Medicare carrier Noridian Administrative Services (which administers Part B claims in Alaska, Oregon, Washington, Arizona, Montana, North Dakota, South Dakota, Utah and Wyoming) recently updated and reprinted a notice on Chiropractic Software-Generated Documentation that I think can serve to educate us as a profession.
Incidentally, although your specific carrier may not be Noridian, you should take note that most Medicare carriers generate the exact same news releases, alerts and notices each week so I wouldn’t be surprised if you don’t receive a similar “reminder” from your carrier. Even if you don’t the information contained and summarized below can be crititical towards getting claims paid as well as avoiding denials and postpayment audits.
Apparently, the piece was generated because Noridian has seen an increase in the use of software-generated documentation for chiropractic services. In and of itself, there is certainly nothing wrong with using EMR or even any form of computerized notes. So what’s their beef? Read More
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? Read More
I’m on the road for the next couple weeks traveling for a number of on-site consultations with clients so this blog post will be a summary of random thoughts on the most common questions that repeatedly brought to my e-mail inbox. Read More
Last year, I posted an article on co-pays, coupons, and discounts – essentially what to do and what not to do.
This subject remains one of the most popular questions I still get asked.
As we recently have celebrated the freedom of the USA with Independence Day, I thought it fitting to re-visit the “freedoms” (or lack thereof) that we are challenged with inside our chiropractic practices.
Unfortunately, when freedoms are abused, trouble sets in. Keep your nose clean and re-visit the post
In business and in life, it is helpful to go back and review the basics, to take a look at where you’ve been and where you want to go.
Today’s blog post feature’s 3 links to our most popular columns of the past – in case you missed them – or in case you need “a refresher course.” (pardon the Fletch reference)
Don’t Panic and Don’t Ignore It! An audit letter is not an automatic presumption of guilt. Some audits are completely random and conducted routinely with no suspicion cast toward your billing activities, documentation ability or treatment parameters. So do not panic in the presence of an audit letter. Don’t assume that your documentation is substandard. Don’t automatically determine they will find your records insufficient and make plans to be subversive. On the other hand, do not ignore the audit letter. Instead, plan to take action.
Can I even be audited? You do have legal rights depending on the state in which you practice and your specific situation. For example, if you are an out of network provider, there is a possibility that the carrier cannot audit unless they suspect fraud. On the other hand a governmental entity like Medicare definitely can audit you, so move on to the next step. Perform your due diligence immediately and research this issue.
Determine exactly what the audit letter states. Are they requesting a chart audit where they want to look at your medical records? Do they want to perform a site visit? Once you’ve determined which type of audit they’re intending to conduct on your practice, you need to formulate response to that audit or to the request that the audit’s making in a timely manner. In some types of audits, no answer is the worst possible answer you could give. So you want to respond in a timely manner to the request for the audit. Also, provide what is requested: nothing more, nothing less. The auditors do not want to review a 42 page explanation of your chart notes; they should stand for themselves. Furthermore, any additional material you provide beyond what is requested can be used against you as well. One tip: do not respond to phone or fax audit requests. Get it in writing!
Do Not Alter Your Documentation. I get many emails and calls from chiropractors who have received an audit letter. The most common question is: “what do I need to do to prepare for this audit?” To be blunt: the time to prepare for your audit is not when an audit request letter is in your hands! Never take matters into your own hands and alter medical records to improve what appears to be incomplete or insufficient documentation. Poorly done records are still better than the best records that have been fraudulently contrived.
Determine IF You Can Meet Audit Requests. If the time frame that the carrier is requesting is not reasonable due to some sort of extenuating circumstances, contact the auditor for an extension. If it’s going to take you more time to produce the information, ask for an extension.
Is this something we need to appeal immediately? If your “audit” letter is actually a demand for repayment, your best option may be to start the appeals process. Do not automatically presume that the payor’s review is final or even correct. If appropriate, an appeal can save you thousands of dollars in unnecessary repayments and headaches.
Is this something for which you will experienced assistance? You may need to obtain the assistance of a certified professional coder or a certified professional medical auditor whose expertise is in chiropractic (such as myself) to help defend you. A healthcare attorney may also be wise, especiallyif there are several zeros in your demand or repayment letter. Again, before you hit the panic button or get out your checkbook, it may be critical to the success of your defense or appeal to get professional help. The reality is that your license, your lifestyle and your livelihood may all depend on it!
I hope that you found this article helpful. For a more detailed discussion on audits, I suggest you check out my program “How to Prepare Your Chiropractic Practice For Recovery Audits.” For specific questions regarding your own audit situation or letter, you may contact me per the guidelines below.
Due to the large volume of requests that I receive for audit advice, opinions and requests from chiropractors to “look this over and tell me what this means,” I can no longer respond to phone inquiries on this matter. If you have need for an opinion or objective discussion on audits or demand letters, the need for attorney/ legal representation or appeals, please contact me via a separate email for this purpose at Audits[at]StrategicDC.com.
Recently, a Medicare carrier (Palmetto GBA) released their 1st Quarter results of Medical Reviews they have been conducting. Even though Palmetto is only one of several carriers who administer claims on behalf of Medicare, their findings are relevant to chiropractors and, in my experience, reflective of trends across the chiropractic profession at large.
The goal of the medical review program is to reduce payment errors by identifying and addressing documentation and billing errors concerning coverage and coding. In their reviews, Palmetto GBA identified ten problem areas for the first quarter of 2010. These areas were as follows:
Split/shared visits
Signatures
Labels/Diagnostic Testing
Hospital & Nursing Facility Discharge Services
Chiropractic Services
Therapy Services
Individual Psychotherapy Services
Evaluation & Management Services
Legibility
10. Teaching Physician Services.
Please note this is not an all-inclusive list but does reflect the majority of documentation issues discovered during the review process. Of this list, however, three items have direct application to chiropractic reimbursements in the Medicare program.
So let’s discuss these three “Frequently committed errors”:
Signatures. Put simply, Medicare requires an “identifier” for services provided or ordered. That identifier is your signature – either in handwritten or electronic form. Signature stamps in your documentation are not acceptable per Medicare Signaure Requirements (See section 3.4.1.1 B) Quite frankly, this is so basic that it is ridiculous that it even makes the top ten. Apparently, despite its simplicity, most physicians seem to overlook it.
Chiropractic Services. As a relatively small profession, we should not even make the top ten hit list. We did, however, so now it is our responsibility to correct these problems asap as a profession. Palmetto found chiropractic documentation to be lacking in the area of Treatment Plans. More precisely, chiropractors were missing treatment plans with specific objective, measurable treatment goals. Follow thru with these specific objective treatment goals on subsequent visits was also often omitted. Difficult? Not very. Documented? Apparently, not very often. Can you fix this, doctor? Definitely!
Legibility. If this is not the biggest commercial for EMR, I don’t know what is! Again, there is no reason any physician should be getting dinged for this one. Alas, I have seen many of your notes and I sadly agree, that they are barely legible, sometimes only to the highly trained eye (yours and that of your longstanding staff) – and sometimes, even you cannot decipher your own notes. Put simply, if your notes cannot unquestionably be read by a third-party without eliciting a migraine or use of some special telescopic lens, it is high time to get on EMR. There are plenty of good systems out there. In fact, ANY system that produces legible documentation is better than marginal handwriting – and I have yet to see an EMR system that fails to product legible documentation!
In summary, we chiropractors need to get our act together pronto – not only for Medicare, but for all third party payers. The items above are not difficult to fix, but I realize that some of you are overwhelmed by how much work you have to do to bring your documentation, billing and coding up to acceptable standards. Others may be so consumed with building your business that you literally don’t have time to look up and see the arrow sailing directly at the target on your chest. And some of you are just plain tired of putting out the fires in all these areas due to a lack of solid systems that both maximize your reimbursements and minimize your audit risk.
The good news is: help is available. And while it is a physical impossibility for me to assist all of you with these needs let alone answer the truckload of emails I receive per month on chiropractic billing, coding and documentation questions from random chiropractors at large! But I am willing to offer a FREE, no obligation look under the hood of your practice for those of you willing to invest the time and effort into completing a Practice Analysis Questionnaire. Download it, complete it, fax it in today and take a concrete step towards improving your practice, your business, your piece of mind and your life.
To Your Success!
Tom Necela, DC, CPC, CPMA
P.S. Not sure what can be done with YOUR practice? Take a look at what my clients have to sayabout the transformations they have achieved in their practice!
Just in case you were actually focusing on your practice and not glued to the news, HIPAA television and the endless assault of compliance related emails that cross your desk, we had three significant deadlines in February that seem to have rattled a significant number of you.
Even though I may not know you personally, I am going to extend you the grace of assuming that you are not normally paranoid, panicky or otherwise possessive of a peculiar tendency to “snap” when confronted with the politics of change that besets our profession.
So, let me first gently remind you of the deadlines of which you may or may not be aware. And then, I’d like to put your mind at ease over a few items that repeatedly hit my email inbox and drip with panic-driven sweat and media-fueled fear.
The Deadlines
New requirements for “Business Associates” – Deadline: February 17, 2010 HIPAA rules were strengthened by extending the responsibility for protection of PHI to “Business Associates.” Under the new law, the “Business Associates” have the same responsibilities for any breach of private health care information as do the provider of the services. “Business Associates” would include Attorneys, Consultants, Accountants, Third-Party Billing Companies, Computer Vendors or maintenance companies, etc.For a more detailed description of this requirement, see my previous blog entry on “Mandatory HIPAA Updates.”
Disclosure Agreement Provision – Effective: February 18, 2010
Patients have the right to pay in full for out of pocket expenses for health care services and request that your practice not disclose his or her medical information to a health plan or other entity. Your practice must comply with this request. Make sure that all your employees are informed about this provision and modify notification or follow-up procedures where applicable. This is information that will have to be shared with all employees in the medical practice that is involved in health information and insurance processing. This one is not likely to happen too often, but regardless, you are still required to follow the rules should it occur. Essentially, if you have a patient that is under- or non-insured and pay for services in cash (or credit card, check), they have the right for their info to remain silent.
Information Breach Notification – Effective February 22, 2010
New provision requiring that HIPAA covered entities such as physicians notify patients (and Business Associates notify the partnering entity) of any breach of health care information. If a breach involves 500 people or less, the responsible party must notify each affected individual by written notice. This notice must contain the details of the breach, the information disclosed, and the steps being taken by the practice or entity to avoid any future breaches, as well as explaining the rights of the patient(s) in protecting their private healthcare information. If the breach involves more than 500 persons, the Act requires that the Department of Health and Human Services be notified as well as the local media outlets. Hopefully, this one will never happen, but you should be aware that if it does, there are required steps to take.
The Reality of the Situation
Of those three new HIPAA requirements, I do not see any as the reason to hit the panic button. Rather, get your Business Agreement in place and train the staff on the other two, should the need ever arise.
As for other recent news affecting our practice (and for which I received a lot of email), the President did signed into law a bill that delays Medicare Fee cuts until March 31, 2010. Hopefully, this delay will be prolonged at least until 2099 or until the government gets its Medicare act together, in which case the 2099 date may happen first. On this item, continue to make your voice known through your state and national associations and hope that we make enough collective noise to stop the feds from cutting our paychecks.
Again, no need for panic, but action may be helpful.
Some FAQs About Chiropractic Compliance Measures
The one interesting byproduct of chiropractors who begin to get their compliance act in gear is that more questions begin popping up over everyday matters. Suddenly, policies and procedures they have utilized for years become the subject of much questioning, much needed revision and, in some cases, not so needed fear.
To set the record straight, here are a few items that I would like to clarify for you so that you can fully understand your responsibilities and which side of the compliance fence that you stand.
Q. Our practice confirms patients’ insurance coverage by contacting their health plans the day before their appointments to verify coverage and patients’ financial responsibility. Do we need their consent or authorization to contact their health plan?A. Patient consent or authorization is not necessary to disclose PHI for coordination of benefits, which is considered part of your treatment. Per HIPAA [45 CFR | 164.501] the full definition of treatment includes: “the provision, coordination or management of health care and related services by one or more health care providers, including the coordination or management with a third party
Q: Are sign-in sheets or calling out the next patient’s name in the waiting room – allowed or not allowed?A: Yes, they are allowed. Believe it or not, if you actually sit down and read through the HIPAA regulations (sick and twisted) one of the intentions behind HIPAA that you will repeatedly see mentioned is “administrative simplification.” To this extent these activities result in other people learning a patient’s name or other information, the disclosure would be considered “incidental” to your of the patient, and therefore acceptable under HIPAA. (7.6.2001, OCR HIPAA Privacy TA 164.000.001 FAQ) Chiropractors should still take appropriate precautions to limit the amount of information that might be incidentally disclosed in this manner. For example, you may not want to ask patients to list “reason for visit” on a sign-in sheet. With respect to placing charts outside of your adjusting rooms, you should take precautions such as turning the front of the chart towards the wall so others do not have the opportunity to read the front page while walking past the room.
Q: What about billing electronically, EMR and all these new proposed regulations? Am I going to be required to do all of this?A: While it may make sense for many individuals to move as much as their practice as possible to an electronic format, you have two reasons to rest easy. 1) Several proposed requirements for electronic communications are still in the future and so there dates may be delayed or never quite arrive. 2) You may be an exception to the rule anyway. For example, back in 2003, providers were supposed to be required to bill Medicare electronically. However, this requirement does not affect many chiropractors, as there are exceptions to physicians with fewer than 10 full-time employees. [42 USC | 1395y(h)]
Keep informed so that you know what you are required to do, but don’t get paranoid. Focus on your practice and your patients. Sleep easy.
In the wake of insurance denials, some chiropractors pose an interesting question in their attempt to get paid for what they do. It is some variation of this:
“If I billed something incorrectly…or the insurance company denied a particular service…or procedure A was bundled with procedure B…can I change my records/billing/coding so I can get paid for this?”
Certainly, my loyal blog readers know that one of the two primary purposes of my writing this column is (1) to help you maximize reimbursements by getting you paid for ALL the work you do. But this purpose is also coupled with keeping you compliant in your billing, coding and documentation while attempting to achieve my other goal for you, which is (2) to minimize your audit risk.
In other words, I would love to see every chiropractor paid well for all of the work they do (not more than they deserve, but not less) and, of equal importance, possess the proper documentation necessary to KEEP the money they earned.
Answering the question(s) posed then is not a simple “yes” or “no” but an “it depends.” Let’s explore this a little further.
Amendment of Records Can Be a Good Thing
Amendment of a medical record can be a good thing. Reviewing your records to check for accuracy and completeness and taking the time to amend them is common and commendable. We all know that the daily duties and pace of practice often cause us to spend less time taking notes that we may want to or that good documentation may warrant. Therefore, a practice of reviewing notes before the day’s end, for example, can be a good way to catch any missed items needing documentation as well as prevent incorrectly billed or coded services.
Obviously, the best practice is to complete your records correctly the first time. But if you didn’t, you can make an addition or correction later. You must do so in a legitimate and above-board fashion—timely and not apparently an “alteration.” Different payers may have varying definitions of what constitutes “timely” documentation, but most appear to indicate that the note should be completed during the actual encounter of shortly thereafter. Most payer descriptions I have seen of this seem to indicate “shortly thereafter” means within 24hours after treatment.
Avoid Alteration of Records
Let’s differentiate between the terms: “Amendment” or “Alteration.” For our discussion, Amendment refers to the process of reviewing and/or correcting mistakes within a short period of time (as above) for the purposes of correction. Alteration, on the other hand, does not quite convey the same corrective intent.
For example, if you alter your records once a lawsuit has been filed or an attorney has requested your records, it’s too late and this would not be considered a legitimate “correction” or amendment of the patient’s file.
Unfortunately, this is a common scenario: you receive a request for records, review your documentation, and see that some fact is omitted or some entry is inaccurate. You quite innocently think that you can “improve” the record.
Let me stop you there. Don’t do it.
Every state chiropractic board in the country has heard numerous cases of records alteration and, I am sure, cringes every time they have to review one.
In reality, the insurance company, plaintiff’s attorney, claim review company and who knows who else has likely already obtained a copy of your records in their original form. As the jury is shown both the original record and your “revised” record, you will see your credibility disappear before their eyes – even if the alteration of the record was innocent, helpful or minor.
At the least, any alterations you make in the records significantly after the treatment date can be viewed as self-serving. Taken to the extremes, it can also be regarded as a cover-up or potential fraud. (See picture at start of blog for what technology can do to squash your attempts to alter records anyway!)
Adding To or Correcting Records
What should you do if you discover an omission? Suppose you review your earlier progress note and discover that you forgot to state that you made an appointment for a patient x-ray? Or what if you reviewed the x-rays and in the process of documenting your findings, inadvertently left a key finding out of your report?
Sometimes, omissions may not have clinical relevance but are needed for accuracy. For example what do you do when you discover that a simple typing error has made your 26 year old patient 62 years old?
In cases like these, adding a note can illustrate the fact that you are a conscientious chiropractor by demonstrating that you are careful enough to review your notes and concerned enough to add the missing information.
To properly amend records, you need to:
Put a notation in the margin next to the original entry: “see my note below.”
Enter another note at the time you discover the error. Write in the added information. Initial and date it.
Draw a single line through the incorrect entry. Make sure that the original entry is still legible.
Explain the correction. If possible, explain why the earlier note was incorrect, the reason for the error, and the reason the error was noticed.
On the other hand, erasing, using correction tape or fluid, or obliterating any documentation in the record is unacceptable and would be a big no-no that can land your tail in hot water.
Billing Snafus
Many chiropractors contact me – after the fact – about their claim denials, payment disputes or billing problems which may have occurred as a result of errors or ignorance. Some of these problems are correctable.
If you legitimately performed a procedure, documented it correctly and simply forgot to bill for the procedure alongside the other services that were rendered during that visit, you may wish to submit a corrected claim and get reimbursed for this. Provided you do this in a timely manner, the insurance should reprocess the claim and pay for your for the service.
Similarly, if an insurance company has denied your service based on a claim submitted with the wrong code on it (due to a human error, mistake, number dyslexia, etc), re-submit your claim for payment consideration. In these instances, I find a short letter submitted with the corrected claim to be helpful. (i.e. Dear Sirs, I inadvertently billed for 58940 instead of a 98940. There was no Oopherectomy performed, in part or total, during the course of the patient’s chiropractic visit nor was it my intention to attempt to get paid for one. The service performed was…)
Some billing problems, however, should not be corrected.
For example, adjusting 3-4 areas of the spine (98941) and performing manual therapy (97140) in one of those same areas won’t fly with payers and will result in a denial. If you have billed this out and find a rejection letter staring you in the face, you should not downcode your service to a 98940, re-bill it and hope to be paid for your “corrected claim.”
Presuming you did adjust three or four areas in the first place, it would be fraudulent to downcode because you are essentially lying to get paid. Again, take your lumps and correct the issue.
Likewise, if you bill for a service only to find it denied, you should not re-submit the claim using a different code in an attempt to get paid. Look in any coding book, page 1 or thereabouts and you will see instructions that read something like “Select the name of the procedure of service that most accurately identifies the service performed.”
Spaghetti billing methods (throw it to the wall, see what gets paid/sticks) are not advisable, inefficient and potentially fraudulent.
Parting Words of Wisdom…From Bob
So what do you do if you have a billing problem that causes you to lose money, but which you cannot correct if you wish to keep your nose clean?
Identify and research the issue so that you can understand the problem.
Seek experienced help. Billing and coding errors rarely occur in isolation. Typically, I find multiple errors that are costing my clients thousands of dollars in unrealized income or potential losses.
For future purposes, and on the lighter side, see Bob Newhart’s classic advice on the matter below. A little on the rough side, but technically accurate! J
The good news is that the new HIPAA requirements aren’t quite as bad as the above cartoon, the bad news is that they are going to require some paperwork on your part. And we know how much all of us chiropractors love paperwork! Here’s the skinny:
Covered entities and Business Associates (BA) are required to amend existing BA contracts or negotiate new contracts. Contracts executed prior to the HITECH Act do not comply with the interim breach notification rule or the new BA-related statutory requirements. The breach notification requirements for BAs became effective September 23, 2009, and many of the other BA-related requirements become effective February 17, 2010.
Are Chiropractors Covered Entities?
The first question most chiropractors will ask is: “Am I a covered entity?” Put simply, if you conduct transactions in electronic form, you are a covered entity. Examples include billing electronically (or through a clearinghouse), using any electronic storage media, etc. Most chiropractors are likely considered covered entities. If you are in doubt, see Medicare’s Covered Entity Chart to help you determine this.
What is a Business Associate?
In chiropractic, we tend to define an associate as the DC who is an employee and who helps us care for our patients. The HIPAA definition, however, is much broader than that. In fact, the HIPAA Business Associate refers to non-employees with whom you do business and who use or have potential access to Protected Health Information (PHI). Common examples of BAs may include: electronic clearinghouses, billing companies, transcriptionists, accountants, etc. For more information and official definitions on Business Associates, go to the Department of Health & Human Services Business Associate page.
Why New Contracts?
As you may know, there was a changing of the guard last year and the Office Of Civil Rights now administers HIPAA per the HITECH Act of 2009. Also, included in that provision was mandatory HIPAA audits.
One simple way an organization can see how much monitoring needs to be done is to throw out a new change and see how well we comply. In other words, new contract + monitoring = lots of money generated in fines for the new organization.
Forgive my cynicism, I am sure that there may be other motives. However, in the meantime, you need an updated BA contract by February 17, 2010…or else.
In case you are not motivated by the “or else” threat, here are some details:
What’s Changed in the new HIPAA Business Associate Agreement?
• Establishes criminal and civil penalties for non-compliance
• Now applies privacy & security rules DIRECTLY to BAs
• Establishes mandatory breach reporting for CEs and BAs
The Hit to Your Wallet
If the threat of jail time is not enough for you (hey, I guess some people might appreciate the alone time), here are some threats to your bank account you might not like:
Penalties will be determined by nature and extent of both the violation and the harm resulting from the violation, so they could be substantial. Civil monetary penalties have tiered increases to progressively punish offenders.
Tier 1: Unintentional or inadvertent violation – At least $100 for each violation, but no more than $25,000
Tier 2: Reasonable cause, but no willful neglect – At least $1,000 for each violation, but no more than $100,000
Tier 3: Willful neglect, but violation is corrected – At least $10,000 for each violation, but no more than $250,000
Tier 4: Willful neglect, violation not corrected – At least $50,000 for each violation, but no more than $1,500,000
What is required?
Make a list of your current business associates and vendors
Identifying entities with which your practice shares PHI because these BA’s are subject to the same privacy and security rules as Covered Entities
Drafting new legal agreements for BAs to comply with the HITECH Act
Updating HIPAA privacy & security policies and procedures (including the creation or modification of existing Breach Notification Policies). See Dept of HHS Breach Notification Policies page for more info.
The Bottom Line
You will kick yourself for getting fined for this new rule. Save the time in emailing me your angry thoughts, I probably agree with you and you’re screaming at the messenger anyway, which is not terribly productive.
Here are your options:
Have your attorney draft a Business Associate Agreementfor you. Search the internet for an agreement that is up-to-date (be sure that the agreement mentions the HITECH Act of 2009! Most that I have seen online are outdated and refer to the HIPAA rules of 2006) and relative to what we do as chiropractors (I have seen ones that are 23 pages long!).
For those who’d like to save time and searching, you can obtain a copy of my Sample Business Associate Agreement that I use with my clients, updated for the recent HITECH Act changes. Simply, open the Word Document, change the names and any relevant info to your clinic and you are on your way! For those who would like to have an attorney review your document, this will save you time and money from having them draft one from scratch.
Anyway you slice it, be sure to act on this promptly as the deadline is approaching!
Best,
Tom Necela, DC
Legal Disclaimer: Every reasonable effort has been made to ensure the accuracy of the information and recommendations provided in respect to the Business Associate Agreement. However, due to the nature of changing payer requirements and state regulations, you may wish to seek advice from a local health care attorney to ensure that the use of the Business Associate Agreement is compliant with your state laws.
