Chiropractic Coding & Compliance Alert

Compliance/Reimbursement:

Don't Get Burned: Palmetto GBA's Scalding Audits Screaming a 60 Percent Error Rate

Published on Thu Dec 10, 2015

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No response to ADRs the top reason for denial.

It seems to be raining audits for chiropractors. After an alarming OIG report this November, get ready for another shady report from Railroad Medicare, stating an error in almost 60 percent of claims reporting either of the two most common services 98940 (Chiropractic manipulative treatment [CMT]; spinal, 1-2 regions) or 98941 (… spinal, 3-4 regions), or both, which were denied for multiple reasons. The carrier reviewed 15,008 chiropractic service claims submitted between July and September 2015. After analysis, only 6,045 claims could be allowed – and the remaining 8,963 were denied.

Good news: Medicare shared the most common, trivial mistakes they found the providers committed. Though much has been said about this, “Only clear and specific documentation” will spare you, says Doreen Boivin, CPC, CCA, with Chiro Practice, Inc., in Saco, Maine.

Read on to learn how you can avoid being grouped with the denials.

1. You Can’t Afford Delaying Your Response to ADRs

As a part of the medical review process, claims are randomly selected for ADRs, or additional documentation requests. Providers have 45 days to respond to the request, failing which the claim is automatically denied. Around 5,400 (or more than half) of the denied claims were for this reason alone.

2. Go the Extra Mile in Documentation

Around 3,100 claims were rejected on grounds of insufficient documentation. The gaps included missing patient history, inadequate treatment plans, incomplete P.A.R.T. exam to document subluxation, and poor handwriting, amongst others.

Palmetto identified missing or insufficient documentation regarding:

Required elements of the history and examination
Treatment plans lacking specific goals with objective measures to evaluate treatment effectiveness
P.A.R.T. (Pain, Asymmetry, Range of Motion, and Tissue/Tone) exam to document subluxation: Two of these four elements must be present, one of which must be asymmetry or range of motion abnormality.
Documentation of the treatment given on the day of visit
Illegible documentation, with use of abbreviations
Subluxation details for each spinal level manipulated
CMT being mentioned as is, not using vague terms like “treatment or therapy”
Whether each manipulation performed related to a relevant symptomatic spinal level identified in the P.A.R.T. exam.
To wade through this list, Palmetto GBA gives you a checklist to assist when you respond to a request for medical records, and also gives clean sweep documentation for the next patient you see.

“A checklist is a great idea to make sure you have everything in order,” says Boivin. Go to the Palmetto GBA website to learn more. Under ‘Medical Review,’ click on ‘Chiropractic Services Checklist.’

3. Don’t Just Correct, Perfect Your Signatures

It’s a pity that 130 claims were denied just because of improper signatures. Here are a few facts that Palmetto tells you to be wary of:

Medicare requires the service to be authenticated by the provider.
The signatures should carry the provider’s first and last name and be legible.
Double check that the documentation carries a signature attestation or a signature log.

Just being a little more careful is all that is required to circumvent a denial you definitely do not deserve.

4. Check Out Palmetto’s Tips for Medical Necessity

According to Palmetto, complete documentation is a prerequisite to create a clear picture of the patient’s illness and treatment. It should tell the reader of the patient’s baseline condition, prescribed treatment, treatment timelines, and how the patient responds functionally. Remember to use objective and measurable parameters in your documentation.

Objective goal setting: While setting goals, remember to include restoration or measurable improvement in the impaired activities of daily living that the patient may be experiencing due to pain and the diagnosed problem. Goals should be according to the patient’s need and be paced in sync with the baseline function as determined with initial assessment.

Example: Suppose a patient complains that he is in so much pain that he cannot stand more than 20 minutes. His pain on the Visual Analogue Scale (VAS) is 9. After your assessment, you decide to set your goal as decreasing the pain VAS level to 3. Going further, you should also consider a goal to improve the patient’s standing capacity realistically, such as to one hour.

No judgments, please: Remember to document measurable improvement toward your goals on subsequent visits, and not a judgmental “patient is getting better.”

Don’t slack on follow ups: Though you do not need this detailed an assessment on the subsequent visits, remember to document the progression of treatment in terms of periodic reevaluations at regular intervals. In case of an ADR request, you must invariably include initial and updated evaluations.

The road ahead: The Palmetto GBA expects to continue keeping a close watch by conducting service-specific prepayment review in the next quarter. This review will identify, substantiate, or disprove questionable billing patterns. The 2016 review will include 98940, 98941, and 98942 as well.

Arm yourself: Follow the ACA documentation guidelines. Take the time now to get it right so in the future you don’t have to fight for getting paid.

“Be prepared, know what you need to be doing,” advises Boivin. “The more delays in payment, the further you get behind. It can get out of control if you don’t get behind it now and correct it.”