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Chiropractic auditing services Archives - Compliance and Auditing Services

Preparing For Significant Revisions To E/M Office Visits 2021

By | Compliance, Insurance Coding | No Comments

In part one of this article we learned that starting January 1st, the American Medical Association implemented major changes to the 2021 Current Procedural Terminology (CPT) code for outpatient evaluation and management (E/M) services.

The stated reason for the need to change the Evaluation and Management (E/M) guidelines was that the guidelines did little to support patient care and that the old E/M guidelines consume too much of the physician’s time and didn’t reflect the actual work done by the physician.

While the current E/M code set guidelines use the 3 key elements of history, examination and medical decision-making to determine the correct E/M code level to bill, The new guidelines will allow practitioners to document office and outpatient E/M level codes 99202—99215 based on the total time spent on the date of the encounter or medical decision making (MDM).

Additionally, because of the new change, it was necessary that the descriptions and guidelines surrounding MDM and time be redefined for better clarity.

For example, when time is used to select the appropriate level for E/M services codes, the following are the time codes used as a determining factor for each category:

New patient codes:

 Established patient codes:

99202: 15-29 minutes 99212: 10-19 minutes
99203: 30-44 minutes 99213: 20-29 minutes
99204: 45-59 minutes 99214: 30-39 minutes

The E/M services for which these guidelines apply require a face-to-face encounter with the physician and remember to count only the practitioner time on the calendar day the patient was seen. Do not include time on any other day, and don’t include staff time.

With that said, in the first part of this article we reviewed the descriptors and guidelines that support the use of time to select the appropriate level for E/M services in depth.

If you didn’t read part one of this article, regarding the use of time, read the last newsletter HERE. Knowing this information and the differences should help you in deciding which method would be best for your office.

The purpose of this article is to learn the descriptors and guidelines that support the use of a Medical Decision Making (MDM) E/M code set.

In general, MDM is related to the process of establishing a diagnosis, assessing the status of a condition, and selecting a management option. MDM is defined by the following three elements:

  • The number and complexity of problem(s) addressed during the encounter.
  • The amount and/or complexity of data to be reviewed and analyzed. This data includes medical records, tests, and/or other information reviewed and considered for the date of the encounter and not a subsequent encounter.
  • The risk of complications, morbidity, and/ or mortality of patient management decisions made that are associated with the patient’s problem, diagnostic procedures, treatment and treatment alternatives at the time of the visit.

This includes the possible management options selected after sharing medical decision making and explaining both the risks and benefits of each management option with the patient, family and/or legal representative.

It’s also important to know the four levels of MDM recognized as part of the new 2021 E/M guidelines: straightforward, low, moderate, and high.

To determine the most appropriate level of MDM to report, the physician would review and meet the qualifications for each of the three elements of MDM.

To aid physicians in selecting the level of MDM for reporting the correct E/M service code, the AMA developed a guideline to assist in selecting the acceptable level of MDM.

The following guideline includes the four levels of medical decision making and the three elements of medical decision making.

Note that to qualify for a particular level of medical decision making, at least two of the three elements for that level of medical decision making must be met or exceeded.

Three Element Qualification Guide:

Level of MDM: Straightforward  (99202/99212)

  1. The number and complexity of problem(s) addressed during the encounter.
    • Minimal
      – 1 self-limited or minor problem
  1. Amount and/or Complexity of Data to be Reviewed and Analyzed.
    • Minimal or none
  1. Risk of Complications and/or Morbidity or Mortality of Patient Management.
    • Minimal risk of morbidity from additional diagnostic testing or treatment

Level of MDM: Low  (99203/99213)

  1. The number and complexity of problem(s) addressed during the encounter.
    • Low
      2 or more self-limited or minor problems or one or more of the following:

      • 1 stable chronic illness
      • 2 acute, uncomplicated illness or injury
  1. Amount and/or Complexity of Data to be Reviewed and Analyzed.
    • Limited (Must meet the requirements of at least 1 of the 2 categories)

Category 1: Tests and documents

  • Any combination of 2 from the following:
  • Review of prior external note(s) from each unique source*
  • Review of the result(s) of each unique test*
  • Ordering of each unique test*

Category 2: Assessment requiring an independent historian(s)
( An Independent historian is any individual (eg, parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history or because a confirmatory history is judged to be necessary.)

  1. Risk of Complications and/or Morbidity or Mortality of Patient Management.
    • Low risk of morbidity from additional diagnostic testing or treatment

Level of MDM: Moderate  (99204/99214)

  1. The number and complexity of problem(s) addressed during the encounter.
    • Moderate
      • 1 or more chronic illnesses with exacerbation progression, or side effects of treatment or one or more of the following:
        • 2 or more stable chronic illnesses
        • 1 undiagnosed new problem with uncertain prognosis
        • 1 acute illness with systemic symptoms
        • 1 acute complicated injury
  1. Amount and/or Complexity of Data to be Reviewed and Analyzed.
    • (Must meet the requirements of at least 1 out of 3 categories)

Category 1: Tests, documents, or independent historian(s)

  • Any combination of 3 from the following:
  • Review of prior external note(s) from each unique source
  • Review of the result(s) of each unique test and ordering of each unique test
  • Assessment requiring an independent historian(s)

Category 2: Independent interpretation of tests

  • Independent interpretation of a test performed by another physician/other qualified healthcare professional (not separately reported)

Category 3: Discussion of management or test interpretation

  • Discussion of management or test interpretation with external physician/other qualified health care professional or appropriate source (not separately reported)
  1. Risk of Complications and/or Morbidity or Mortality of Patient Management.
    • Moderate risk of morbidity from additional diagnostic testing or treatment

Examples only:

  • Prescription drug management
  • Decision regarding minor surgery with identified patient or procedure risk factors
  • Decision regarding elective major surgery without identified patient or procedure risk factors
  • Diagnosis or treatment significantly limited by social determinants of health

In review, history exam is no longer a defining element when choosing the appropriate level of medical decision making. But it is important to understand that even though the nature and extent of the history and/or physical examination is determined by the treating physician, the guidelines still require that all E/M services include a medically appropriate history and or physical examination.

Remember that billing for outpatient evaluation and management (E/M) services is based on complexity as documented, and not based on implied or undocumented complexity.

All the Best,

Dr. John Davenport
Chief Compliance Officer

Compliance & Auditing Services

(800) 509-0538

Changes To the Advance Beneficiary Notice of Non-Coverage

By | Department of Health and Human Services, Medicare | No Comments

The Advance Beneficiary Notice of Non-Coverage (ABN), is a notice given to Medicare beneficiaries to convey that Medicare is not likely to cover the service provided, or it is issued by providers in situations where Medicare payment is expected to be denied.

It is important to note that physicians’ offices must complete the ABN and deliver the notice to beneficiaries or their representative for review, and any questions raised during that review must be answered before it is signed.  This ensures that the patient or their representative has time to consider the options and make an informed choice.

Once all the blanks are completed and the form is signed, the physician’s office then gives a copy to the beneficiary or representative.  CMS mandates that the provider retain a copy of the ABN on file.

All of this is required before providing the items or services that are the subject of the ABN.  If these procedures are not followed or the form is filled out incorrectly, the ABN is considered invalid.  In certain cases, an invalid ABN could require repayment by the provider for all services rendered, as well as sanctions.

To quote Medicare, “Medicare will hold any provider who either failed to give notice when required, or gave defective notice, financially liable.  Additionally, when authorized by law and regulations, sanctions under the Conditions of Participation (COP) may be imposed.  A provider who gave defective notice may not claim that she/he did not know or could not reasonably have been expected to know that Medicare would not make payment as the issuance of the notice (albeit defective) is clear evidence of knowledge.”

As a chiropractic compliance consultant, I’m always asked about filling out an ABN for non-covered services (i.e. therapies, exams, and x-rays).  The ABN is only required when you feel a service will be denied, and for chiropractic physicians, the adjustment is the only covered service.

If you wish to issue an ABN as a courtesy to the beneficiary, advising them of any financial liability for services that Medicare never covers (anything that’s not an adjustment), you can.  This is called a voluntary ABN and this is considered non-valid by Medicare.  If an office chooses to issue a voluntary notice, the beneficiary doesn’t need to choose an option box and is not required to sign the notice.


A better way to do this would be to design a statement form that tells the patient that Medicare only covers the adjustment and that the patient will be financially responsible for non-covered services provided as part of your treatment.

The ABN is approved by the Executive Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 and is subject to re-approval every 3 years.

With that said, the form has been revised to include language informing beneficiaries of their rights to CMS non-discrimination practices and how to request the ABN in an alternative format if needed.

Providers are expected to exclusively use the current version of the ABN, and even though there are no changes to the form itself, providers must pay attention to the OMB approval date on the notice and obtain the current version.  The date of mandatory use of the new ABN starts with claims made on or after 06/21/2017.

The new ABN form may be downloaded using the following links:

English version:


Spanish Version:


You should be able to click on the links. If you have problems with the link just copy and paste it into the browser, then click enter.

Hopefully, this Compliance & Auditing Services notice will give you time to switch to the newly approved notices.

If you have any questions or need help, don’t hesitate contacting Compliance & Auditing Services.

All the Best,

Dr. John Davenport
Chief Compliance Officer
Compliance & Auditing Services


Get Ready for Medicare Provider Enrollment Revalidation

By | Compliance, Medicare | No Comments

Section 6401 (a) of the Patient Protection and Affordable Care Act established a requirement for all enrolled providers to revalidate their Medicare enrollment information roughly every five years to prevent fraud within the Medicare system by ensuring that Medicare provider records are accurate.

Cycle 2 Revalidation began on February, 2016. Basically this means a physician’s maintenance of the Medicare billing privileges cycle. Simply put, revalidation is re-enrollment and all providers are required to revalidate their enrollment information.

If the provider doesn’t submit a complete revalidation application by their specific due date, the Medicare Administrative Contractor (MAC) may hold your Medicare payments or deactivate your Medicare billing privileges.

Typically, your Medicare Administrative Contractor (MAC) will send a revalidation notice within two to three months prior to your revalidation due date either by mail or to the email address reported on prior applications indicating the providers due date.

Note that your MAC must receive your enrollment application within 60 days of the revalidation request.

The best way to prevent a lapse in coverage is to verify your due date, listed on  Data.CMS.gov/revalidation. The list will include all enrolled providers and will display the provider’s revalidation due date. In addition, a crosswalk to the organizations that the individual provider reassigns benefits will also be available as well.

For providers not up for revalidation, the list will display a “TBD” (To Be Determined) in the due date field. This means the provider’s due date is more than 6 months away.

The list was revised on April 10, 2017. All dates are updated every 60 days at the beginning of the month and are listed up to 6 months in advance. Do not submit a revalidation if you have not received an email/mailed letter from your MAC requesting you to revalidate, or your due date is not listed on the CMS revalidation website. If you do, it will be considered an unsolicited revalidation and will be returned.

If you are within 2 months of the listed due date on the CMS revalidation website and have not received a notice from their MAC to revalidate, as a chiropractic consultant I recommend that you make every effort to submit your revalidation application immediately.

The most efficient way to submit your revalidation information is thru the Internet Based PECOS. Here you can review information currently on file, update and submit your revalidation and electronically sign after uploading the supporting documents. If you wish, you can just print out your revalidation , sign and date it  and then mail your paper certification along with supporting documentation to your Medicare Administrative Contractor (MAC).

It is important that providers check their due date immediately in order to avoid a hold on your Medicare payments.

If you have any questions or need help, don’t hesitate contacting the ACS or Dr. Davenport at complianceandauditingservices.com.

All the Best,

Dr. John Davenport DC, CCSP, FIAMA, MCSP, CIC

Certified Compliance and Insurance Consulting Services

Post Payment Audits

By | Audits | No Comments

Screen-Shot-2013-12-03-at-1.13.23-PMAudits are big business for insurance carriers. For every 2 dollars that insurance companies spend on investigations, they profit $17 dollars in recoveries. In fact, audit and investigation divisions are one of the most profitable divisions for insurance companies.

Even though this doesn’t mean insurance carriers are out to get you, studies show that chiropractors have one of, if not the highest error rate when it comes to documentation.

In other words, insurance companies know chiropractors are bad at documentation and it’s easier to get money from them.

In general, chiropractors assume that as long as insurance carriers and Medicare are paying, they must be billing correctly. This is a very dangerous assumption to make.

Both insurance companies and Medicare collect information on all providers to identify those who fall outside the accepted parameters.

If your claims are coded improperly, you will be held responsible and required to pay back all the payments you received and possibly an additional fine.

The average payout by a practice seeing an average of 70 patient visits per week is $40,000.00 and $800,000.00 in an office seeing an average of 350 patients visits per week.

Because audits can be conducted on any provider that receives payments, and that includes cash practices as well, you can be audited. It’s not a question of if you’ll get audited; it’s a question of when you’ll get audited.

What Triggers an Audit?

Audits can be triggered in several ways, but the two most common are complaints and profiling.

As an example, a doctor contacted me recently for consulting services because a patient submitted a complaint to the board of chiropractic. The board requested the patient’s record for review. Because his documentation was so poor, the board requested five more files to be reviewed by the Department of Healthcare Quality Assurance.

Concerned, he called my office to review the files before submitting them to the board. Unfortunately, his documentation did not support his billing and without going into detail because I’m now working with his attorney, he is facing fines up to $10,000 dollars, the loss of his license, and possible referral for criminal prosecution.

With profiling, insurance companies gather information from claims submissions and then use the information to profile your billing patterns. If your office falls outside accepted parameters, then you get picked out for an audit.

Usually it starts with a request to review a certain number of patient files. Then the auditor reviews the files to determine if your records support the services that you received payment for.

If the records can’t prove the medical necessity of your treatment or support the billing codes, then the auditor will calculate a “percent deficiency,” and then extrapolate that over all the claims paid to you for the past five years.

That will then determine your payback amount and the insurance company sends you a letter demanding you pay them back.

As an example, a doctor called Compliance & Auditing Services for help when he received a request for $400,000 dollars.

Medicare audits can be triggered by a complaint, profiling or even randomly.     Medicare has a policy requiring them to randomly audit doctors’ offices.

The worst-case scenario is to have criminal charges filed against you.

Specific triggers include:

  1. Billing for maintenance care
  2. Overusing CMT code 98941(3-4 regions) or 98942 (5 regions).

   *Payers consider the correct percentage of utilization by chiropractors for CMT codes is:

                                   98940–25%, 98941–60%, 98942–15%*

  1. Excessive use of the E/M codes 99204 and 99205.
  1. Billing massage therapy (97124) with a CMT 98941 or 98942.
  1. Billing manual therapy (97140) with a CMT 98941 or 98942.
  1. Repeatedly billing neuromuscular re-education (97112).
  1. Billing passive therapies beyond the first 12 visits of care.

Being audited doesn’t mean you are guilty, it means you have to prove that you are innocent. So be able to justify your treatment with accurate documentation and evidence-based research.

Take the first steps now, before you get audited, by taking the time to improve your documentation and billing polices.

Start implementing active rehabilitation directed at the improvement of function rather than symptom relief. Most importantly, take compliance seriously.

Though there’s no way to completely avoid an audit, performing internal audits and having a comprehensive compliance program in your office can flag potential problems in billing or coding and avoid costly mistakes.

In fact, federal regulation requires you to do regular audits and to have a documented compliance program in your office.

Signed into law by the Health Care and Education Reconciliation Act of 2010, having an active office compliance program is mandatory. So you don’t have a choice, it’s the law.

Compliance programs must be updated regularly and followed to the letter.

If you haven’t completed an internal audit or developed a comprehensive compliance program, now is the time. Both can be done by outside consultants, or done in-house.

For example, all Compliance & Auditing Services consultants are certified as medical compliance specialists, insurance consultants and certified peer reviewers. Our company can design a compliance program that meets all federal and state regulations for you from scratch and conduct the required internal audits.

So why struggle to be compliant alone when there’s a team of qualified experts ready to give you the personal support you need to protect your office from losing 1000s of dollars to audits.

These are trying times for all doctors and ignoring the new regulations is no longer an option.


Dr. John Davenport DCM, CCSP, FIAMA, MCSP, ICI

Chief Compliance Officer Compliance & Auditing Services