Even if your systems are slightly outdated, here are five ways to improve policies, coding and record-keeping — and collection rates
If your practice is seeing more patients but collecting less money, outdated record-keeping, coding and collection systems could be taking a bite out of your income. Adding services and products over the years to an antiquated system can strain billing and documentation efforts.
Here are five ways to improve coding, compliance and reimbursement:
Stay abreast of coding changes
Most insurance carriers cover evaluation and management (E/M) codes (e.g., 99202, 99203, 99212, 99213). Medicare, unfortunately, 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. Here are radiology CPT codes added two years ago that relate to chiropractic:
72081: radiological examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine (e.g., scoliosis evaluation), one view.
72082: same as above with 2-3 views; 72083: same as above with 4-5 views; 72084: same as above with a minimum of six views.
73501: radiological examination, hip, unilateral, with pelvis, one view.
73502: same as above with 2-3 views; 73503: same as above with minimum of four views.
73521: radiological examination, hips, bilateral, with pelvis, two views.
73522: same as above with 3-4 views; 73523: same as above with minimum five views.
73551: radiological examination, femur, 1 view.
73552: same as above, minimum two views.
Have your policies in place
Solid financial policies in place for insurance, personal injury and cash patients will save you headaches down the line. For insurance with reimbursement, call to verify coverage prior to submitting bills. Some insurance plans (in and out of network) have high deductibles, so even if chiropractic is covered, it may take 20-30 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, offer an affordable, quality cash plan, despite the fact that most patients who enter your office will have some sort of insurance that covers chiropractic.
If you’re a cash practice and non-par with all insurance plans, including Medicare, what do you give patients who want to get reimbursed by their insurance company? 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 the services or products are provided. Give patients ample opportunity to ask questions about their financial obligation, other treatment options and right to refuse care. Use standard CPT codes such as 99203, 98940, 97012, 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.
Appropriate diagnosis codes
If clinically applicable and justified in your documentation, use longer-term diagnosis codes such as disc herniation, sciatica, cervical radiculopathy, ligament sprain, etc., as your primary codes followed by pain, stiffness, spasm. I also recommend the M99.01-M99.07 subluxation codes and using complicating factor diagnosis codes to paint the most compliant patient clinical picture. Examples include chronic fatigue syndrome (R53.82), diabetic neuropathy (E08.40), pins and needles (R20.2), anxiety or depression (F41.8), and dizziness (R42).
Denials and fighting back
Make sure you are clear on what constitutes “medical necessity.” According to the Centers for Medicare & Medicaid Services, a medical necessity is a service, treatment, procedure, equipment or supply provided by a physician or other health care provider that is required to identify or treat a patient’s illness or injury. It 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 health care provider; and
d. the most appropriate service, treatment, procedure, equipment or supply which 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 maximal medical improvement, use appropriate “fight-back” or appeal letters. You should respond and appeal improper denials, especially on medical necessity. Examples of good appeal letter phrasing 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 9/10 to 5/10 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 exacerbations of joint pain and discomfort. Part of the care provided in this office resulted in the patient reporting he/she now takes less medication.
Use scores and grading scales to prove care was beneficial. Use orthopedic or neurological tests, pain questionnaires and outcome assessment tools. Include radiology results, MRI findings and any other diagnostic test results in the patient records to connect findings to the patient’s symptoms, or to the inability to perform certain normal daily activities. Example: “At the present time, due to the patient’s radiating pain, numbness and stiffness in his right leg, stemming from a herniated disc in his low back, he cannot play on the floor with his children, and cannot put on his socks and shoes without assistance.”
For Medicare you are allowed, and should be able, to collect normal fees for exams, x-rays and therapies. Make sure you are enrolled in Medicare and have an active Medicare provider number — otherwise, stop seeing Medicare patients. You are required to bill Medicare for spinal manipulation. If you are not billing Medicare for spinal manipulation because you think you do not have to, then stop what you’re doing and contact your state association as soon as possible.
Proper use of Advance Beneficiary Notice of Noncoverage (ABN) is also very important. If you’re not enrolled in Medicare, you are not allowed to use the Medicare ABN form. You also do not have to accept assignment on secondary or supplemental plans (unless under contract).
Regarding maintenance therapy, chiropractic spinal manipulation 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 on every patient, and make sure functional improvement is evident in chart notes. Also thoroughly document levels of subluxation adjustment, and perform regular re-exams to establish medical necessity and conversion to wellness or maintenance care. Have a HIPAA Notice of Privacy Practices form filled out on every patient. For minors, have a consent to treat minor form on file.
To round out your documentation and ensure compliance, make sure you document specific levels of subluxations treated (with legible notes), progress toward goals, time spent in therapy and for each exercise, provide planned re-evaluations, obtain a valid signature that services were performed, and supply worksheets indicating the specific exercises done.
No matter the state of your current record-keeping, coding and collection systems, these tips will add to the quality of your documentation, and subsequently to your bottom line.
Marty Kotlar, DC, CPCO, CBCS, is the president of Target Coding. Over the last 12 years he has helped hundreds of chiropractors, acupuncturists, physical therapists and massage therapists with compliance as it relates to billing, coding, documentation, Medicare and HIPAA. Kotlar is certified in compliance, a certified coding specialist, a contributing author to coding and compliance journals, and a guest speaker at state association conventions. He can be reached at 800-270-7044, targetcoding.com or firstname.lastname@example.org.