblings, and offspring. This includes cardiovascular factors, cancers, diabetes, neurological diseases such as Parkinson’s, Multiple Sclerosis, dementia, and Alzheimer’s. Social history includes use of alcohol and tobacco, sleep habits, health eating rank, exercise habits, water consumption, emotional stresses (caring for aging parents, job, illness, family), and physical stresses (occupation). Current medication as well as over-the-counter drugs and illicit drugs need to be included in the documentation.”
The chain of necessity
The assessment of patients is critical because, as Barton says, this is where chiropractors get paid to think. “Pulling together the range of motion, ortho, neuro, history and co-morbidities, projections of how the patient is expected to fair. The treatment plan is also crucial. This is short term—trial care of two weeks. And long term— four weeks—with goals derived from outcome assessment tests. All these points lead to ‘medical necessity,’ ” Barton says.
Gwilliam provides the following overview, which he refers to as the “chain of medical necessity”:
- History of onset (mechanism of trauma for acute complaints, reason for the visit for chronic illness).
- Complaint (the onset should tie to a complaint within the scope of the provider’s licensure). Treating problems that the patient does not want help with may not be payable.
- Objective findings (these should provide an explanation for the complaint. An exam with nothing abnormal does not support treatment).
- Diagnosis (the condition needs to be supported by the clinical criteria identified in the objective findings and correlate with the treatment).
- Plan (services, duration, and frequency of care, with patient-centered measurable and specific goals).
- Progress (measurable, preferably quantifiable changes to goals, such as outcomes assessments).
“If all of the links in this chain are present for every service, they are much easier to support when challenged by a third party,” Gwilliam says.
Chang is a documentation auditor, and she says the basics of auditing for medical necessity include these questions:
- Does the patient have a complaint in the area? If so, is that complaint causing a lack of function?
- If yes, did the examination corroborate that complaint and lack of function and are there physical findings that validate the complaint?
- Is there a diagnosis derived from what you learned in the history and the exam? For Medicare, did you find a subluxation in that area that is being caused by a secondary neuromuscular complaint?
- Based on what you found, what treatment is necessary to reach specific functional goals? Does the treatment plan include these goals, within a specified timeline, and list how you will evaluate the effective- ness of the treatment?
- Do the subsequent routine visits of the episode address the functional goals along the way, noting progress toward resolution or lack thereof?
- If the active treatment exceeds 30 days, has there been a re-evaluation conducted to document progress and establish the next leg of the treatment program?
- When the patient has reached the maximum improvement possible, has the patient been properly discharged from active treatment? Should they have been? If so, that would be the last medically necessary visit approved by a third-party payer.
In addition to keeping proper documentation and understanding codes, you must use them correctly as well. Munsterman says that one of the most common mistakes DCs make is becoming complacent and not coding based on the actual services provided during a visit, but rather on a system of what the DC would normally code in a visit or on a day.
“I have seen chiropractors who always code for 98941 because they are ‘full-spine adjusters,’ and their staff gets used to coding a 98941,” he says. “Then, on some visits, they only adjust one or two regions, but do not inform their staff, who continue to bill for 98941, which is up-coding for that specific visit.”
A similar issue exists with therapies. There is a “system” that bills out the same codes for each visit, but the patient may not receive all of the coded services on each episode of care.
By having a daily-visit billing card or some system that is not on autopilot and accurately reflects the services provided on each visit, the DC can avoid this error.
When a DC adjusts five regions for a Medicare patient, that doesn’t mean they can code a 98942, Munsterman says. “All of the adjusted segments have to be medically necessary according to Medicare requirements,” he states. “By doing a proper history to obtain all of the symptoms and correlation to specific vertebrae, the DC can avoid the coding of compensatory adjustments and prevent up-coding.”
Another mistake DCs make with codes happens with Medicare patients, Munsterman notes. They will code all visits as 98940 for Medicare patients. “This again is incorrect and could lead to down-coding, which could land the DC in trouble for potential inducement claims for Medicare and Medicaid,” he explains.
Tools of the trade
The use of specialized software and a claims clearinghouse can help.
Remember, Chang says, if you use electronic health record (EHR) soft- ware, it won’t do all the work for you. You will still need to personalize your notes on each patient. “I wrote some documentation macros with ChiroTouch, an EHR software, that assists with properly prompting the doctor to document properly,” Chang says. And Gwilliam recommends that doctors get a demo with at least two or three EHR systems before purchasing one.
On Barton’s part, she says that DCs need to learn to use their documentation software. “If you are too busy to do this, then hire a scribe to learn the program,” she says. “The outcome assessments, pain scales, examinations, updating subjective complaints, the doctor’s objective findings, doctor’s assessments, recording what was adjusted and with what techniques, and follow-up plans can be input by a scribe.” She adds that voice-transcription Dragon systems work well for some DCs and using tools provided by ChiroCode can be helpful.
“We developed an audit program that allows us to provide standardized criteria for each element and service related to chiropractic documentation and billing. The report scores each item and gives the provider a grade, along with suggestions for identified deficiencies. It is a relatively inexpensive service and it can be redone every six months, with the goal of earning a better grade each time. Since we implemented this standardized system, very few have earned an ‘A’ grade on the first attempt, and there are more ‘D’s’ and ‘F’s’ than we would like to admit,” Gwilliam says.
In terms of billing, Munsterman says, “Outsourcing your billing to a third party is becoming more popular and affordable for the chiropractic practice because it costs less than a staff person and delivers consistent service performance in claims payments.”
Gwilliam has one caution, though, “Using a third-party billing service can be a great option, but it may not be right for everyone. For a price, they can provide the billing expertise that a small provider may not have time to learn on his or her own. But the tradeoff is a loss of control, and some doctors have had problems with that.”
Michele Wojciechowski is a national award-winning writer based in Baltimore, Maryland.
1 Best Practices Academy. “The Project That Is Transforming Medicare.” Webinar. https:// bestpracticesacademy.com/free-webinar- the-project-that-is-transforming-medicare. Updated Sept. 2017. Accessed Sept. 2017.