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Hi everyone, this is Michael Miscoe with Miscoe Health Law with this week’s installment of ChiroSecure’s Growth Without Risk program. And today we’re going to talk about post payment audit risk, specifically what your billing profile tells a payer when they’re trying to identify who they want to audit.
The first thing you have to understand about post payment audits is First of all, there’s absolutely nothing random about an audit. Audits are created two ways. Data profiling, meaning they look at your billing profile. And we’ll talk about a number of different queries that they do to identify providers that they want to take a look at.
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And the other reason is a patient complaint. Those come up. Very rarely probably 98 percent of all the post payment audits that get done are done because of something they see in your billing profile. And we’ve talked over the years about a number of things, code pairings and whatnot that trigger audits, but we’re going to look deeper into more of the medical necessity type audits and how they identify cases to look at or pro providers to look at and then identify claims that they want to pick.
The first medical necessity profiling audit that most commonly gets done is what I call frequency of care analysis. And in that analysis, what they do is they figure out per patient what your billing profile is relative to how many times per week most of your patients, and they develop an average.
Now, in a perfect world, that average would be three times a week. Period, meaning you do three time a week care until you get the patient to a plateau and you dismiss and, showing objective measurable goals and improvement and all that other stuff. But we’ll talk about another audit analysis that they do, but in this particular analysis, the perfect number is three.
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When you get down closer to two it’s not as good, but, it doesn’t necessarily really raise alarm bells. When the number is less than one, that’s bad. And what it means is that on average, you’re either seeing patients episodically, which means they likely do not have an air quote, significant health problem.
And certainly if you’re doing one or two visits the traditional one and done, two and done type of treatment, that’s indicative of palliative care. That’s not sufficient. It’s not a sufficient amount of care to justify a significant improvement in the patient’s condition or capacity to function.
Palliative care not covered. That’s what they’re looking to find. If they find a very predictable pattern of once every, that’s indicative of maintenance care. But looking at the visit schedules and calculating the average. number of visits per week is how they identify providers who predominantly do medically unnecessary treatment, send those claims in for reimbursement.
No doubt under the premise that patients, like I get 20 visits a year and they do if they’re medically necessary. That type of care is not considered medically necessary by payers and those services should be billed cash. It’s non covered services to the patient under the S code. And we’ve had some discussion about that issue in the past.
And if necessary, we can do it again. ICD 10 analysis, another way that they look at medical necessity. If you’re wimping out and coming out with diagnoses that I could figure out. Having not gone to doctor school then your diagnosis is probably do not accurately describe the condition you’re actually trying to treat.
And what I’m talking about is when you do an M99. 01 through 5 and you do an alga cervicalgia, thoracalgia, lumbalgia, basically neck pain, mid back pain, low back pain. When you tell the payer that you’re treating pain rather than the symptom causing pain, you create an almost. de facto conclusion that the care is palliative in nature because you’re stating that’s what you’re trying to do.
You’re treating pain and unfortunately payer definitions of medical necessity require that the care that you’re doing be the most cost effective way or at least as cost effective as other means of treating that condition. The cheapest way to treat pain is with drugs. I call it the Motrin test and when Motrin doesn’t work, Demerol or something like it will, and it’s still cheaper than you.
So for that reason, that’s why they don’t cover palliative care. But when you’re indicating in your diagnosis that’s what you’re treating and it looks like we’ll talk about duration of care analysis, but that is also an indicator that there may be medical necessity problems.
Another one is duration of care, and I’ve hinted at this one, but they look at the average number of visits per condition not taking into account breaks in care but In that context, they look at number of visits per condition per year. And, when that number gets, high interestingly enough for Medicare, their number is like 5.
8 visits per year is the average that they believe is appropriate for a Medicare patient per year. And I would argue that probably isn’t enough. Care to cause a significant improvement, but nonetheless, that’s a number that they’re looking at. Commercial payers, they have different, bottom line is when you’re two standard deviations from the norm and that makes you an outlier.
That’s who they pick to get audited. Now, understand that. They don’t audit everybody, and the reason is they don’t have to. They know that when they do a series of audits and they start looking for a certain thing it’s going to cause what they call change of behavior and they actually track it.
I’ve seen in discovery data from payers where they actually track. That statistic, and it’s not only your change in behavior, but the change in behavior across all chiropractors their billing services to a particular payer because they know that you talk to each other and when they, when audits start dropping, providers start getting a little more cautious pay a little bit more attention to the rules and a lot of the things that they try or that they believe They shouldn’t be covering they, they start seeing those numbers start to change, and that’s the whole point of postpayment audits.
Yes, they’re trying to recover money, but the bigger impact is on the money that they save because they’re changing behavior across the industry. The final thing that they do in data profiling is problematic code pairs. Because we’ve, I’ve. I feel like I’ve discussed this many times, but obviously not often enough because I’m still seeing audits with these code pairs, specifically spinal manipulation and manual therapy or massage 97140 or 97124 with a 59 modifier.
There’s a whole litany of problems that get. Every payer has a policy that’s loosely built off of the National Correct Coding Initiatives, which establish a bundling edit between CMT and those two codes. They also establish an edit between neuromuscular re education, which is something that you’re probably not actually doing, because that’s actually for patients with severe neurologic trauma or disease.
But in any event. Those are problematic code pairs. If you build those routinely, you’re going to get audited. It’s just a matter of time. You need to avoid. Billing, manual therapy, or massage in addition to CMT. If you’re delegating to massage therapists, that creates a whole nother problem.
Some payers have expressly eliminated the ability to report massage when it’s performed by an LMT under the supervision of a chiropractor. They will pay it only if it’s performed personally by the chiropractor, which nobody’s actually going to do it, and they know that. I’ve seen some employer self funded plans where they expressly preserve the ability to bill for delegated services, but even then, you’re going to run into unbundling, is it done in the same region as manipulation?
And there’s a whole technical analysis for that. Payers have their perception of what they think region means, and then there’s. The technical definition under CPT, and oftentimes their policies aren’t clear, and while it gives us some room to push back and potentially negotiate a settlement, the whole idea is to avoid ever getting audited in the first place.
So you want to those types of code pairs. I have been solid for more than two decades. Massage services should be cash, period, case closed, end of story. If you’re trying to get paid for them through insurance I even had a provider recently that, thought he was being really smart.
He’d send out his CMT claim, and then a couple days later, he’d send out a claim, separate claim for the massage, and he got paid for years. And then they finally figured it out and they wanted it. It and it was lucky because of the purposeful way that he was using to bypass their claims processing edits.
It, he was lucky that it did not turn into a fraud case because it very well could have. So in any event. Those type of code pairs you got to watch out for. Another one is spinal manipulation and extremity manipulation. It’s fine to adjust extremities for most payers and in most states but you got to make sure that you have a source extremity injury.
I want to see a mechanism, like how did they hurt their knee separate and distinct from what’s going on in their spine. You need an extremity history of present illness. You need an extremity exam. You need extremity diagnoses and you need an extremity treatment plan. And if all that exists, great.
Go ahead and do it. It’s part of the plan. A patient may be getting both spinal and extremity treatment. Don’t. exclude the possibility that the patient might only be there for an extremity problem. So don’t, like you do with what I call a condition creep in the spine where the patient comes in with neck pain, and then you start asking how’s your low back feel?
And I’m sure it doesn’t feel, perfect. In which case ding, and now you got a 98941 case which is another profile they run. They look at your Your CMT utilization, you break down between 4 if you’re all 4 1’s, they call it cluster coding. They know there’s probably some medical necessity issues there.
So be cautious of that as well. The ways that you fix all of this stuff or try to avoid creating profiles that are indicative that you are somebody that they want to audit is don’t do the stuff that we just talked about simply enough. But, as far as the diagnosis, accurately diagnose the condition that’s causing the symptoms.
If they have a radiculitis, that’s obviously more difficult, indicative of a significant health problem, and is gonna. Provide a better argument for why you needed to see the patient for four weeks than neck pain is. The other thing, get rid of whatever shortlist that you have for diagnosis codes.
Diagnosing should be based upon your exam findings. Okay, so whatever your exam findings indicate, those tests are positive, negative, they’re positive in certain ways. Maybe they mean that you do additional tests or you take an x ray or you do something, but eventually you should be able to make a definitive statement as to what condition is causing their problem.
That’s what you need to put on the claim if it’s a problem that you can actually fix. Utilize established treatment protocols and when you develop your plan of care, don’t get comfortable in doing therapies, the same mix of therapies all the time, because it doesn’t make sense. It might work. Okay, but there’s likely therapies that you’re doing that the patient doesn’t need to have done.
So don’t, Look or build a consistent pattern of doing the same therapies all the time because it doesn’t make sense. You want to order a therapy, use your protocols, and then you have a diagnosis that you intend to fix with treatment. What is the therapy that’s going to treat that condition?
And lay that out in your treatment plan so that if you do get audited, there’s at least a justifiable basis for doing what you’re doing. Enforce patient compliance. Okay, the reason providers get visit schedule issues and become suspect to audit is because patients don’t show up when they’re supposed to show up.
And they don’t for two reasons. That’s one. They probably don’t need to, okay? That you order three times a week for four to six weeks is irrelevant if the patient doesn’t have a significant condition that requires that care. And if you know they’re not going to show up for it, then it’s pointless for you to embark on a covered plan of care because you know it’s not going to work.
And if you know it’s not going to work, that Destroys your entire medical necessity argument, meaning you have to have a reasonable expectation that the treatment is going to significantly improve the patient’s condition or capacity to function in a reasonable and generally predictable period of time, and be the most cost effective, yada yada.
When a patient is, a confirmed one and donner, they did some aggressive feather dusting, or they slept funny on the couch, or took a long car ride, or whatever it was, and they show up, or they don’t know what happened, that’s just not a circumstance that you can build a medically necessary plan of care around, and it’s too much work anyway.
Do all that work for a patient that’s going to come twice, you just wasted a bunch of your time. But the other aspect of it is that when other things become more important and showing up to your office to get care that they supposedly, air quote, need that means they don’t really need it.
In which case those patients should be discharged to cash plans. Avoid consistent patterns in your CMT level. Don’t ever, in the infiniteness of ever try to unbundle manual therapy or, and especially massage but manual therapy, there are some circumstances, but if you’re going to do it.
Okay, one, keep at least one degree of separation in your spinal region so you’re manipulating the neck and let’s say you’re doing manual traction techniques to the low back where you are not doing manipulation, document why you’re not. You have to demonstrate that manipulation is contraindicated because from a fee perspective, it would be more cost effective even if it raised the level of your CMT from a 4.
That would be cheaper. Then you doing manual therapy. So you have to justify why you’re not doing manipulation in that area. And the reason can’t be because you want to make more money. Okay, and be cautious about doing that a lot. Okay, because again, you build a pattern, you’re going to get audited and payers are probably going to look with somewhat of a jaded view I don’t want to suggest that they’re biased, but they are.
And probably deny all that, force a fight, and then there’s going to be a settlement. You’re going to pay something back and avoidance is the better strategy. We talked about extremity CMTs. We talked about doing the same therapies on all your patients. It just looks irrational. My dad did that for 43 years, and I asked him one time, I said, how can that possibly make sense?
And he looked at me with that, Dad, you just asked me the stupidest question in the world look. And he said, because it works. And, back in, the Mercedes 80s, you could get away with that. But now you can’t. Data analysis is way too precise. You’ll get smoked out. It’ll get audited.
And I’ve actually seen fraud cases over cookie cutter. Treatment plans. Bottom line, if you’re still committed to billing insurance, which I think is crazy, but just because there’s not enough money to make it worth it in a compensable course of care, but if you’re still committed to doing that, getting your patients in the door, using their insurance for a short period of time, converting them to cash, fine.
But get them in, set, objective, measurable goals even if you’re using outcome assessment get them in two times a week, two, three times a week for two to four weeks and get them out and convert them to cash because, when your profile looks like that, they’re probably going to leave you alone, especially if there’s diversity in your CMT levels.
in the therapies that you’re using and you’re not doing problematic code pairs. As a final point I don’t see this as often as I used to, but be cautious about your E& M billing, your office visits the 9920 or 21 2 through 5, 201 through 215 or 205. The new patient E& M, most payers will allow it.
I’ve seen payers get snarky about paying the initial E& M, and the key is with a 25 modifier, and the key is, can you demonstrate an unusual amount of decision making or time to justify why you’re billing that E& M separately. Don’t bill E& Ms for routine re evals, especially if nothing changes in your plant diagnosis or plan of care.
If a patient comes back after a significant break in care, significant break meaning months, plural then sure, you need to start off, do an evaluation diagnose the condition, even if it’s a recurrence of a prior condition, you need to be clear about saying that you have to demonstrate the regression, if they’re coming in with something, and I think we covered this last month, that you’ve treated before, you have to start your subjective inquiry with Okay, what’s been going on since the last time you were here and bring the reviewer up to date as to, They were fine for a couple of months and their condition started regressing and then this happened And now they’re here with a recurrence of fill in the blank so you need to make that clear and when you do that you re establish your diagnosis plan of care your expectations for treatment You’re probably going to be able to justify billing the E& M with modifier 25 If you’re billing level fours only do that when you document the time appropriately.
We’ll save that for another presentation. Maybe we’ll do that next month. How to document your E& Ms appropriately, either based on medical decision making or time. Hopefully that’s helpful for you and hopefully you can avoid audits if you follow some of the guidance that we’ve provided here today.
And if you don’t give me a call and we’ll help you work it out. That’s all we have time for today. See you next month.
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