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chiropractic compliance consulting Archives - Compliance and Auditing Services

Preparing For Significant Revisions To E/M Office Visits 2021

By | Compliance, Insurance Coding | No Comments

Starting January 1st, the American Medical Association (AMA) 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 do little to support patient care. Simply put, adherence to the old E/M guidelines consume a significant amount of the physician’s time and don’t necessarily reflect the actual work by the physician.

So, in accordance with President Trump’s executive order, directing federal agencies to cut red tape, CMS proposed revisions to the E/M rules to decrease administrative burden and make code level selection more intuitive. CMS feels this will improve payment accuracy and minimize the amount of note bloating from EHR copy and pasting of the same problem list day after day.

The current E/M code set includes guidelines on using the 3 key elements of history, examination and medical decision-making to determine the correct E/M code level to bill.

With that said, starting on January 1st, 2021 practitioners will now document office and outpatient E/M level codes 99202—99215 based on total time on medical decision making (MDM) or the total time on the date of the encounter.

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

Starting with time, except for 99211, time alone may be used to select the appropriate code level for the office or other outpatient E/M services codes 99202 – 99215 whether or not counseling and/or coordination of care dominates the service.

When time is used to select the appropriate level for E/M services codes, time is defined by the service descriptors in each category.

The E/M services for which these guidelines apply require a face-to-face encounter with the physician.

Here are the major points from the 2021 guidelines for Time:

  • You will be able to use time alone to select the correct code from 99202-99205 and 99212-99215. Note that 99211 is not in that list because no time is listed in that descriptor.
  • The 2021 Time guidelines explain that for 99202-99205 and 99212-99215, total time on the encounter date includes both face-to-face and non-face-to-face time spent by the provider on the same day as the visit.
  • When you start counting time for the 2021 codes, you should not include time spent on services you report separately. For instance, if you report care coordination or x-rays using a separate code, you should not include that in the time for the E/M code.

This is because the performance and/or interpretation of diagnostic tests/studies during a patient encounter are bundled together under a separate billing code and not included in determining the levels of E/M services. Even so, it should be documented in your records.

  • The total time also will not include time for activities the clinical staff normally perform such as taking vitals.

Physician professional time includes the following activities, when performed:

  • Preparing to see the patient (eg, intake forms and studies from other providers)
  • Obtaining and/or reviewing separately obtained history
  • Performing a medically appropriate examination and/or evaluation
  • Counseling and educating the patient/family/caregiver
  • Ordering tests or other procedures
  • Referring and communicating with other healthcare professionals (when not separately reported)
  • Documenting clinical information in the patient’s health record
  • Care coordination (not separately reported)
  • Typically, because a chiropractor cannot justify the use of the 99205/99215 codes they will not be used.
  • If coding using the 99204/99214 codes, make sure that your documentation supports its use.

The following are the time codes used as a determining factor for each category:

New patient codes:

  • 99202: 15-29 minutes
  • 99203: 30-44 minutes
  • 99204: 45-59 minutes

Established patient codes:

  • 99212: 10-19 minutes
  • 99213: 20-29 minutes
  • 99214: 30-39 minutes

 

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.

Additionally, It isn’t necessary to note how much time was spent in each activity but the total time for the encounter.

Describe what was done, and document time in a single statement as in the example below.

“I spent 30 minutes reviewing the patient’s intake form, examining the patient, and documenting my diagnosis and findings in the record. I also discussed treatment with the patient, including the possible risk associated with treatment and alternatives to care. The patient stated that they understood the risk and requested that treatment be performed.”

  • Though a medically appropriate history and/or examination will not be part of the basis for code selection, history and exam findings that are pertinent to the visit should still be documented.
  • Physician documentation must accurately depict what occurred during the encounter, as you still need to be covered in the event of a lawsuit or post-payment audit.
  • It’s crucial to understand that your E/M documentation must support the medical necessity of the diagnosis and treatment provided.
  • When using time as a coding factor, if a physician reviews medical records or special studies from another source on the day of the encounter, they should document what specific records or studies and their origin.

Also, the physician should sign the document with their full name and credentials (eg, DC) to show that they reviewed them.

  • Keep in mind, the AMA does not process or pay claims and as such, they are not the final word on billing policies or payment guidelines. This means that though CMS is accepting the new E/M guidelines for 2021, single payers and commercial Insurance plans may not.

So, it is your responsibility to contact the individual commercial insurance providers and make sure that they are accepting the new guidelines.

Because starting in 2021 practitioners will document office and outpatient E/M level codes 99202—99215 based on time or medical decision making (MDM), part two of this article will review the requirements for medical decision making (MDM) and the different categories associated with each E/M level code.

Knowing this information and the differences should help you in deciding which method would be best for your office.

The “Compliance Made Easy” program is the most complete course on office compliance and includes how to document the correct E/M code.

_____________

All the Best,
Dr. John Davenport
Chief Compliance Officer

Compliance Consultant

Compliance Consultant Explains Active Treatment

By | Compliance, Compliance Consultant | No Comments

As a compliance consultant,I find that a high percentage of chiropractors are guilty of providing only passive therapies to their patients.

In fact, third-party payers have coined the phrase M.U.S.H. for chiropractic treatment. This is an acronym for manipulation, ultrasound, stem, and heat.

Due to the increasing amount of evidence-based research and increased scrutiny on the chiropractic profession by insurance carriers, prolonged use of passive therapies is frowned upon and could be a red flag for doctors.

Insurance carriers require providers to prove medical necessity of the treatment they provide and show a direct therapeutic relationship to the services rendered.

 

Based on research, carriers feel that prolonged passive therapy leads to dependence by the patient for symptom relief, and do nothing to improve the patient’s complaints in the long run.

Since passive therapies are typically used in the initial, acute phase of care to reduce pain and swelling, their clinical effectiveness tends to decline after one to two weeks of treatment.

In fact, the Council on Chiropractic Guidelines & Practice Parameters, stated, “Although passive care methods for pain or discomfort may be initially emphasized, “active” (ie, exercise) care should be increasingly integrated to increase function and return the patient to regular activities.”

It recommended that physicians limit the use of therapeutic modalities only to, “facilitate the shift from passive-to-active care and not dependency on passive modalities with limited evidence of efficacy.”

 As a compliance consultant, I tell my clients that when moving to active care, the goal of treatment is to improve functional deficits, increase the strength and endurance of a given area, and minimize the potential for re-injury or exacerbation of the patient’s chief complaint.

Therefore, Insurance carriers not only encourage active rehabilitative care, they see it as the natural progression of treatment and feel it justifies the medical necessity of longer treatment.

Additionally, encouraging patient participation in treatment incentivizes the patient to continue treatment once their pain has improved in an effort to prevent future problems.

It’s a win-win for everyone involved because improving the patient’s functional weakness is the best thing for your patients, and insurance companies pay more for active therapies than passive care.

Having taught human performance and sports rehabilitation on the college level, I know there are many different ways to approach active care besides having a full-size gym in your office or employing physical therapists or athletic trainers.

With a little knowledge, you can develop a viable rehab program in your office for less than $200.00. In addition, you make more money while minimizing denials, request for more information to justify treatment, and being flagged for an audit.

If you have any questions or would like additional information, don’t hesitate to contact one of our compliance consultants at 800-509-0538

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

CMS Targeting Against Payments for Chiropractic Services?

By | OIG | No Comments

The Office of Inspector General (OIG) released a new report titled, “CMS Should Use Targeted Tactics to Curb Questionable and Inappropriate Payments for Chiropractic Services.”

OIG Report  According to the Centers for Medicare & Medicaid Services (CMS) Comprehensive Error Rate Testing program, Chiropractic services have the highest rate of improper payments among Part B services.

Past OIG investigations found that between 40 and 47 percent of all paid chiropractic claims were for maintenance therapy and stated that, “Medicare paid out over $76 million for chiropractic services that were questionable.”

In addition, Medicare fraud cases suggested that vulnerabilities existed with other chiropractic services, such as physical therapy.

The OIG analyzed paid claims for chiropractic services to identify any chiropractors who exhibited questionable billing. Using the data, the OIG uncovered 809,945 claims resulting in overpayments. In addition, The OIG identified over twenty-five thousand chiropractors who received high amounts of questionable payments and then determined their locations, past questionable payments and whether their patients received same-day physical and occupational therapy.

Important to doctors of chiropractic is that the report outlined plans on how to determine questionable chiropractic claims and recoup payments using different measures.

The first area to be targeted is treatment that is suggestive of maintenance therapy. Using 20 services per beneficiary per year as a threshold, the OIG looks at all claims in excess of the threshold to be questionable and suggestive of maintenance therapy.

Even though there are legitimate reasons for a Medicare patient to need treatment more than 20 times per year, you need to be able to justify your reasoning and have good documentation that supports it.

Additionally, a common issue for chiropractors is that they forget to change the date in box 14 when a Medicare patient comes back to the office for a new injury or exacerbation of a chronic condition. Forgetting to change the date in box 14 makes Medicare think that you are continuing to treat the patient from the date of the original condition and not for a new condition.

Just know that if you regularly see Medicare patients more than 20 times in a year, you risk being reviewed by the Department of Health and Human Services.

The second target is to identify chiropractors with high, questionable payments for upcoding claims.

Statistically only 10-15 percent of all paid chiropractic services are for the five-area adjustment code, 98942. As a result, the OIG set a threshold to identify doctors who billed out higher percentages of their claims using the 98942 code.

In the third measure, the OIG developed three ways to identify paid claims that did not meet Medicare requirements for payment:

  1. Submitted claims that, “Lack a Medicare Covered Primary Diagnosis. These claims lacked a primary diagnosis code that was covered by Medicare based on CMS guidance and the local coverage determination where the chiropractic service was provided.” In the report, almost 39 percent of chiropractors were identified as having filed at least one claim without a correct primary diagnosis. This amounted to a total of $20,709,516.00 in paid claims without the correct primary diagnosis. This means that Medicare requires an M99 subluxation or segmental dysfunction diagnosis as primary or the first coded diagnosis, except in Florida, the Virgin Islands and Puerto Rico. The local coverage determination for your state determines the M99 ICD-10 code you need to use as your primary diagnosis (ie subluxation or segmental dysfunction).
  2. Claims for Duplicate Services, meaning services provided on the same day for a patient with the same diagnosis and procedure codes by the same chiropractor.
  3. Claims Lacking the AT Modifier. “The AT modifier indicates active treatment is being provided and is a requirement for payment.”

Medicare only pays for chiropractic services to improve function (active treatment) but does not cover “maintenance therapy,” which is when further clinical improvement cannot be expected from ongoing treatment.

The next measure is an unlikely number of services per day on which paid chiropractic services totaled 16 hours or more. The threshold here is billing an average of 65 chiropractic services per day.

The OIG stated that, “This raises questions regarding the quality of patient care and, perhaps, whether these services were even rendered by the chiropractor.”

Lastly, according to experts in chiropractic practice and fraud detection, is the potential sharing of Medicare beneficiaries with claims from multiple chiropractors, which indicates potential kickback arrangements or medical identity theft.

The OIG stated, “We considered all of their payments for the beneficiaries seen by other chiropractors to be questionable.”

OIG Recommendations:

As a result of the study, the OIG made the following recommendations to the Centers for Medicare and Medicaid Services:

  1. Establish a more reliable control for identifying Active Treatment
  2. Develop and use measures to identify questionable payments for chiropractic services.
  3. Collect overpayments based on inappropriately paid claims.
  4. Ensure that claims are paid only for Medicare-covered diagnoses.
  5. Take appropriate action on chiropractors with questionable payments.

In a separate memorandum the OIG said, “we will provide CMS with information on chiropractors with high questionable payments, so that it may take action. CMS and/or its contractors should review their claims and take appropriate action.

Such actions could include:

  1. Recouping inappropriate payments.
  2. Educating providers on proper billing.
  3. Making referrals to law enforcement.
  4. Imposing payment suspensions.
  5. Revoking billing privileges.
  6. Taking no action, if the payment is determined to be appropriate.
  7. “Collect overpayments based on inappropriately paid claims. CMS should collect the $20.7 million in payments that resulted from the inappropriate claims we identified.”

So what does this mean to you as a chiropractic physician?

It should tell you that Medicare is stepping up its investigations and is continuing to develop the means to analyze your claims. Because of this increased scrutiny, chiropractic claims are going to be reviewed in more detail.

So don’t just sit back and hope the laws and regulations are going away; they’re not. It’s more important than ever for you to take advantage of everything Compliance & Auditing Services provides to its members.

If you’re not a member, the best advice I can give you is to take your head out of the sand. Thinking that it won’t effect you is no longer an option.

Review all of your documentation, coding and billing procedures to ensure you’re in compliance with all laws and regulations. Make sure you have a documented compliance program in place. If you’re too busy with running your office or feeling overwhelmed by all the laws and regulations, consider a compliance consultant that will develop, implement and help you maintain an office compliance program that will meet and exceed all government regulations.