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
How to Prepare Your Chiropractic Practice for Recovery Audits
It’s no longer IF your practice will be audited, it’s WHEN.
Build a $300,000 Massage Practice in Your Chiropractic Clinic
How to Create the MOST Highly Profitable, Passive Source of Income For Your Practice With Massage Therapy
How to Oversee Your Chiropractic Billing Service or Staff
Can you really afford to be losing money due to a poorly producing billing staff or service?
The Best of…Strategic Chiropractor Blog Flashbacks
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)
Here they are (in no apparent order):
Enjoy!
Tom Necela, DC, CPC, CPMA
Chiropractic Audits — What To Do When You Receive THE Letter!
- 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, especially if 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.
Medicare Releases Chiropractic Medical Review Findings for the 1st Quarter
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 say about the transformations they have achieved in their practice!
Correcting Chiropractic Billing Snafus, Altering Records & Advice from Bob
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
To Your Success!
Tom Necela, DC, CPC, CPMA
The 25 Meaningful Use Criteria for Chiropractic EMR Systems
Adopting an electronic medical records (EMR) system can net you up to $44,000 in government incentive money. Or can it?
Some of the most frequently asked questions I received in 2009 (which still continues through 2010) is in regards to how to select an EMR system and the stimulus funds that potentially go with EMR implementation.
The problem?
All stimulus incentives hinged on practices adopting “meaningful use” of the EMR systems in question. The problem? Up until December 2009, “meaningful use” was left undefined!
In other words, you could not get the money unless you were using EMR according to certain set criteria but no one went on record to establish exactly what those criteria were!
Unfortunately, the cloud was not exactly lifted this past December because the proposed rules for “Meaningful Use” are 556 pages long! Worse yet, industry experts don’t expect the final rule to be much different so knowing the proposed rule is essential to meeting meaningful use and getting paid.
So, then, how does one crack the mystery code and define meaningful use? Lost in those 556 pages are a total of 25 requirements your practice must meet to achieve meaningful use. Don’t worry, I will spare you the trouble of reading the electronic equivalent of War and Peace (which is far more difficult to understand and much less entertaining) and summarize the 25 points below.
But let me cut to the chase. For those of you who have recently purchased an EMR system or who are considering a purchase, don’t bank on getting those stimulus dollars just yet.
For those of you who are still considering getting an EMR system, let me go on record and state that I think that is a great idea for most practices. However…don’t purchase one just because you feel the stimulus dollars are going to be rolling in afterward.
Purchase one with the intent of having a system improve your clinical documentation, practice management and overall efficiency. Most will do that, provided you choose the right system to suit your needs.
Can’t decide which system to choose?
Given that you should take stimulus dollars out of the equation, there are certainly other factors to consider in choosing the right system for you. Before you make a $10,000 mistake, perhaps you should consider investing less than 1% of that figure into my “How to Choose a Chiropractic EMR System audio program.”
This 1.5 hour program (on 3 Audio CD’s) walks you through the thought process of how to make an intelligent decision on purchasing the right system for your practice. I won’t come out and tell you to buy X, Y or Z but teach you how to shop and the tough questions you should be asking to make sure that you are getting the right system.
Frustrated with Your Own System?
It’s not too late to start over and think strategically about what will be a better fit for you and your practice. I see far too many chiropractors who have expensive EMR systems collecting dust because they abandoned ship out of frustration and went back to paper.
There was a reason you chose to get EMR, you should find a system that you can actually use – they ARE out there! Again, before you run out and buy another program, consider a small investment in strategy, some collective wisdom and a system to make a good purchase – my “How to Choose a Chiropractic EMR System” audio program accomplishes all of these.
And now, as promised, here are the 25 “Meaningful Use” Criteria for eligible providers. (These criteria were taken from the proposed rule: Medicare and Medicaid Programs; Electronic Health Record Incentive Program.)
The List: 25 Meaningful Use Criteria
1- Objective: Use computer physician order entry (CPOE)
Measure: CPOE is used for at least 80 percent of all orders
2 -Objective: Implement drug-drug, drug-allergy, drug- formulary checks
Measure: The EP has enabled this functionality
3 – Objective: Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry or an indication of none recorded as structured data
4 – Objective: Generate and transmit permissible prescriptions electronically (eRx)
Measure: At least 75 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology
5- Objective: Maintain active medication list
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient is not currently prescribed any medication) recorded as structured data
6- Objective: Maintain active medication allergy list
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient has no medication allergies) recorded as structured data
7 – Objective: Record demographics.
Measure: At least 80 percent of all unique patients seen by the EP or admitted to the eligible hospital have demographics recorded as structured data
8 – Objective: Record and chart changes in vital signs
Measure: For at least 80 percent of all unique patients age 2 and over seen by the EP, record blood pressure and BMI; additionally, plot growth chart for children age 2 to 20
9 – Objective: Record smoking status for patients 13-years-old or older
Measure: At least 80 percent of all unique patients 13-years-old or older seen by the EP “smoking status” recorded
10 – Objective: Incorporate clinical lab-test results into EHR as structured data
Measure: At least 50 percent of all clinical lab tests results ordered by the EP or by an authorized provider of the eligible hospital during the EHR reporting period whose results are in either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data
11 – Objective: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach
Measure: Generate at least one report listing patients of the EP with a specific condition
12 – Objective: Report ambulatory quality measures to CMS or the States.
Measure: For 2011, an EP would provide the aggregate numerator and denominator through attestation as discussed in section II.A.3 of this proposed rule. For 2012, an EP would electronically submit the measures are discussed in section II.A.3. of this proposed rule.
13 – Objective: Send reminders to patients per patient preference for preventive/ follow-up care
Measure: Reminder sent to at least 50 percent of all unique patients seen by the EP that are 50 and over
14 – Objective: Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules
Measure: Implement five clinical decision support rules relevant to the clinical quality metrics the EP is responsible for as described further in section II.A.3
15 – Objective: Check insurance eligibility electronically from public and private payers
Measure: Insurance eligibility checked electronically for at least 80 percent of all unique patients seen by the EP
16 – Objective: Submit claims electronically to public and private payers.
Measure: At least 80 percent of all claims filed electronically by the EP
17 – Objective: Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and allergies) upon request
Measure: At least 80 percent of all patients who request an electronic copy of their health information are provided it within 48 hours
18 – Objective: Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies)
Measure: At least 10 percent of all unique patients seen by the EP are provided timely electronic access to their health information
19 – Objective: Provide clinical summaries to patients for each office visit
Measure: Clinical summaries provided to patients for at least 80 percent of all office visits
20 – Objective: Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically
Measure: Performed at least one test of certified EHR technology’s capacity to electronically exchange key clinical information
21 – Objective: Perform medication reconciliation at relevant encounters and each transition of care
Measure: Perform medication reconciliation for at least 80 percent of relevant encounters and transitions of care
22 – Objective: Provide summary care record for each transition of care and referral
Measure: Provide summary of care record for at least 80 percent of transitions of care and referrals
23 – Objective: Capability to submit electronic data to immunization registries and actual submission where required and accepted
Measure: Performed at least one test of certified EHR technology’s capacity to submit electronic data to immunization registries
24 – Objective: Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice
Measure: Performed at least one test of certified EHR technology’s capacity to provide electronic syndromic surveillance data to public health agencies (unless none of the public health agencies to which an EP or eligible hospital submits such information have the capacity to receive the information electronically)
25 – Objective: Protect electronic health information maintained using certified EHR technology through the implementation of appropriate technical capabilities
Measure: Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308 (a)(1) and implement security updates as necessary
The Sum Total
Again, not all these criteria seem terribly relevant to chiropractic and quite frankly, I would love to see how some EMR providers can define these in such a way that they can guarantee stimulus dollars.
My recommendations:
- If you already are using EMR, approach your provider with this list and see how their system can complete the measures to obtain each objective so that you at least have a chance at getting some stimulus funding.
- If you do not yet have an EMR system, use these criteria as part of your questions to each system that you are considering for purchase, particularly if they are claiming to get you some stimulus funding. Also, consider purchasing “How to Choose a Chiropractic EMR System” Audio series to further assist you in making a wise choice of systems that will fit your needs.
- If you are unsatisfied with your current system, consider shopping for another and following the instructions in #2 – but do not purchase your new system just because you think you are going to get the HITECH dollars!
Best wishes for continued success!
Tom Necela, DC
What Exactly is "Defensible" Chiropractic Billing, Coding & Documentation?
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!
“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.
Your Toughest Chiropractic Billing, Coding, Documentation Questions Answered – FREE!
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!
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Thursday December 17, 2009
– 9 am PST/10 am MST/11 am CST/Noon EST
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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!
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Hope to see you there!
Tom Necela, DC, CPC, CPMA
The Strategic Chiropractor
Are You Coding Your Chiropractic Adjustments Incorrectly? New Coding Clarification!
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!).