Hi everyone. This is Sam Collins, your coding and billing expert for chiropractic, specifically the H J Ross company, but also Chiroscope. And I want to welcome you to another episode of Growth Without Risk. Today’s episode is going to focus on Medicare, and specifically Medicare documentation.
Now I sit on what’s called the reimbursement and coding committee for Opium Health, which oversees United Healthcare as well. And we always have a meeting that deals with issues of documentation, reimbursement, but also when an office is audited. And of course they use the Medicare protocols. I want to make sure that everyone understands the Medicare protocols, which in my opinion aren’t hard, but they’re just unique when it comes to documentation for chiropractic care. And often I think chiropractors simply aren’t compliant because they didn’t know the nuance of what’s required. So let’s take some time today to really go through Medicare documentation.
So let’s go to the slides and let’s take a look. Medicare documentation, CMS of course, Centers for Medicaid and Medicare services. And note at the bottom of course the company Samuel A Collins, and then our company H J Ross Company. Take a look, we’ve got a lot of information for you.
That being said, let’s talk about what goes on for Medicare and where the errors come from. This is going to be the percentage of issues done by doctors of chiropractic over the last year. 34% of the time there is improper or missing evaluation. Remember, a patient does need an evaluation for care. Now does that evaluation always require a high level? Not necessarily, but it does require to be done. So make sure that it’s not missing.
In addition, diagnosis, that’s improper or missing. Remember, Medicare has very specific diagnosis requirements for doctors of chiropractic including [inaudible 00:02:20] and neuromusculoskeletal.
Also, and this is the big one, notice 83% of the time chiropractor’s failed to put a treatment plan. So that’s really going to be one of the big issues I want to touch on today. In addition, often, or 67% of the time, medical necessity is not shown or miscoded. Now what they mean by miscoded is that it does not have an AT, or it has an AT and it’s not seen as medically necessary. Medicare of course is looking for the patient is getting better as a result of care with a focus more on function.
And then finally, this is the one area that it says contraindications not checked. One of the things that doctor of chiropractic should do, and I know that we all do, before you adjust someone, you obviously are going to check to make sure there’s no contraindications to your manipulation. Well make sure that you have a form or something that indicates there is no contraindication such as malignancy, fracture, things of that nature.
You do have to indicate it before the first visit. It’s not something very complicated, and I’m sure you’ve really thought of it. Just make sure you have something in your notes that indicates there is no contraindications to manipulation.
Well, let’s deal with the number one issue, which is a treatment plan. One thing I want to make sure is clear, PRN is not considered a treatment plan. Patient to return as necessary means no further treatment is indicated and frankly treatment is over. That is not a plan. A patient returning means that they have to have another exam and fulfillment to show that it’s medically necessary. So PRN is only appropriate if you’re releasing a patient from active care where they’re going to maintenance.
A treatment plan that’s says three times a week followed by a subsequent of two times a week can at least establish a pattern of progress. So simply put, you must indicate, what are your expectations. Now that doesn’t mean the plan has to be followed exactly. There could be alterations based on how the patient is responding or not coming in. And it should include some short and longterm goals of care. Now this is where most people get confused, but the simplest way to think of it, short term probably is going to be pain. And I would suggest using the visual analog scale or something similar. Don’t focus only on the pain, however, focus on the functional changes. So when the patient tells you their pain is a five, I would certainly ask, “Well, what things does it stop you from doing?” Or, “What things can you do better?”
In addition, I would highly recommend for any Medicare patient to use a validated outcome assessment tool, whether it’s an Oswestry, Neck Disability Index, and so forth. I have a little bit of bias. I think patients don’t do a good job of filling out Oswestries unless you [inaudible 00:04:55] with them. So I might recommend using the General Pain Index and the Patient Specific Functional Scale. Those two are a little bit simpler, but allow you to show a validated outcome of the patient and how they are changing. Ultimately, they want to see the patient is better and the plan should have some protocols for that.
Finally, think of it as just simply creating a roadmap of patient progress and patient improvement. And of course we’re trying to reach a point where the patient has zero pain, or complete function. Obviously probably not true for a Medicare patient.
Now, where’s the documentation error come from? It says insufficient documentation. By insufficient documentation they mean medical documentation is inadequate, or a specific component that’s required as a condition for payment is missing. A good example requires that doctors of chiropractic often forget to have the proper diagnosis. Remember in some States, you can use subluxation alone and Medicare will pay, but if they ever audit your notes, in the notes, they’re going to look for a secondary neuromusculoskeletal diagnosis.
So does the record show a significant neuromusculoskeletal condition? Is there a precise subluxation? Remember by Medicare standards, you can’t say subluxation of cervical. You must indicate the specific vertebra of each area, and of course you can do by physical exam or x-ray. Does the exam substantiate the condition of this subluxation? If you’re doing a part and the patient has a history of some type of trauma, that would be pretty easy. But remember that there must be a correlation.
And make sure, is the complaint consistent. If I see complaints, obviously to the cervical spine and all of the information is about lumbar, that’s potentially going to be a problem.
And is the primary diagnosis of subluxation there with a secondary international classification, meaning neuromusculoskeletal condition caused by the subluxation. Remember many states, for instance ones that are overseen by Novitas, Meridian, Palmetto, even national government services, all require a secondary neuromusculoskeletal condition. And many of these MACs, Medicare Administrative Carriers, list the codes that are required. Make sure it’s one that relates to the spine.
Now again, is there a treatment plan? Remember that must be there.
Is the adjustment clearly recorded in the record being done on each visit? And this is one area that is often a problem. You literally have to indicate on every single visit, chiropractic manipulation to C5, T4, and L1, for instance, if you’re doing a 98941. It is not sufficient just to say I adjusted cervical. That’s certainly okay for other insurances, but not for Medicare. And make sure in the notes, why not just have those subluxations listed each and every time [inaudible 00:07:34] your part exam so there’s never any confusion.
So the note stands alone. They don’t have to refer to another visit. Because often what Medicare will do is ask for a single date of service. If they look at that single date of service and don’t see the subluxation and the areas, then they indicate it’s not current. So therefore make sure to just include each and every day.
And is there a response to the adjustment noted in the records? Every visit, you should have a little bit at the end about how the patient responded to care. And I’m not saying you have to do a full evaluation, but tell me something. Did they feel any decrease in pain, increase in range of motion, anything at all? Or for that matter, nothing at all. But make sure it is documented.
And of course, make sure that the adjustment is therapeutic, not maintenance. Be careful of using the terms where you indicate supportive or maintenance. Because of course, Medicare of course sees that is non-corrective. Medicare is always looking for a correction, make the patient better.
Now another documentation there, beyond the obvious for chiropractor requirements, is a missing signature or date. Believe it or not, a lot of providers forget to put a date. And remember if you turned the page over, still indicate the date and make sure the patient’s name is on both sides of the paper, and I would suggest to have with their date of birth. But a big issue for chiropractic, and this shows a 90% failure rate for some offices. Medicare requires that services provided order be authenticated by the offerer. In other words, you have to sign them. Initials aren’t going to work, and it is recommended that you put your name followed by your credentials such as D.C.
Now acceptable written signature is just a full signature, first initial and last name. But you’ll notice none of these indicate that you put initials. So I’m going to make sure everyone knows when you have a record, simply sign it. And if your signature’s not that legible, my suggestion have something underneath that shows what the name is or make sure you have a legend.
Now, signature stamps are not allowed, but there is an exception. If you have a disability, and that disability doesn’t allow you to, a rubber stamp could be used. So there is one exception to that. But generally for most offices of course, no signature stamp.
Electronic signatures are certainly welcome. Notice all these various ones where it can say authenticated by, signed by. Those are all acceptable so long as your name appears. And I would again suggest to have it with your credential. It must appear after every dated entry in the record.
Abbreviations and legibility is also an issue. The chiropractic medical records that are illegible, or revisions that cannot be determined, be careful. Any non-standard abbreviations must have a legend to decipher. And it’s certainly okay to have certain types of abbreviations that are standard. But also if you have something non-standard, please explain it so that someone reading it knows what you mean. I would say be careful to not create a note of hieroglyphs that someone has to take an hour, and I’m exaggerating, to really figure out what the notes actually say.
Now, another big documentation error is, incorrect coding. This means that the records were submitted that supports a different code that was built. And of course this big problem occurs for CMT. Remember that the diagnosis and subluxations and the secondaries must match the code bill. So if you’re billing a 98941, that means you need three specific regions diagnosed with subluxation specific to vertebra, along with a secondary diagnosis potentially for each region. So if you’re billing a 98941, I would state that you likely are going to need six diagnosis, meaning three subluxations with three secondaries.
Finally, the big fifth top error is a failure to submit documentation. It’s hard to believe that some providers failed to respond to repeated requests, but that’s an issue. When they request records, go ahead and send them. Just make sure the records are complete because if they are not, that’s where the issue comes. Medicare is not as punitive as people think. They actually have a protocol where that if there’s errors, they’re going to point out what those errors are and how to fix them. They want you to be more compliant than anything.
None of these issues are very hard, but it’s simply that most offices aren’t aware of the simple things that are needed. So for an initial visit, think of we want a relevant history of the patient’s condition, obviously, You want an evaluation of that area, chiropractic related, meaning makes sure there’s a part.
And then of course there’s a diagnosis as a result, and that diagnosis fits the Medicare protocol. Then of course a treatment plan, recommended level of care, specific goals, and objectives to measure. `This is where orthopedic testing range of motion can all help, but of course validated disease specific. So notice this is really just a SOAP, Subjective Objective Assessment, meaning diagnosis and what you did for care.
Then of course, the date of initial treatment. Of course, being on part of the note.
Now, what does the subsequent visit require? A subsequent visit requires the review of the chief complaint. It doesn’t mean you have to rehash everything, but how is the patient doing based on the symptoms from the last time. They want an evaluation of the spine area involved in the diagnosis. So some assessment, and again, most chiropractors generally do some type of maybe a leg check, palpatory, range of motion, that’s all fine. Please make sure it’s documented along with some objective measure. Don’t just say that the muscles are taught and tender. Give me a relative level of how taught and tender so we can compare over time.
And then of course documentation of treatment given on the day of the visit. Now I’m going to recommend within this, please make sure to always include the diagnosis on every date of service. Don’t refer back. I would also include always the subluxation. And then of course if you’re making changes to a treatment plan, this is the time to do it. The treatment plan may go along just fine, or it may have updates. Just update as necessary. So if you think of it, each time a patient comes in, there’s a SOAP note, on the first visit it’s much bigger. Follow-up visits, less. Probably a couple of sentences on a follow-up visit are adequate, with specific level of adjustment and how the patient is changing as a result of care.
Medicare is not hard and we try to make it easy. The H J Ross Company, along with Chiroscope is your source. Please take a look at our website our Facebook page and other places. We try to get out as much news as possible. We’re here for you. Your success is our success. Our seminars always deal with issues to make sure your practice is doing well, and are always continuing education.
So I thank you for some time for Medicare and please follow-up with me as needed. And I wish you the best. Take care, until next time.
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