Daniel: Welcome to “The Future Adjustment,” Chiropractic Economics podcast series on what’s new and notable in the world of chiropractic. I’m Daniel Sosnoski, the editor-in-chief of Chiropractic Economics, and our guest today is Ted Arkfeld, DC. He’s a certified professional coder and the director of risk management for Best Practices Academy, but he hardly needs an introduction. Dr. Arkfeld is one of the nation’s leading authorities in chiropractic coding and documentation. He’s authored two textbooks and is a regular presenter at conventions. If you know anyone prominent in the world of coding education, Dr. Arkfeld is probably the one who trained them. And he’s here today to talk to us about the current state of compliance in the chiropractic field. Good afternoon, Dr. Arkfeld.
Ted: Hey, Daniel. Thank you for having me on the podcast today.
Daniel: Okay. Well, it’s our pleasure. Well, you know, one of the things that always comes up when you talk about compliance in coding is the office of the Inspector General who’s had it out for DCs for quite some time now. Can you give us any information on the latest word from the OIG’s office on civil rights and inspectors and auditors?
Ted: Well, the OIG, as you mentioned, has had us on their work plan. And it’s not something we want to be on as a profession. But they have increased their auditors and their investigators, especially the Office of Civil Rights, which that is truly the HIPAA police in today’s health care.
Daniel: In some reading about the current state of the federal government, I’d heard that various offices of Inspector General exist in most federal agencies, as a sort of an internal watchdog and that a lot of them have been defunded and destaffed considerably, 25% cuts and so forth. Is that the same for the one that controls CMS?
Ted: No, not to my knowledge. As a matter of fact, they have found it so profitable with the OIG to watch health care, and their whole task is to eliminate fraud and waste and abuse when it comes to health care. And so one of the stats that I had read was that for every $1 that they pay out in investigation, they receive or recoup $7 back. So it is still a very profitable situation for them to look at us, and I say us as a chiropractic profession, because, unfortunately, we still are the number one health care providers that have coding and documentation error rates. And even though that is getting better, we have dropped that, we still are number one, unfortunately.
Daniel: Right, and to kind of put this in context, the OIG released a statement earlier this year. An auditor’s report was the technical name of that document. And they said that they estimated that they’d paid out something on the order of $900 million incorrectly to doctors of chiropractic. And that was through misuse of the AT modifier. Do remember that paper?
Ted: I do, and it’s nothing new. The AT modifier indicates that when a Medicare beneficiary, Part B patient, or your traditional Medicare, comes into your office that they are exhibiting signs and symptoms of a neuromuscular skeletal condition and that it’s up to us to substantiate our care in that that’s active treatment. Now, where we as a profession get into trouble is that those patients may continue on and care past what the various Medicare carriers believe is reasonable and necessary or falling under the definition of the AT modifier. In other words, we’re still doing too many maintenance and wellness visits. And that’s where most of our post-payment audits are arising from. And that’s where most of the negative post payment audits…and I call them negative because that’s when the doctors have to actually repay money back to the various carriers.
You know, and unfortunately I still see misuse of the AT modifier and the GA modifier, the GA modifier signals that an ABN is on file. And just a quick coding tip, please, doctors, do not put AT and GA modifier on the same claim form. When you do that, you’re signaling that you think the patients is in active care, but, oh, you’ve got an ABN on file. It’s almost like hedging your bets. Well, each of the carrier’s computer system have edits built into it, and those edits will just trigger a red flag. Some of the worst post-payment audits I have been involved with with doctors have been because of AT and GA modifier being on the same claim form.
Daniel: Right, and “Chiropractic Economics,” we report on the dangers of upcoding and downcoding regularly. It’s often the case that a doctor will code in some way hoping that they’ll avoid detection, but now the computer algorithms that the carriers are using are pretty savvy at showing behavior that is abnormal. I know that downcoding and upcoding has been problems with doctors trying to stay under the radar of the various providers’ computer systems. What often happens is they wind up actually raising their visibility by coding in ways that are abnormal and flag themselves. Do I understand it correctly that the AT modifier is to demonstrate medical necessity?
Ted: Well, it’s to demonstrate that the patient is in active care which meets the medical necessity requirements for Medicare. And obviously, the diagnosis goes a long way when your treatment programs are expanded out, you know, maybe past 12 visits. And your documentation must be spot on and support the care that you’re providing for the patient. So there’s a lot of fluid elements going into this thing that we call medical necessity, which the AT is one part of that equation.
Daniel: Right, so, when the patient presents for care, and they’re having an acute episode, it’s appropriate, if possible, to code that with AT. But if the patient at some point transitions to maintenance or wellness care, then you have to stop using the AT modifier. Is this kind of the place where the problems tend to arise?
Ted: It is, and what happens is that the doctors will continue to treat the patients even though they’re in wellness or maintenance care. And they’ll continue to use the AT modifier, and that’s not what Medicare will pay for. And this stems from a lot of different factors. One of them, you know, and it’s a big thing, I think, that plagues the profession is the doctors are trying not to make the patients financially responsible for some of the care that they receive. And that’s the reason I always recommend that doctors need to stay out of the financial relationships with the patients. Give the patients what they need, and then delegate it to a support staff to cover all the financial aspects. And then do a really good job of patient education. Outline what medical necessity is and what Medicare will pay for and what they won’t pay for.
Daniel: That sounds like good advice. And with respect to that OIG report that talked about those overpayments stemming largely from this issue, I was reading that. And I was surprised to discover that what they had done was, essentially, to audit the records of two practices, something on the order of 100 charts. And then they extrapolated from the numbers that were miscoded here. They extrapolated that was probably the size of the overpayment made to the entire profession. That seems somewhat unfair to me. Did it strike you that way as well?
Ted: And this has been going on, the unfair extrapolations have been going on with post-payment audits for years. And so what they will often do is they’ll take a small sample of patient files. And they’ll look at that, and if there’s an error rate, they’ll now go back and extrapolate and say, “Well, we found a 25% error rate on this small sampling. So we believe that over this last two year period, or whatever years that they wanna look at, we believe that there was a 25% error rate on that.” And that’s how these overpayment demands just ballooned into the thousands of dollars. And it’s absolutely not fair and that’s the reason you have to get a health care attorney involved immediately in order to battle on your side.
Daniel: That’s good advice. I definitely reported on that as well. And I understand there’s these people called the Medicare hired guns, the recovery audit collectors or RAC auditors. Are they still out there? Are they still basically collecting commissions on overpayments that they find in practices?
Ted: Yes, they are. It was such a successful trial period for the RACs that they renewed their contracts, and I believe they run through 2018. And you hit it right on the nail. They are hired guns, okay, so their sole means of income is to come in and find overpayments or treatments that are not medically necessary, and then they get a percentage of what they recoup.
Daniel: That sounds pretty frightening. If a RAC auditor shows up on your doorstep, how would you advise the average DC to respond to that?
Ted: Well, first of all, I would say, “Listen, I’ll be happy to meet with you, but let’s arrange a time and a meeting.” And then I would have that DC, you know, get in touch with a health care attorney immediately just to get the ball rolling. Make arrangements. Don’t let them interfere, interrupt your normal daily operations. They can’t just come in. That’s a whole other topic right there. Those are ZPIC auditors, and those guys can come in any time because they are suspecting fraud. But with the RAC auditors, you know, if they come in, then you need to set up a time and a place, find out exactly what they need, how many patients they’re looking for, and then make those arrangements to get those files. But get everything going on your defense right away. And then the other thing too, I think a lot of doctors forget this, is that the majority of them, I think their documentation probably is pretty good. There’s been such excellent education and training over the last five years in Medicare documentation. I think a lot of the doctors, they run scared, and they really don’t have to, because I think that they probably do have pretty good documentation. So get your ducks in a row, get on board with the health care attorney, and then find out what they want and then proceed from there.
Daniel: You know, one piece of advice that I’ve seen our experts in the magazine make repeatedly is that when an auditor is showing up on your doorstep, that’s probably the wrong time to discover you’ve been making some systemic mistakes in your office procedures. And a good way to prepare against that is either to conduct a self-audit or to hire an auditing firm to come in and give you a test audit. Is that something that you would recommend? And if so, what frequency would be wise to do that?
Ted: Absolutely, I recommend it. You know, right now compliance programs are voluntary, and a compliance program is really a wellness check for your practice. And so, doctors are busy nowadays. You know, they have to wear many hats, and they’re not major medical groups where there’s a whole compliance department, so they have to turn to outside help. But I would recommend every chiropractic office in the nation needs to adopt a compliance program. And not just for defensive purposes in case the auditors come in, but to make sure that you’re plugging any revenue leaks, to make sure that there are no mistakes occurring. It’s a way to self-evaluate your practice to see how are you doing documentation-wise? How are you doing in coding-wise? Are you making sure that your diagnosis are the highest level of specificity that it can be and that you’re recouping, in a compliant, ethical fashion, insurance reimbursements to the highest level? And then the other biggest thing is your cash plans. Do you have a compliant cash plan for your patients? So it’s an ounce prevention. And I always try to tell doctors, “We recommend wellness or maintenance care to our patients. Why don’t you adopt the same thing for your own practice?” And that’s really what a compliance program is.
Daniel: Oh, really good advice. And one phrase I’ve heard a lot is that a compliance program is a living, breathing collection of documentation for your practice, and it’s not just a binder that’s sitting on a shelf collecting dust.
Ted: That’s correct, and, actually, a compliance program is tailored to the individual office. It’s not the same for everybody. You know, so, the goal of a compliance program is to identify any risk areas, address those risk areas with education and training, and then monitor throughout…and really, when we talk about monitoring, we’re talking about quarterly reviews of the files, and of the billing and coding and of your ABNs. And do a review, and just make sure that everything’s compliant, everything’s good.
Daniel: Gotcha. Well, you mentioned that in your opinion DCs are making progress in this area. The rates of compliance should be improving from your view of things, and that’s good to hear. I was wondering, does having a certified electronic health care record software system in your office help you with this subject?
Ted: It does, and, actually, a certified EHR is a must. You know, you just cannot practice in today’s health care without a certified EHR. The days of the travel cards are over with. The days of the illegible handwriting on forms are over with. The documentation requirements, they’ve been there for years, but what’s changed is now Medicare and other third party carriers are really holding us to the documentation requirements when they ask for our files. And then the other thing too, we need to have better communication amongst all providers. We need to have continuity of care with the primary care physicians, with any specialist. And your clinic right now is being judged on your documentation. That’s how you communicate. It’s a direct reflection of you as a provider, and then, really, the whole purpose of documentation in the recent EHRs are so important is it tells the patient’s story. And you just have to do that. That’s the best defense against denials and post-payment audits.
Daniel: Right. Telling a consistent story that a reviewer can easily understand is absolutely vital. And, you know, this is anecdotal, but this year various issues have resulted in me having to visit a hospital on several occasions. I’ve had to visit my dentist for a number of procedures, and I had to go to my eye doctor and get my annual check up and a new prescription. And in all three settings, optometrist, dentist, and physician practices, I saw effectively no paper records. Everything was being handled electronically, and as I was moving throughout these facilities, I could see that my chart, my records was moving from screen to screen within these practices. And this is what health care looks like today. This is what patients are expecting to see. And so, to that extent, if you’re still using travel cards and manila folders and things. It really is gonna give you a very old fashioned look.
Ted: It is, and I would even take that one step further. Unfortunately, I had to visit an ER last December, and what I found really interesting, and the ER physician came in to talk to me, and he had a scribe with him. He came in, and he was face to face, one on one and was listening to everything I said, and his scribe was in the back plugging everything into the computer. And so, I was so amazed by that, and I’ve been fortunate to visit other care practice clinics that have back office CA’s that come in with them to the patient encounter that I hired a CA 90 days ago. And a matter of fact, today is the end of her 90-day probationary period. And I hired her to be in the room with me, to take care of the EHR. So I would verbalize everything, and she’s typing down the subjective comments of the patients. And then we go onto the spinal exam, and I’m telling her, you know, areas of tenderness and asymmetry or fixation, and it acts as a report of findings, many recorded findings for the patients.
Now, here’s what the side benefit of this…and I didn’t expect this to happen, but it’s been just a remarkable event. We have doubled our practice in 90 days, because it took away all of that internal dialogue about documentation. And I often get this asked at seminars, “Oh, you must really like to document.” No, I’m like everybody else. I didn’t go to chiropractic school to learn how to document. I went to treat people. This takes that away, and I often hear about doctors that say, “Well, I was gonna implement an EHR, but I don’t know anything about computers.” I mean, that’s fine. Get a back office CA and train them, you know, so that your EHR is working for you. I mean, geez Daniel, we could do a whole seminar just on EHRs. The EHR should guide the doctor not only in his evaluation of management coding. It should guide them in their treatment program. It should be providing evidence-based outcomes, and it should be a tool that they use to increase revenue in the office. And having a back office scribe is one of those ways to do it.
Daniel: Well, that’s a really great tip. I know that some doctors will wait until the end of the day before writing out their SOAP notes, cleaning out their documentation. Some will wait until the end of the week to catch up on paperwork and have to spend a half a day getting caught up or transcribing notes from a tape recorder. It sounds to me like having a scribe basically complete all the paperwork pretty much on the spot in real time would allow you to achieve much greater efficiencies. And it’s logical that you would report that.
Ted: And you hit the perfect, you know, quote, the efficiency. Your office is more efficient. I mean, I live in northern Michigan, and we have to take advantage of this wonderful weather we’re having right now. I don’t wanna be coming in Friday or Saturday morning to finish up notes. You know, so when I’m done for the day, the notes are done for the day. And I can go home and spend quality time doing whatever I wanna do and leave the office at the office.
Daniel: Well, that sounds like a strategy that could definitely pay for itself in short order. Well, that pretty much takes us over the ground I wanted to cover with you today. And I really wanna thank you for spending this time with us, Dr. Arkfeld. It’s been extremely informative, and you’ve given us a carefully coded look at the future adjustment. I’m Daniel Sosnoski, and we’ll see you all next time.