Q: My collections have been flat for the last two years, even though I’m seeing more patients. Can you share some tips to help me improve collections, especially from regular insurance, Medicare, personal injury carriers, and cash patients?
A: Yes, I can. To improve reimbursement, I recommend you consider the following critical areas.
Most insurance carriers cover evaluation and management (E/M) codes (e.g., 99202, 99203, 99212, and 99213). Unfortunately, Medicare does not cover E/M codes when performed by a chiropractor.
Covered chiropractic manipulation treatment codes include 98940, 98941, 98942, and 98943. Modalities such as mechanical traction (97012), unattended electrical muscle stimulation (97014/G0283), ultrasound (97035), and therapeutic procedures such as therapeutic exercises (97110), manual therapy (97140), and therapeutic activities (97530) are often covered by many insurance companies and personal injury carriers.
Many insurance companies also cover X-rays when performed by chiropractors. There are new radiology Current Procedural Terminology (CPT) codes effective January 1, 2016, that relate to chiropractic. These include the following:
- 72081: Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical, and sacral spine if performed (e.g., scoliosis evaluation); 1 view.
- 72082: Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical, and sacral spine if performed (e.g., scoliosis evaluation); 2 or 3 views.
- 72083: Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical, and sacral spine if performed (e.g., scoliosis evaluation); 4 or 5 views.
- 72084: Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical, and sacral spine if performed (e.g., scoliosis evaluation); minimum of 6 views.
- 73501: Radiologic examination, hip, unilateral, with pelvis when performed; 1 view.
- 73502: Radiologic examination, hip, unilateral, with pelvis when performed; 2–3
- 73503: Radiologic examination, hip, unilateral, with pelvis when performed; minimum of 4
- 73521: Radiologic examination, hips, bilateral, with pelvis when performed; 2
- 73522: Radiologic examination, hips, bilateral, with pelvis when performed: 3–4
- 73523: Radiologic examination, hips, bilateral, with pelvis when performed; minimum 5
- 73551: Radiologic examination, femur; 1
- 73552: Radiologic examination, femur; minimum 2
Have a clear financial policy in place for insurance, personal injury, and cash patients.* For insurance reimbursement, call to verify coverage prior to submitting bills. Prepaid plans are wonderful as long as it’s within your state’s scope of practice. Some states allow prepays; however, limitations might exist.
For example: Florida allows prepaid plans; however, the amount is limited to $1,500. Some insurance plans (in- and out-of-network) have high deductibles, so even if chiropractic is covered it may take 20 to 30 visits to get past the deductible. For patients with high deductibles, or if you’re out- of-network with a plan that only covers in-network providers, you can offer an affordable, high-quality cash plan.
Whether you like it or not, most patients who enter your office have some sort of insurance that covers chiropractic.
Let’s say you’re a cash-only practice and non-par with all insurance plans, including Medicare.
Question: What do you give patients who want to be reimbursed by their insurance company?
Answer: Have patients sign a form acknowledging that certain portions of their care may not be covered by insurance. Patients must understand and agree to pay for all services and products at the time they are provided. Give patients ample opportunity to ask questions about their financial obligation, other treatment options, and their right to refuse care.
Use standard CPT codes such as 99203, 98940, 97012, and 97110 for medically necessary services and insurance billing. CPT codes are not needed if a cash patient needs a simple walk-out receipt.
For wellness or maintenance examinations, consider using ICD-10 code Z00.00 (encounter for general adult examination without abnormal findings). For wellness or maintenance adjustments, consider using HCPCS code S8990 (manipulative therapy performed for maintenance rather than restoration). Do not use S8990 for Medicare claims.
Use appropriate diagnosis codes If clinically applicable and justified in your documentation, use longer-term diagnosis codes such as disc herniation, sciatica, cervical radiculopathy, or ligament sprain as your primary codes followed by pain, stiffness, or spasm. It is also recommended to use the M99.01 through M99.07 subluxation codes and the complicating factor diagnosis codes to paint the most compliant clinical picture. Examples include chronic fatigue syndrome (R53.82), diabetic neuropathy (E08.40), pins and needles (R20.2), overweight (E66.3), anxiety/ depression (F41.8), and dizziness (R42).
Make sure you know what constitutes “medical necessity.” According to the Centers for Medicare and Medicaid Services (CMS), medical necessity is a service, treatment, procedure, equipment, or supply provided by a physician or other healthcare provider who is required to identify or treat a patient’s illness or injury and which is: a) consistent with the symptom(s) or diagnosis and treatment of the patient’s illness or injury; b) appropriate under the standards of acceptable practice to treat that illness or injury; c) not solely for the convenience of the participant, physician, or other healthcare provider; and d) the most appropriate service, treatment, procedure, equipment, or supply that can be safely provided to the patient and accomplishes the desired end result in the most economical manner.
If you’re getting denials based on the patient reaching maximum medical improvement, use good “fight-back” letters. Always respond to and appeal improper denials, especially on medical necessity. Examples of what good appeal letters include the following:
- The patient went from being in pain 80 percent of the day to only 30 percent within the first month of care.
- Pain levels went from 9 (on a scale of 1 to 10) down to 5 over a 30-day period.
- Bending and lifting abilities improved approximately 30 percent over the past six weeks of care.
- Lumbar flexion range of motion went from 40-90 with pain to 65-90 without pain.
- The patient needed pain medication due to the exacerbation of joint pain and discomfort. Part of the care provided was to try and help the patient reduce the amount of medication taken. The patient reported that due to the care provided, it is now possible to take less medication.
- Use scores and grading scales to prove care was beneficial.
- Use orthopedic and neurological tests, pain questionnaires, and outcome- assessment tools.
- Include radiology results, MRI findings, and any other diagnostic test results to patient records and try to connect those findings to the patient’s signs and symptoms or to the inability to perform certain normal daily activities of living.
For example: At the present time, due to the patient’s radiating pain, numbness, and stiffness in his right leg, which stems from a herniated disc in his lower back, he cannot play on the floor with his children and cannot put on his socks or shoes without assistance.
Use the following for Medicare:
- You do not have to accept assignment on secondary or supplemental plans.
- Charge patients your normal fees for exams, therapies, modalities, and extremity adjustments.
- Make sure you have an active Medicare Provider Transaction Access Number (PTAN).
- The proper use of the Advance Beneficiary Notice of Noncoverage (ABN) Form CMS-R-131 is important.
Chiropractic spinal manipulation for maintenance therapy is not payable by Medicare. According to Medicare, maintenance therapy includes services that seek to prevent disease, promote health, and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition.
When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive, the treatment is then considered maintenance therapy.
Create a chiropractic treatment plan for every patient. Make sure functional improvement is evident in chart notes. Document levels of subluxation adjusted. Do regular re-exams to establish medical necessity and conversion to wellness or maintenance care. Have a “notice of privacy practices” form for every patient. For minors, have a consent-to-treat-minor form on file.
Address the following to ensure documentation compliance:
- Document specific levels of subluxations treated.
- Make sure your notes are legible.
- Document progress towards goals.
- Provide planned re-evaluations.
- Have a valid signature that services were performed.
- Document time spent in therapy and for each exercise.
- Supply worksheets indicating the specific exercises done.
As you can see from the above guide- l lines, there’s more than one aspect to increasing reimbursements. You’ll need more than one trick; instead, employ a multifaceted strategy as explained here and reap the rewards.
Marty Kotlar, DC, CPCO,CBCS, is president of Target Coding. Kotlar is certified in CPT coding and healthcare compliance and has been helping chiropractors nationwide with billing, compliance, coding, and documentation for over 10 years. He can be reached at 800-270-7044, firstname.lastname@example.org, or through targetcoding.com.
*Note: If you would like to receive a copy of my financial policy, send an email to email@example.com.