Medicare Releases Chiropractic Medical Review Findings for the 1st Quarter

Written by Tom Necela, DC, CPC, CPMA, CCP-P on April 6th, 2010

Topics: Audits, Chiropractic Audits, chiropractic coding, chiropractic documentation, chiropractic EHR, chiropractic EMR, Coding, Documentation, EHR / EMR, Medicare

detective

Recently, a Medicare carrier (Palmetto GBA) released their 1^st 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 say about the transformations they have achieved in their practice!

What Exactly is "Defensible" Chiropractic Billing, Coding & Documentation?

Written by Tom Necela, DC, CPC, CPMA, CCP-P on January 5th, 2010

Topics: Audits, Billing, Coding, compliance, Documentation

steal-this-bike

There has been a lot of talk and a lot of panic surrounding the ideas of “compliant” billing, coding or documentation in the chiropractic practice.

Most of you who have read my blog or attended my seminars are well aware of our poor performance as a profession in this arena and the backlash that has ensued in terms of post payment audits, claim denials or payment delays.

Following a recent column of mine in Dynamic Chiropractic (Insider Secrets About Postpayment or Recovery Audits), I received a wave of requests for templates that create “bullet proof” documentation every time. Similarly, I get more questions than I can physically answer from random chiropractors wanting to know if certain procedures they utilize fit the definition of a specific CPT code. Finally, either before (or in some cases, after) an audit, many DC’s (and even professional billers) have emailed me asking if a certain methods of billing are legit.

Most of these questions come from hard working, well meaning and nice chiropractors who are probably a lot like you in the most basic sense. Some are from worried DC’s who are on the verge of audits. Many are from individuals irritated or angry with the system that we play within which changes rules and requirements arbitrarily and seemingly without much notice.

In a number of different ways, all of these questions revolve around the same issue: how can I create a “defensible” system for what I do on a daily basis?

While this is an excellent question, there is no simple answer. First, let me dispel a few myths, then allow me to explain my lack of cookie cutter response.

Audits Don’t Presume Guilt Nor Innocence

Let’s be clear on one thing: Just because someone requests your notes does not automatically mean you have done something wrong. It may be a sign of some questionable practices on your part, or it may just be your random luck of the draw. Don’t take it personally, unless there is a pattern that emerges that you need to fix.

Even if a payer suggests that your practice patterns are outside industry norms, regional averages or plan parameters, it STILL does not mean you are a bad egg. However, it generally will mean that you have to justify why you act, look or treat differently than others.

Finally, while the above scenarios are certainly true, do not for one moment believe that you operate “above the law.” Statistically speaking, as a chiropractor, you create a mess that stinks just like many of our colleagues. And if third party payers persistently or frequently request your notes, delay your billings or force you to argue over the care you rendered, there is a good chance your mess needs some cleaning up before the stink sabotages your clinic or before you no longer have a business that you refer to as your practice. License plate manufacturing does not look good on a chiropractor’s resume.

Why Some DC’s SHOULD Be Scared

While this may sound like unnecessary scare tactics to some of you, let me remind you that I have seen enough chiropractic documentation to know that there is a significant portion of you who SHOULD be very scared! Here’s why:

1) There are few of you who have taken adequate steps to protect yourselves from audits. I have met no chiropractic equivalents of the above bicycle owner, who is obviously well-protected, if a bit paranoid.

2) If you repeatedly asked me to give you $50,000 per year and I was generous (or dumb enough) to give it to you with hardly any questions as to what, where, or why you needed the money…how long do you think this scenario would go on before I started asking some questions about the perennial need for this funding?

While this may sound like a strange question, how is it much different than many insurance scenarios?

Sure we provide a service to our patients. But if we don’t adequately communicate what we did in that service to deserve payment (via our billing, coding or documentation) why would or should the insurance company keep paying us?

Furthermore, why wouldn’t the insurance company want to take some of that money back if we didn’t provide them with an adequate “receipt” (again, in the form of our billing, coding and documentation) for our services?

When you put things in this perspective, it is not too surprising that third party payers are auditing doctors of all types. Sure they already are making tons of money and probably don’t need the extra dough they are squeezing out of the hard working docs but…they can, so they will.

Creating a Defensible Plan

Our job, then, is to reduce the impact of insurance profiteering on our practices. We do this by adhering to proper standards of billing, coding or documentation. By creating a record of what we did and why we did it. And by learning and staying up-to-date with the rules so that we can keep our noses clean.

This is how you create defensible documentation, coding or billing. Those interested in learning, I look forward to bringing you more of this information via my blog, webinars and seminars in 2010. Those who are well aware that they need this information customized to their specific practice needs and requirements , you would do well to have me take a look “under the hood of your practice.” The first step is to complete a FREE, no obligation Practice Analysis Questionnaire.

Best wishes for a successful 2010!

Tom

Chiropractic Billing Ignorance or Fraud? Inconceivable!

Written by Tom Necela, DC, CPC, CPMA, CCP-P on December 29th, 2009

Topics: Audits, Billing, Business, Coding, compliance, Documentation, Politics

inconceivable

“You keep using that word,” Inigo Montoya says to Vizzini in the cult-classic comedy The Princess Bride. “I do not think it means what you think it means.” The word that Vizzini so frequently misuses in the film is inconceivable. Unfortunately, it’s a term that seems to be floating around in the heads of too many chiropractors as well. As we near 2010, many chiropractors are now painfully aware that their coding and billing activities are being scrutinized more closely than ever before.

(Inconceivable? Read on…)

If you have been following recent legislative developments, you will have noted increasing overpayment recovery efforts by Medicare and its contractors. The current administration has declared that health care fraud enforcement will be a top white-collar crime priority for the Department of Justice (DOJ) and the various investigative agencies. Moreover, additional funding to fight health care fraud has recently been proposed in the Senate. Senator Ted Kaufman (D-DE) has sponsored the Health Care Fraud Enforcement Act of 2009, which, in addition to increasing the criminal penalties for health care fraud, allocates an additional $20 Million per year for health care fraud detection and investigation.

($20 Million extra for fraud detection? Inconceivable!)

While universal health care coverage may remain controversial, there is widespread support for additional legislation aimed at reducing health care fraud. This is not an attack on chiropractic per se (that would be inconceivable!) — these guys are going after every health profession at large!

Though I hesitate to get involved in all manners of political wrangling, there are some major issues creeping our way which can vastly affect our profession of chiropractic. We need to be aware of these not only on a profession-wide political level, but also in terms of how they affect our everyday practice.

If you haven’t already heard, here’s what’s coming unless someone puts a stop to it:

Requiring that the U.S. Sentencing Commission amend the Federal Sentencing Guidelines to redefine the term “health care fraud offense” to include all health care crimes, regardless of where they are codified. Notably, it would also increase the offense score associated with health care fraud offenses, considerably increasing the length of any sentence handed down by the Court;
Making it clear that all payments made in connection with illegal kickbacks constitute “false claims” under the False Claims Act; and
Clarifying that it is not necessary that a defendant be aware that their conduct violates a specific provision of criminal law in order for them to be held accountable for their actions. Instead, a person would be guilty of a health care fraud offence if he (or she) knowingly does what the law forbids. (Inconceivable!)

That last proposed provision in Senator Kaufman’s bill should scare the bejeebees out of all small physician practices, including (and perhaps) especially chiropractors. Here’s why:

Unlike the big entity hospitals who have a fleet of attorneys to defend their every move, this provision puts the small timer at a big mechanical disadvantage.

To make matters worse, we have another problem related to the meaning of the word fraud. For many physicians, Inigo Montoya’s clarification is again applicable: “I do not think that it [ in this case, the word fraud] means what you think it means.”

For many of us, we have heard lawyers argue that the fine line between what constitutes fraud and good old fashioned red blooded ignorance (oops I made a mistake) is intent.

This definition makes sense to me, as a non-lawyer type. If I repeatedly conduct my business or an aspect of it (say documentation, billing or coding) in a way that is deemed illegal, substandard or just plain wrong and despite my knowing better, I continue to do so for financial gain, this seems like a reasonable definition of fraud. On the other hand, if I don’t really know what I am doing, I may be wrong but it is out of ignorance not bad intentions. Consequently, the ignorant (but well meaning) doctor who is reprimanded, fined or otherwise correct then proves that his intent was always good by doing one thing: he corrects his actions.

Again, I am not an attorney, but if this provision passes through, I believe it sounds like the word fraud may not mean what we think it means. Or at the least, the lines of intent will be sufficiently blurred to be inconsequential. It won’t matter whether you acted honestly but erroneously; you will still be guilty of health care fraud.

The Bottom line: I see a few action steps here:

1. Now, more than ever, is the time to support your local (state) AND national association to help fight these battles on our behalf! No excuses. Most state or national memberships will cost you the equivalent of one adjustment per month to join. Membership in both will run you two whole adjustments per month. The safety of your livelihood is certainly worth that much regardless of your political persuasions, philosophical differences or nitpicking with their ability to fulfill your agenda. Get over it and support these associations now!

2. Training in compliant billing, coding, documentation should be a priority for both doctor and staff. The only way you can adequately defend yourself, prevent fraud and screen for errors is to know what you are looking for. Unfortunately, chiropractors are either woefully inadequate at detecting their own problems or unwilling to address the issues. Both can have devastating effects on your practice and the profession.

3. Encourage each other to rise to a higher level. Many states are requiring billing, coding or documentation education as a part of their CE requirements. State Boards need to be proactive in teaching doctors on how to comply with the requirements of their state before the docs get in trouble. Unfortunately, I have seen many docs disciplined for things that are “grey areas” such as exam documentation, SOAP note requirements, cash or TOS discounts, etc. If we fail to meet local standards, it’s practically a sure bet that we will fail nationally as well. So we need to go to our state Boards and associations with our challenges and work to find solutions so they don’t become national problems on public display.

Certainly, I am not proclaiming that better billing, coding and documentation will solve all our chiropractic problems (that would be inconceivable!) but a lack of proper systems in these areas will definitely put us at risk for failure in a variety of different forms.

Changing with the Times in Chiropractic

Written by Tom Necela, DC, CPC, CPMA, CCP-P on December 22nd, 2009

Topics: Billing, Business, chiropractic practice management, Coding, Collections

Changes_next_exit

Although some pundits have declared that the worst of the recession is over, I know that some offices are seeing the pinch of the slow economy and/or the holiday season on their patient’s finances. And while it may be true that you cannot get “blood from a stone,” don’t take comfort in all the talk of economic doom and gloom by leading yourself to believe that everyone’s practice is down right now. Those lies are told by those who want others to join them in their own shortcomings. Plus, it most certainly is not true.

However, this is not to say that chiropractic offices that are thriving in this marketplace by doing the same old thing. For example, my client who called to tell me he was still alive (hadn’t heard from him in a while, so I sent him a search & rescue email!) has been busy adapting new strategies for his office, adding staff and been busy, busy, busy to the tune of a $60,000+ increase in the last three months since he hired me. His excellent stats are not the result of pure luck, being in the right place at the right time or multiple mantras chanted towards attracting infinite abundance. Sorry to all you fans of “The Secret” or other similar think and grow rich spinoffs – this fella did the work, made some proactive changes and is reaping the rewards of his smarter strategies.

Let me make one thing clear: I am not telling you to start to do your own billing, over the counter collections or put a register in your treatment rooms to collect co-pays! However, I do think that, as the CEO of your business, you need to spend time in consideration of the way your office currently handles finances.

Unless you have been wearing blinders for several years now, $5 co-pays and $250 deductibles are becoming as rare as a monogamous celebrity. In many cases, the insurance step children have taken their place in the form of $50 co-pays and $5000 deductibles. Obviously, the clinic who approaches patient finances like it were 1985, 1995 or even 2005 has strategies that either won’t quite fit in today’s environment or ones that don’t even border on reality.

Instead, savvy practices that are succeeding today are coming up with an assortment of ways to make sure that the patients still get the care they need AND to ensure they are paid to deliver it. Here are a few ideas and tips to think about in this regard:

1. Your Credit Card machine is mandatory. The first line of defense for a patient who doesn’t have cash on hand – be it for a co-pay, deductible or to purchase the bulk of needed care – is to have a credit card machine. You are a dinosaur if you don’t. Those of you who would laugh at the notion at someone practicing without a credit card machine need to meet some of the characters who send me snail mail because they “don’t do internet.” I bet they “don’t do credit card machines.” And it is likely, they “won’t do practice” for long either. Get the machine. And for those of you who have one, shop yearly for transaction rates, fees and other little ways the companies will suck more of your money than need be.

2. Consider Auto-Debit. Some people don’t like the idea of paying 22.5% interest on their credit card which seems to be the direction many companies are headed. As an alternative, allow them to make payments. But whatever you do, refuse to accept payments the old-fashioned way! In other words, someone owes you $500 and your well-meaning staff member agrees to accept $50/month payments only to find out that 10 months turned into 17, included 19 reminders sent by your staff to get the $500 and in total, you actually lost money by spending more in staff time than you received. Instead, use auto-debit through your bank or a processing company such as FirstACH.com or PaySimple.com. Patients are used to having their bills paid this way, and with a simple form, they can pay you the money over time without having it be a headache and a financial nightmare on the back end.

3. Make Sure Your Hardship Agreements are in Writing. Some of you are too easy on what constitutes a hardship in your clinic and you waive co-pays at the drop of the hat. Not only is this potentially dangerous for legal and/or contractual reasons, it may make little business sense. Certainly, if someone is in need, you want to get them the care because you have a good heart. But be sensible about this. DEFINE what a hardship is and stick to it. I get way too many emails from staff that complain about their doctors being all over the map in this regard. Get the poverty levels for your area and see what your state says about who doesn’t have any money and who should qualify for your generosity. That way, when someone approaches you with what seems like a legitimate financial challenge, you have some concrete criteria to see if they meet the definition legitimately. One final note: your hardship agreements should be in writing and be temporary (put an end date in which the hardship ends or must be re-qualified).

4. Beef Up Insurance Savvy, Cash Friendly Services. Even though much of the coding, billing and documentation advice I give slightly favors third party payment systems, it is a wise move to have services that are both reimbursable through insurance and for which patients readily pay cash. My favorite choice in this category is massage therapy because it costs little to start up, has excellent profit margins, generates quick cash flow, is frequently reimbursed by insurance companies and routinely paid for in cash as well. My How to Build a $300,000 Massage Practice in Your Chiropractic Clinic program is one of our top sellers for this reason – and it continues to get rave reviews because the program is a simple step-by-step model for how to create a successful massage department. Certainly, massage is not alone in the insurance savvy, cash friendly category; but I do believe it outweighs the other choices by a large margin.

5. Clean Up Your Messes. Many of us are willing to point the finger at the patients or the economy for our financial struggles when the real answer is the mess that is in our own backyard. To put it bluntly, you will never achieve high levels of financial success if your Accounts Receivables are too high or inappropriately pushing beyond the 90 day mark. If your billing person (or system or company) is a mess and can’t get you paid, there is no amount of compensating you can do on the other side to squeeze more profits out of your patients that will ever balance the scale. Finally, if your documentation and your coding systems stink or were passed down to you by Uncle Louie, DC who was a big roller in the 70’s, you are in for financial trouble at the least. In today’s marketplace of heavily scrutinized claims, post payment demands and recovery audits, it makes little sense to bill for anything and everything with little attention paid to proper billing, coding or documentation standards because you will only to pay it back later. Instead, spend some time cleaning up your own messes. If you have even an average practice in terms of volume and visits, I can virtually guarantee you are leaving hard-earned money on the table because of your lack of expertise in these areas. I say this, not to brag, but because this is what I do every day of my consulting business and there is literally that much to improve in most of our practices.

So, which of these steps are you missing in your practice?

Is it all of them? Can you survive doing business the same way you are doing it now or is it high time to “kick it up a notch” and change with the times. You may not be able to do much individually about the state of the economy, but you can do a whole lot about how your private practice handles finances. So, get to work. And if you don’t know where to start, consider completing my Practice Analysis Questionnaire so I can give you some guidance in this regard. There’s no charge nor any obligation to utilize my services, but I am willing to give you some candid opinions/recommendations (like ‘em or not!) for those who take the time to fill out the questionnaire.

Happy Holidays!

Tom Necela, DC, CPC, CPMA

P.S. For those of you who would like more in-depth strategies, check out my Chiropractic Collections & Financing Secrets program which has dozens of different tips and techniques to improve collections.

Your Toughest Chiropractic Billing, Coding, Documentation Questions Answered – FREE!

Written by Tom Necela, DC, CPC, CPMA, CCP-P on December 15th, 2009

Topics: Audits, Billing, Business, chiropractic documentation, chiropractic EMR, chiropractic practice management, Chiropractic Seminars, chiropractic webinars, Coding, Collections, compliance, Documentation, EHR / EMR, HIPAA, Medicare, Medicare ABN, OIG Report, seminars

You are invited as a guest to Join Tom Necela, DC, CPC, CPMA — Certified Professional Coder, Certified Professional Medical Auditor, former Insurance Claims Analyst, and current President of The Strategic Chiropractor — for a special FREE 60 minute Webinar!

FREE WEBINAR!

Thursday December 17, 2009

– 9 am PST/10 am MST/11 am CST/Noon EST

So…

Bring your TOUGHEST questions on Chiropractic:

Billing

Coding

Documentation

Collections

Getting Paid for the Work You Do!

And receive the ANSWERS you need that will help you:

Maximize your reimbursements

Decrease denials

Shorten Payment delays

Lower Accounts Receivable

Reduce your risk of audits

We are hosting this seminar as a special “thank you” to all of our blog readers, clients and customers who have made The Strategic Chiropractor the #1 source for teaching chiropractors how to “Work SMARTER, not harder” for increased profits.

As a sign of our appreciation we’d like to offer you a FREE seat for this webinar and the chance to have your question answered “live” during the event.

(If you cannot attend or would like a CD copy of the webinar, see below for details.)

Historically, this is our most popular event webinar of the year, so you need to act quickly! Previous editions of this webinar resulted in hundreds more questions than we could physically answer in a limited time format.

Space is limited and ADVANCED REGISTRATION is MANDATORY to submit questions (the earlier you submit them, the better chance they have for being included in the presentation material). So register below, submit your questions and get your front row seat for the ultimate biggest bargain on the subject of chiropractic, billing, coding and documentation!

CLICK HERE TO REGISTER!

Hope to see you there!

Tom Necela, DC, CPC, CPMA
The Strategic Chiropractor

Are You Coding Your Chiropractic Adjustments Incorrectly? New Coding Clarification!

Written by Tom Necela, DC, CPC, CPMA, CCP-P on December 1st, 2009

Topics: Audits, Billing, Business, chiropractic documentation, Coding, Documentation

hip adj

The October 2009 edition of the CPT Assistant featured some clarification on chiropractic coding issues specific to coding for Chiropractic Manipulative Treatment, both Spinal (98940-98942) and Extraspinal (98943). In addition to spelling out what constitutes each of the five spinal regions, the CPT Assistant provided some additional clarification on the Extraspinal Regions that was previously left unclear in previous editions of the CPT code book. Specifically, I would call your attention to the definitions of Lower Extremities and Upper Extremities, which are now well defined.

To give you a little background, the CPT (Current Procedural Terminology) coding book is published each year by the American Medical Association and is the “official” coding standard rules and guidelines for proper coding procedures throughout all health professions. As the full volume of the publication is quite large, various spin-offs of the CPT book exist (such as ChiroCode) in specialty professions to help practitioners in specific disciplines access the portion(s) of the CPT that are relevant to their profession. Similarly, the CPT Assistant is published each year for coding professionals (from all disciplines) and it clarifies updates, problems, commonly misunderstood items, deletions and additions to the CPT codes.

For most issues of this pricey publication, the CPT Assistant has little relevance to anything we do as chiropractors mainly because we represent only a tiny fraction of health professions at large. To be honest, each year, I wrestle with the idea of canceling my subscription but the occasional nugget of useful information I can pass on to you and/or my clients keeps me going. The most recent issue of the CPT Assistant has by far the most relevant hairsplitting that has been published on chiropractic in a looooong time. The issue featured definitions of chiropractic manipulative therapy codes (most of which you already know) but there were a few tidbits that were included that could potentially have a major impact on your ability to bill, code and document your services correctly. Done right, they can help you INCREASE income. If done incorrectly, you could be LOSING money. Here they are:

Extremity Coding Clarifications
For Lower Extremities, perhaps the most critical definition for chiropractors is the inclusion of the “Hip” in this category. As you know, a patient presenting with a hip problem could really have a chief complaint of SI joint pain, pelvic pain or problems in many other anatomical structures located in the surrounding regions of the lumbar spine, hip, pelvis or sacrum.

Similarly, many chiropractors have expressed confusion over what structures constitute the Upper Extremities. The present edition of CPT Assistant also clarifies this issue: the upper extremities include the shoulder, arm, elbow, wrist, and hand. Therefore adjustments that you perform in the Thoracic region of the spine would not include the shoulder, even though some of the surrounding structures are adjacent anatomically. The CPT Assistant makes it clear: Shoulder Manipulations are Extra-spinal (98943).

From a coding, documentation or billing perspective, it is essential to be specific in your reporting of pain in these areas, as it may have significant impact on your selection of the appropriate CPT code to bill for your services and in turn, the revenues generated from that service. For example, since the SI joint is classified under Pelvis for coding purposes, adjustments to this region would count towards the number of spinal areas for which you are billing. On the other hand, if you perform an adjustment to the hip, your service should be coded as an Extraspinal Adjustment (98943) and would not count towards the number of regions you would choose for spinal area adjustments (98940-98942).

Potential Risks and Benefits of This Coding Clarification Obviously, if you incorrectly document, bill or code for any of these regions incorrectly, you run the risk of either upcoding your services (because you have billed for more regions than you truly adjusted) or downcoding your services (because you failed to bill for all the areas you adjusted). Neither is correct and both have financial implications.

One final note: the CPT definitions of anatomical regions are not consistent with the diagnosis code selections included in the ICD-9 code set. This discrepancy was pointed out in the 2009 edition of the ChiroCode Deskbook, but its application becomes particularly relevant when dealing with coding issues in reference to the regions mentioned above. Because it may not be possible to correlate all anatomical regions with specific ICD-9 codes, use extra caution to make sure that your documentation fully supports both your choice of CPT codes and ICD-9 codes. Failure to do so may result in your claim being denied or delayed.

Now that you have been informed, the next step is to go back and correct your procedures if you have been doing it wrong. For those of you who suddenly found out that you are leaving lots of money on the table by the current way you are billing, coding or documenting your services, let me suggest a three step plan:

Fix It! The insight is not the solution — your improvement requires action! So get to it before you expose yourself to potential audit trouble and/or keep losing hard earned money.
Admit That You Don’t Know Everything. This is sort of a “healthy” view of ignorance. Some call it the beginning of wisdom. It is the realization that you cannot possibly know everything there is about all aspect of your business. Certainly there are other similar items that you don’t know that are also costing you money (or will cost you money if you are audited). Once you can own up to that, perhaps it’s time to fill out my Practice Analysis Questionnaire and see how I may be able to assist you. My review of your Questionnaire is free and there is no obligation to utilize my services, so the only thing you have to lose is your stubbornness to admitting you know everything. By the way, just in case you think I may be a little hypocritical here, I don’t claim to know everything either. It’s highly likely I know more than you about billing, coding, documentation as this is what I specialize in, but you won’t find me telling you how to adjust your patients or what to do with your 401K plan. For some things, it is helpful to have access to someone with specialized knowledge around. If you can accept that line of thinking, fill out my Practice Analysis Questionnaire and we’ll talk.
Give Something Back. There is potential for some of you to make big bucks off this blog post due to the fact that you have been doing it wrong for who knows how long. Take an average of only 20 adjustments per week @ $50 per adjustment for 50 weeks of the year. That’s a $50,000 impact on your practice for one item! At the very least, you may owe me a nice dinner (just kidding), should hire me (kidding – sort of — it will cost you less than $50K and make you more) or give something back to the profession (not kidding at all — choose your state and/or national association and send a check – they need the money!).

How Can I Increase My Chiropractic Income?

Written by Tom Necela, DC, CPC, CPMA, CCP-P on November 10th, 2009

Topics: Billing, Business, Coding, Collections

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At one point in time, virtually every business owner – chiropractors included – has asked the question “How can I improve my income?” Today’s post will discuss this mega-dilemma of nearly all entrepreneurs.

But before we discuss potential SOLUTIONS, let’s take a critical and closer look at the question, knowing that the only way to arrive at better answers is to ask better questions.Truly, do you really want to just increase your income? Most would shout: “YES!” But looking at things from a broader perspective, the astute entrepreneur would probably also want to know the costs involved with increasing income.

Let’s take a look at two common ways to increase income. First, you could raise your fees. This almost immediately produces an income boost. The cost to do so is nothing. Sounds perfect? And while increasing fees is one thing I believe is critical to your financial success, it does have limits. After all, in theory you could double your fees and double your profits. You also may multiply the number of patients who head for the door. So, although raising fees may be smart, it is a limited strategy by nature.

Now let’s look at the example of new patients. Most chiropractors would agree that having more new patients is key to increasing income. Certainly that is often true. But don’t be too hasty in proclaiming new patients as the premier method of increasing income. Why? Two words: acquisition costs. If your new patients come from referrals, the cost to acquire them is nearly zero so this can be a profitable venture. On the other hand, if the new patient walks in as a result of an ad you placed, you need to now calculate the costs of the ad and the potential income the patient will generate for your practice. In this way, some new patient acquisition methods can certainly be profitable while others less so or not at all.

So, perhaps a better question to ask is:

What’s the most cost-effective improvement I can make to increase income?

In the October 9, 2009 edition of Medical Economics, healthcare consultant Keith Borglum gives the answer, plain and simple: “The most cost effective improvement is usually in improving your coding.”

Of course, as a Certified Professional Coder myself and one who routinely utilizes proper billing and coding to help improve revenues for my consulting clients, I certainly would agree. Sure I am a bit biased, but here’s the reasoning behind Mr. Borglum’s proclamation:

“An extraordinary number of physicians fail to stay current in their knowledge of coding, resulting in reduced reimbursement or delayed and denied claims. Many physicians purposefully undercode out of fear of penalties for overcoding or unbundling. Others leave their coding to support staff – an inappropriate approach virtually guaranteed to result in errors …”

Although this consultant is speaking in reference to Medical Doctors, in my experience, we chiropractors are really no different. In chiropractic school, we were taught examination procedures based on creating a working diagnosis so we could accurately assess the patient’s condition and create an appropriate plan of care. In other respects, our exams were also about protecting ourselves from malpractice resulting from potential hazards that could be mis-diagnosed. But I have yet to meet a chiropractic graduate from any school who was taught how to properly document an exam for purposes of correct coding and billing.

As a result, most fall into one of two camps mentioned above. Conservative chiropractors tend to undercode or underbill, thus denying themselves reimbursement for procedures they actually performed. More aggressive chiropractors tend to bill for procedures out of some sense of justification for the time they spend performing a service that may not necessarily match up with coding or documentation requirements. As a result, they overbill or upcode.

Many clients come to me seeking ways to improve income, but most also have some predetermined methods that they believe they need to use to achieve this and hope that I can somehow teach them a new “trick” or “secret method.” On the contrary, most clinics I see would benefit not from something new, but by returning to the old.

In other words, they can reliably improve income by making sure they are being paid for what they are already doing. They can increase revenues by maximizing reimbursements and minimizing errors that cause them to leave money on the table. Proper billing, coding and documentation can help you achieve this – without the added expense of new equipment, extra staff or additional funds in the marketing department.

On top of that, if you consider correct coding from an expense point of view, proper coding not only has the potential to increase your income, but also prevent you from losing income –few strategies can ever achieve both.

If you want to get down to pure return on investment, taking a coding class for $100 could easily find you at least one item that you could improve. Even if that resulted in a $25 increase for a service or procedure you performed just a few times a week that could result in a $5000 increase over the course of a year or a 50:1 ROI! Personally, I have had seminar attendees tell me that one of my strategies was worth $25,000 to their bottom line! Take that one step further and spend a few hours consulting with a coding expert and you could easily turn your investment into a 6 digit return. I do this routinely for my clients.

So, the next time you are seeking ways to increase income in your practice, remember the following:

All income increases are not equivalent – consider return on investment
Correct coding can help you prevent income loss AND increase income

One of the most basic steps towards improving your coding should include the purchase of the ChiroCode deskbook. Quite frankly, no office should be without it. Every office I have seen without one of these books that is making major coding errors that are costing them money and exposing themselves to audits. Unfortunately, I can think of no exception to this rule.

Now is the time to start planning and investing in next year’s success!

Answers to Common Chiropractic Medicare Problems

Written by Tom Necela, DC, CPC, CPMA, CCP-P on November 3rd, 2009

Topics: Audits, Billing, Business, Coding, compliance, Documentation, EHR / EMR, Medicare, Medicare ABN, OIG Report

questions2

In my last article on The Perennial Problem of Medicare for Chiropractors, I offered to respond to some common questions and dilemmas that you have been experiencing in regards to Medicare and your chiropractic practice. Since the blog was posted last week, we received a total of 326 responses with questions, comments, angry remarks about CMS and a few demonstrations of our collective chiropractic misunderstandings about all things Medicare.

In other words, the rumors are still out there, docs are still frustrated and problems still abound. To be fair, I did receive ONE response from a DC who was a bit perplexed about all the fanfare and indicated that Medicare was the easiest payer to deal with. Certainly, his response was the exception, not the norm. The one caution I would raise for docs who similarly feel that they are sailing along without any trouble: the RAC audits have started and they may change your opinion of the matter.

Now, let’s get to the questions! Obviously, I cannot address all 326 responses, so I have summarized the concerns into a few basic categories as follows:

Payment Denials or Downcoding. Several readers were upset that Medicare had denied or downcoded the level of service and paid them less (or not at all) as a result. More were confused about what this means. Since your adjustments are the only service Medicare pays chiropractors for, the “level” of service refers to the number of areas that you adjust and bill for – i.e. 98940, 98941 or 98942. When I perform Documentation Reviews for clients, the most common mistake I see here is that your objective findings don’t match the level of service billed. In other words, you billed a 98941 (3-4 region adjustment) but only had objective findings for perhaps 1 or 2 areas (or less). Therefore, Medicare concludes that either you didn’t meet medical necessity for the service you performed at all or that you only met medical necessity for a service that was lower (fewer areas) than the one you billed. The result: your claim will be downcoded (i.e. a 98941 will be paid at 98940 rates) or denied ( you didn’t meet medical necessity at all).

Fixing Problem Claims. This question of what to do with incorrect, incomplete, or problematic claims came in a variety of formats. Per Medicare Transmittal 1588, you can submit a corrected claim if your original claim was filed in a timely fashion and was incomplete. By incomplete, Medicare means items are missing such as NPI #, patient demographic info or other such requirements on your claim form. Incomplete does not mean that you get to re-submit your corrected claim because your original clinical documentation was substandard or missing items you should have included in the first place.

Error Rate and the Aftermath. Error rates probably mean bad news for most DC’s! Error rates are the % of claims submitted in error to Medicare that are determined to be such after a review. Error rates can result in overpayment demands (Medicare paid you, but since 20% of your claims were in error, they want a refund) or can lead to future audits (your error rate is too high, therefore Medicare will audit you again in the future to monitor your progress) or can even cause “Pre-Payment Reviews” (Medicare determines that your error rate is repeatedly too high and they will have to review your documentation prior to approving any future payments). As I said at the start, none of this is good news, although if you are receiving notices of PrePayment reviews, you definitely need help in the area of proper billing, coding and documentation.

Avoiding Medicare Patients. Some of you indicated that the only sure-fire way to avert Medicare disaster was to avoid treating Medicare patients. Certainly, you have the right to refuse to treat Medicare patients so long as you do so within the confines of your state laws. Whether this is a good tactical move may be questionable, as the Baby Boomers represent the single largest segment of the population who will be driving lots of healthcare dollars in the name of Medicare. To exclude them may represent a significant portion of your practice base. Also, be careful when you state that you do not treat any Medicare patients. By the questions some of you posed (whether hypothetical or not), you ARE treating Medicare patients but you are simply not billing Medicare for the service. If you are not doing this correctly, you could be accidentally committing fraud by doing so.

Medicare, EMR and Stimulus Funds. Several questions came in regarding integration of EMR and Medicare. According to the program, physicians (including chiropractors) will be eligible to receive stimulus funding as soon as 2011 for EMR that meets certain “meaningful use” criteria. At this point, the specific details of these requirements are still to be determined. While I am a big proponent of moving to EMR, in this respect, I agree with the ACA’s advice on the matter: “do so with the fundamental focus of improving patient care.” In other words, get the EMR because you want it to help your documentation, your clinical practices and business management – not because you may get some money from the government.

CERT Request and Audits. Apparently, there are many of you who wonder if CERT requests are an audit. CERT stands for Comprehensive Error Rate Testing and it’s likely many of you have received such a notice from Medicare. It is their way of randomly testing the accuracy of payments made. So the key word is random and is in no way an indication that you are doing things wrong (or right for that matter). Comply with the request and do not ignore it. For more detailed information on the Audit process (for both Medicare and other third party payers), types of audits and what to do I suggest you get a copy of How to Prepare Your Chiropractic Practice for Recovery Audits so you can understand what auditors are looking for and how to respond.

ABN Mysteries. ABN questions dominated my inbox in varying forms and it’s obvious there’s still a lot of confusion over ABN’s. First, by definition the ABN is an advanced notice (meaning, you have to give it to the patient beforehand not to cover your tracks afterward) that Medicare may not pay for the service you are about to render. Secondly, to simply have your patients sign an ABN each and every visit is incorrect. It presupposes that none of your chiropractic adjustments are necessary. This is not something you want to communicate to Medicare or your patient! Finally, for more detailed discussion of ABNs, let me refer you back to an older post entitled: ABN Abuse: A Common Chiropractic Practice.

FREE or Discounted Medicare Services. The “Can I include Medicare patients in my Free or Discounted…” question was posed in several ways, but the same theme is underlying. What can I give away or discount to my Medicare patients? Here is your answer. According to OIG interpretation of Section 1128a(5) of the Social Security Act, exam specials, coupons, or similar discounts should not exceed $10 individually or $50 annually per patient. So, your FREE exam or adjustment may be problematic in that it either exceeds the $10 value or that you don’t charge enough for your services. One way, you’re in trouble with Medicare; the other, your business is not likely to generate a profit if you are charging less than $10 for exams, x-rays, adjustments, etc.

Split-Second Audit Destruction, Chiropractic Mayhem & Profits

Written by Tom Necela, DC, CPC, CPMA, CCP-P on October 6th, 2009

Topics: Audits, Billing, Business, Chiropractic Seminars, Coding, compliance

Breaking Into Piggybank

Here’s the bad news you already know: an increasing amount of good chiropractors are being audited by insurance companies and asked to repay hefty sums due to “insufficient documentation” or “improper coding” or other practices that somehow get viewed as substandard. And the ensuing mayhem that this creates is destroying many practices and robbing more of profits.

Here’s the good news: for those of you who haven’t yet experienced this first-hand and who would like to learn an “insider’s perspective” on how to protect yourself, read on.

As a matter of disclosure, I used to work for “the other side” as an Insurance Claims Analyst prior to becoming a chiropractor. I am also Certified Professional Auditor and Certified Professional Coder which only means I received the same training as those who are trying to take your hard earned money.

Just for the record, I have never performed an Independent Medical Exam, Audit, nor any other such work for an insurance company while a chiropractor (nor do I intend to!). On the contrary, this article is focused on how to help you avoid this monster and how to protect yourself when he strikes.

While audits are too commonplace to be considered earth-shattering news (by now, most of us either know a DC who has been audited or have personally been through an audit), it is surprising – even appalling – how little knowledge of chiropractic, correct coding initiatives or even documentation standards are possessed by the auditors themselves! Even if you have not been audited in an “official” manner by Medicare or some third party insurance payer, the next time one of your claims is reviewed by an “Independent” Medical Examiner, this message may prove useful to you as well.

How to Fight Back And Hit ‘Em Where It Hurts

When you are audited or have your claims reviewed by some IME (sorry, but the reality for most DC’s today is WHEN not IF), here are some fighting tactics that are effective and easy to use:

Check out their credentials. You may be shocked to find out that your auditor or IME have absolutely no qualifications to review your claims, other than the need or willingness to take a check from the Insurance Company (or Third Party Administrator). Insurance companies routinely deny or demand repayment based on codes that contain high error rates (For example, 97140 or 97112). However, just because an auditor says you used them incorrectly doesn’t mean it is necessarily the case. After all, does he have enough experience with chiropractic to know how you are performing the procedure, is he a certified coder who can adequately judge the usage, or is he simply acting on statistical norms and assuming you are wrong?

Don’t write a letter asking for your research to be considered, demand that the reviewer/auditor be a licensed chiropractor in your state. This will automatically kick aside the DC who sits in his comfy chair across the country performing paper reviews on his unsuspecting colleagues. This also gives the boot to the nurse who is making a nice income auditing chiropractic claims despite the fact that she has no technical knowledge of chiropractic.

Demand that the reviewer be in active practice AND that they do not derive the majority of their income from performing reviews or audits. I like this step because it really levels the playing field. After all, not many reviewers are going to bite the hand that feeds them – especially if that hand gives them most of their food! You are much better off being judged by some chiropractor who is trying to make an extra buck or feels some sort of moral obligation to cleanse the profession of the crooks and therefore performs audits on the side, but still gets most of his money from practice.

Demand to See the Actual Notes of the Reviewer/Auditor – Not Just the Final Summary. I have seen too many clients get out their checkbooks to write the insurance company a check for a failed audit when they have not examined the details of what made them fail. The average audit tool contains 18 items — wouldn’t it be nice to know which ones were at fault so you could correct them or (even better) dispute them?! Get the specific records reviewed, treatment dates, and what specific items were at fault or substandard.

Obviously, there are more tricks to use and traps to avoid. If you don’t know where you stand, consider taking my Billing Quiz to give yourself an overall status report on common mistakes that are either costing you money or exposing you to trouble.

If you’re in the Northwest (or would like to be) in October and November, you may also want to consider attending one of my Seminars where you will be treated to live demonstrations of the split-second type of destruction a cranky auditor can inflict on your practice. And, of course, what to do to prevent this mayhem. Oh, and how to increase profits while decreasing your audit risk. In other words, necessary tidbits that will save your tail and bolster your bank account in the process. Hope to see you at a seminar soon!

Chiropractic Billing, Coding, Documentation Seminars come to Seattle, Portland, Boise

Written by Tom Necela, DC, CPC, CPMA, CCP-P on October 2nd, 2009

Topics: Audits, Billing, Business, Coding, Collections, compliance, Documentation, EHR / EMR, HIPAA, Medicare, seminars

seattle idaho-boise portland

Many of you have been emailing me regarding upcoming seminars for Fall 2009.

Here are a list of dates for Seattle, Portland and Boise:

SEATTLE, WA

Thursday, October 22, 2009
Saturday, November 14, 2009

River’s Edge Best Western
15901 West Valley Highway
Tukwila, WA 98188
425-226-1812
http://www.bestwesternwashington.com/hotels/best-western-rivers-edge/

PORTLAND, OR

Saturday, October 24, 2009
Thursday, November 12, 2009

Avalon Hotel
455 SW Hamilton Ct
503.802.5800
http://www.avalonhotelandspa.com/

BOISE, ID

Saturday, October 31st

Cambria Suites Boise Airport

2970 West Elder Street
(208) 344-7444

Discover the latest strategies to maximize reimbursements AND reduce audit risk from Tom Necela, DC and The Strategic Chiropractor!

New Red Flag/ Identity Theft Plan Needed by 11/2009 – get one FREE at the seminar!
Medicare Recovery Audits started in August – are you ready?
What you need to know about the HITECH Act of 2009, EHR stimulus hype & your compliance
Learn Surefire Methods for Defensible Documentation
Avoid the 4 Deadly Mistakes of EHR or computerized SOAP notes that trigger audits
Learn ’09 Premera Blue Cross, Aetna & Cigna policy changes that affect your practice!

Also — save $$$ on taxes and get your corporation in gear with Jim Bowen’s fast paced, business & tax info that you just can’t get anywhere else!

Registration for all seminars is available online at my co-presenter Jim Bowen’s website at www.bowen.us/seminars

Hope to see you there!

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