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Well, hello everyone and happy holidays. This is Michael Miscoe with Miscoe Health Law for my final installment of the ChiroSecure Growth Without Risk presentation series this year. And I thought being to the end of the year, I should talk about some ways to mitigate risk in 2024. So you don’t find yourself with the need to call me or somebody like me.
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And have a successful year without any post-payment hangups. For those of you that are still billing we’re gonna talk about cash practices as well, but if you’re still billing insurance companies, you need to be very thoughtful about who you’re participating with. It’s a good time to break out your contracts.
Review the medical policies and make sure that you understand the requirements for documentation. You understand what they think is experimental, investigational, that you understand what they think is not covered, what they think. Bundles with other things like manual therapy or massage, what their delegation policies are.
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Because, it becomes virtually impossible to comply with the rules when you don’t understand what the rules are. So if you’re gonna have a, a New Year’s resolution enjoy your downtime, certainly over the holidays, but this is a great time to get together with your staff, review these medical policies for the payers that you part with, and even some of the payers that you don’t.
If your practice does cease quite a few of their patients because understanding their requirements is quintessential to avoiding problematic billing and coding that is likely to get revealed during a data analysis audit. And by which you come to the top of the heap and they decide to send you a letter requesting records.
Some problematic coding things that I’ve seen over the past year that just, that come up with unfortunately increase just very common and they shouldn’t be. If you’ve listened to these presentations in the past, I’m not telling you anything new. Watch your level of cmts. There should be diversity in the level of CMT that you bill, and for those of you that, that.
Treat full spine fine. Wonderful. But billing full spine means that the patient’s got a source complaint in each region of the spine, hopefully with an associated mechanism of injury. if They fell off a building, sure. I’ll believe that they’re a full spine case, at least for a while. But, even though you treat full spine, many of you will do what’s called cluster coding and you’ll bill the middle level 9 8 9 4 1 and you’ll bill it all the time and it looks odd. It’s just unlikely that everybody’s gonna have a medic medically necessary need for treatment in three to four regions of the spine.
It’s possible, but is very unlikely. You need some 9, 8, 9, 4 oh cases. Your, generally your neck and upper back cases. Those are your 9 8 9 4 ohs. Your mid-back, low back cases. That’s where your 9 8 9 4 ones come from. dePending on your patient population, maybe you see a lot of low back cases, but try to achieve some diversity in your billing profile.
Take the patient’s complaint. Whatever it is that they’re coming out with, don’t do condition creep. If they’re coming in complaining, neck pain and headaches, don’t ask ’em about how their low back is feeling. ’cause they’re gonna say something and you’re gonna go dinging.
And now we got neck midback, low back and every case is neck, midback low back and you’re billing 9, 8, 9, 4, and one’s all the time. And you’re gonna get audited sooner or later. Also. Watch your billing with, your frequent flyers. Because in every case that we do, there’s always, the couple of patients, sometimes when they do a probiotic, they only select these patients where the visit history is just horrible.
You’ve seen the patients for years and years. They keep coming. thE documentation doesn’t do a good job. When there are breaks in care explaining why the patient came back there’s no mechanism. There’s really no way to establish a start point that allows me to whittle down the course of, into just these six visits where we would have a decent medical necessity argument.
If a patient comes. Treat ’em like a new patient. Explain what’s gone on since you’ve seen them last. What mechanism or what brought them back. Hopefully it’s not something wimpy, like aggressive feather dusting or long car rides or whatever, slept funny on the couch. I know it happens, but it doesn’t present the, an argument for a significant health problem that allows you to start a new course of care.
Similarly, January 1st is just around the corner and, patients get new visits on the first of the year, and just because they get new visits doesn’t mean that you have an authorization to start billing again. If they ran out of visits and you’ve been doing ’em cash, you keep ’em cash until they trip over the cat and do a head plan into the wall strain their low back lifting Christmas presents something.
But before you start billing a new course of care, make sure there’s a reason to do it. Also with your frequent flyers, watch billing profiles where you’re billing, one and done two visits and done, and then maybe a couple weeks later they come in for a visit. It’s almost impossible to establish medical necessity for those, for that type of care because it is predominantly palliative.
Given that it has, it’s relatively short in its duration. And while some payers like the one and dones and two and dones, just watch how many visits you’re accruing over the course of a year. And remember, just ’cause they get 20 visits or just because they have unlimited visits doesn’t mean that you can bill for forever.
You still have to establish medical necessity, and this is where digging into those medical policies and understanding what that means, it doesn’t mean what you think it means clinically just because they have symptoms. You have established a significant health problem demonstrate through outcome assessment potentially that there’s functional limitations.
The care plan needs to be three times a week. Two to three times a week for two to four weeks at least and have established measurable and objective goals. And it is a huge documentation burden for just a short amount of care. But if you don’t have it, they’ll take the money back. As far as the care that you provide, be very cautious about your ENM reporting or evaluation management reporting.
I’ve seen cases where patients run out of manipulation encounters, and either the practice switches to ENMs or they switch to manual therapy. in Order to continue treating the patient and as, as long as you can, one, establish, let’s say, let’s talk about switching to manual therapy. If you actually change your adjusting technique to something that merely mobilizes the spine or only performs traction or works on soft tissues only, and you’re not doing manipulation at all.
Your documentation supports that, and you can justify that the ongoing care is medically necessary. Maybe you can pull that off, but when they see that you’re going so many visits with manipulation, then you switch to manual therapy or you switch to and s, it’s pretty clear you’re trying to bypass their coverage limit.
Be very cautious ’cause it will draw an audit. Bill and evaluation, management service, when there’s a reason to do it, something significant has to change that causes you to engage in decision making where you’re changing your diagnosis, changing your plan of care. And that happens somewhat in infrequently.
Payers are becoming increasingly resistant to just . Paying for an EM when you do your monthly re-exam. A monthly re-exam is a stupid concept because it, you should do re-exams. When there’s a reason to do one, they’re significantly better, significantly worse, but decision making should be the byproduct of that ENM and where it’s not, they’re gonna take that money back.
Your billing profile for e and m should not exceed. One in, nine to 15 visits. But demonstrate when you do an e and m, if you’re doing your typical salt note and adding the word re-exam to the beginning, it’s not gonna get it done. They’ll get recouped the. Unbundling of manual therapy from manipulation.
Whether it’s actual manual therapy performed by you it’s maybe trigger point therapy performed by an assistant or a massage therapist that brings in delegation issues that have been especially, consistent in the post-payment audit arena over the past year and have caused providers a lot of problems.
Payers really don’t like it where massage therapists, if you choose to employ them. My advice is keep their services cash. But if you feel like you have to bill it just understand you’ve got a couple burdens to get over. First of all, medical necessity one hour massages, head, shoulders, knees and toes are almost never gonna be considered medically necessary.
Even if you’re doing focal massages, be sure to write a very precise order telling them exactly what technique to do. Where to do it, what muscles and how long to do it. Without that, I can’t justify that your billing of their services under your name and NPI is appropriate under what’s called the incident two rule.
So if you are gonna bill for delegated services, make sure you always have a very precise order telling that auxiliary person, whoever they are exactly what they’re supposed to do. And then we might have a prayer of saving it. The second issue with unbundling manual therapy or massage. Is the actual unbundling issue.
Most payers consider them to be part of a manipulation when they’re performed in the same area of the body as manipulation. That’s not technically the rule, but that’s how they perceive it and it always gets a lot of attention. anD then we mentioned the delegation issue. And then of course the medical necessity issue as well.
So there’s a couple of hurdles to get through. It’s not a great way to get an extra service. You’re better off doing active resisted exercises where you can bill 9 7 1 1 oh. There’s no bundling problem. The delegation problems still there. You still need to write a precise order, but and make sure that delegation is permissible under.
But the CMT 9 7 1 1 oh code pair is not gonna get as much attention as the CMT 9 7 1 4 oh or 9 7 1 24. anD the one, one oh does not need a modifier, a 59 modifier in that code pairing with CMT. That’s a safer way to go. fInally, also think about extremities. I don’t have a problem with extremity manipulation at all.
As long as the patient has a source extremity complaint and you do an extremity examination, do an extremity diagnosis, and do an extremity plan of care. And if they also have a spinal condition, and you’re gonna do all that same work for the spinal condition, unfortunately, most times. Where we see over utilization of extremity CMT 9 8, 9, 4 3.
The provider is the extremity manipulation is supportive of the spinal condition. There’s no diagnosed extremity problem. There’s no extremity exam. There’s not even an extremity complaint except for complaints radiating to an extremity in which case you have to treat the source where it goes to.
usUally isn’t considered medically necessary, so be cautious of that as well. Finally, look at your billing profile and make sure that you’re not always billing the same code. Sequences for every patient, every visit. It’s very noticeable by a computer. There’s expected to be some diversity. If you follow your exams, diagnose the patient property and then order care consistent with what the patient’s presenting conditions are, you will get that diversity by choice.
I realize it’s a lot of work. it’s why a lot of docs go cash, but if you’re still committed to billing insurance in 2024 those are the things that you have to do, had to do. For many years now in order to survive a post payment audit, mitigation is. Avoiding the audit. Watching your billing profile is the one thing that you can do to help mitigate the potential of an audit.
But if you’re audited, digging into those policies, making sure you understand what they need in terms of documentation, content especially for Medicare. Medicare is all about the documentation content. So if you haven’t gotten cozy with the Medicare Benefit policy manual, which is Pub 100 dash two, chapter 15, section two 40, make sure you do so or.
You can pretty much expect that they’ll be asking you to pay all the money that you paid back to Medicare. Also, remember, with Federal Healthcare benefit programs which includes federal employee benefits through the blues federal workers’ comp, postal workers’ comp, tricare, Medicare, Medicaid, anything that’s paid directly or indirectly with Federal healthcare program dollars, any audit that exposes, an issue for which there’s likely, errors in the remainder of your claims, you have a six year voluntary disclosure and lookback obligation. And if you don’t do that lookback or that disclosure and refund on your own, then those claims potentially become false claims. Just be very cautious when you’re billing federal healthcare programs.
I’ve noticed this year the state Medicaids have become, especially where the benefits are very good out in Oregon, California Washington. Those states come to mind immediately. Be very careful because they’re being very aggressive in their post-payment efforts. Finally, for cash practices, while you avoid all of the post-payment things from insurance companies by billing cash, be mindful of your marketing.
Okay. Because being somewhat imprecise in your marketing or how you market can get you in trouble with your state licensure board. alSo be cautious that you are doing sufficient documentation. To protect yourself from medical malpractice liability, it is very easy to get lazy with a patient that you have seen for years and years.
And I just recently had a client, a very competent doctor in fact got lazy. I. Did a 12 visit care plan. The 12th visit, the patient was injured and unfortunately there wasn’t an exam. There were x-rays, his malpractice carrier’s gonna pay out some money. So you don’t wanna be hitting your malpractice carrier’s hall of shame because you did not.
Do competent physician work before starting a treatment plan with a patient. And remember, cash non-cash. It doesn’t matter anybody you haven’t seen in a while. You start ’em out, do an exam, figure out what’s going on. Take the time. Trust me, if things go sideways later on down the road you’ll be very happy that you took, underwent that extra additional expert.
Effort rather than just assume because you’ve seen this patient for years that, that you understood what was going on with ’em. So that’s probably all we have time for. I wish you a very healthy, happy, and prosperous 2024 devoid of any post-payment inquiries. And until next time I’ll look forward to seeing you again soon. .
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