When faced with decisions on major life purchases – house, car, building purchase, even expensive remodels or repairs – most of us responsible adult chiropractors tend to do some comparison shopping. We may go out and get three or four quotes, make a list of the pros and cons and then pick the best choice, right?

Wrong.  While most consumers think they are making buying decisions based on logic, marketing research shows that we actually buy based on emotion.  While this is bad news on the spending front, it can be even worse news when the same is applied to our earning power.

Unfortunately, the vast majority of chiropractors I observe at work in their clinic are doing just that with their exam billing and coding. In other words, they do not make their coding choices, which directly affects their billable services, based on logic, coding rules or any sort of methodical guidelines. In fact, most of the time, chiropractors choose their codes based on emotion. (If it’s any consolation, my former life as an Insurance Claims Analyst confirms that MD’s do this too)

In other words, some chiropractors “feel” that the depth of their probing, the length of their history and the thorough nature of their examination warrants a higher level code.  Others let the emotions of fear overcome them and they feel that they want to stay “under the radar” so they choose a low level code for their services. Still others shoot straight down the middle, feeling safe and a little bit savvy that they are not part of either extreme.

Where’s the Logic in Emotions?

So, regardless of their reasons, why are doctors coding level 2s exams instead of more level 3s? Part of the problem is not knowing what the difference is in terms of reimbursements. They don’t pay attention to their billing or their coding or their accounts receiveable and so they don’t realize the impact of their random and emotional coding.

Another reason is the tendency to forget the rules – if you ever learned them in the first place.  Unfortunately, I think the latter is more common.  Schools train chiropractors to perform examinations for clinical or med-legal purposes but they do not intertwine this with the applications to billing or coding.

Lately, I have been speaking to more chiropractors who are down coding out of audit fear. With the threat of a Medicare and other third party post-payment audits looming, coding in the middle or at the bottom doesn’t raise any flags, right? Perhaps but perhaps you are just robbing yourself of income you deserved.

What’s more is that your coding patterns (for exams and procedures alike) never really escape scrutiny or “the radar.”  Case in point, I was contacted recently by a DC who received an audit notice from Medicare stating that he was the #2 provider in his state for billing code 98940. Now, some might say that this guy under-bills his services because he may be performing more 98941 adjustments than he’s letting on.

Regardless of whether he is under-billing, over-billing or billing accurately, the facts are that someone has to be at the top of the bell curve and someone has to be at the bottom.  Rather than try to constantly base your decisions on hitting the “sweet spot” of the curve and landing square in the middle, perhaps it’s time to actually learn about what you are doing.

After all, there is really no safety in any position on the curve if it does not represent your services accurately and if you have not justified your procedures through proper documentation.  So while you may think that coding the lowest level exam or adjustment provides a measure of safe harbor, if your documentation stinks, even the lowest reimbursements may be considered overpayments!

Logical, Compliant Coding Critieria

So before you place yourself on autopilot and check off another 99202 or 99203 or 99204, consider what that really means. To properly document for new patient encounters, you must meet a set and determined level for three criteria:

• History.
• Exam.
• Medical decision making.

Many chiropractors fly through exam decisions and recommendations so quickly after years of practice they scarcely notice they’ve done the work, let alone document it.  They reason that auto accidents or work injuries need a bit more documentation, so they code higher.  Cash patients may take less time and effort, so they code lower level exams.

While this reasoning has nothing to do with the three critiera mentioned above, it can also vary widely with reality. When I go into practices, I often see documentation that supports a higher level, but they undercoded because they didn’t realize was what was needed for the higher code. Some offices are the opposite and are exposing themselves to audit risk by coding higher than they should.

Also, while playing it safe by staying in the middle seems like the easy road, consider this: You are very likely leaving income — your income — on the table and auditors can still come in and look for errors on individual claims. The best bet is to do it right and back it up with proper documentation. Otherwise you might end up paying a high price for inadequate payment and your roof could seriously fall in.

If you don’t feel you are in the wrong or if you want to accelerate the urgency towards making sure you are doing things right, do this simple math exercise to see how much money is at stake in your office.

Take the price difference between the level of exams above and below the one you typically code for new patients. Now, take  number of new patients you see per month and multiply it by those differences.  Then multiply it again to see how much income you stand to lose or gain with your exam coding.

For example:

Say you normally code a 99202 and charge $100.  Your 99201 is $75 and your 99203 is $150.  You see 20 new patients per month on average.

By undercoding (using a 99202 instead of 99203), you are losing out on $12,000 per year in services generated.

By up-coding (using a 99202, but only documenting to support a 99201), you potentially risk post-payment demands of $6000 per year in income you didn’t really deserve to be paid.

The Bottom Line.

Now that some of you have received your painful lesson, let me tell you that this is typically the tip of the iceberg in what your improper billing, coding and documentation is costing you in terms of lost revenues and audit exposure.  If you don’t like the thought of your income being tied to multiple emotional decisions you make on a daily basis and/or what these numbers say in your case, I suggest you take steps to correct this immediately.

Let logic, strategy, compliance and correct billing, coding and documentation be the guide for your revenues, not emotion. My FREE Practice Analysis is a good way to start.