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Auditing Chiropractic Services

By:  By Evan M. Gwilliam, DC MBA BS CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow Clinical Director, PayDC Chiropractic EHR Software President, Gwilliam Consulting LLC drgwil@gmail.com
Published:  April 22nd, 2019

Chiropractic is unique from other types of health care and auditors need to be aware of the nuances of this alternative field. While few services are performed and billed, the rules are very specific. This is due in part to the fact that chiropractic is typically delivered in an episode of care. This episode is often documented as an initial evaluation with a care plan, then a series of visits where the care plan is carried out, often over several stages of care delivered in four-week intervals. Then, ideally, the care ends when the patient reaches maximum therapeutic benefit as measured by the goals established when care began.

The most common CPT codes used (and the only ones payable by Medicare to chiropractors) are chiropractic manipulative treatment (CMT) services. There are three spinal CMT codes:

98940 spinal, 1-2 regions

98941 spinal, 3-4 regions

98942 spinal, 5 regions

Chiropractic has become the focus of more and more audits as doctors seem to struggle to create records that properly support the care provided to the patient throughout the entire episode. The Office of the Inspector General released a dozen reports focusing on chiropractic since 2005, and three of them came out just last year. Most of them indicated error rates of more than 90% and refund demands of several hundred thousand dollars.

One common issue identified was overutilization of 98942, spinal chiropractic manipulative treatment of 5 regions. 98942 has a higher reimbursement rate than the other CMT codes (the Relative Value Unit or RVU is 1.5 for 98942, 1.16 for 98941, and 0.8 for 98940), therefore the financial incentive is there to bill for the higher-level code. Based on Medicare claims submission data from 2015, 98942 was billed 7% of the time, with the remainder of the CMT codes coming from 98941 and 98940. Therefore, if a clinic appears to bill 98942 much more often than the other CMT codes, it may be a red flag.

The challenge with 98942 is that it includes five spinal regions. These regions include the cervical spine, the thoracic spine, lumbar spine, the pelvis, and the sacrum. For Medicare and most other payers, that means that each region must meet certain criteria in order to establish medical necessity. When auditing a chiropractic record and looking for documentation to support manipulative treatment, look for the following (in each region):

  1. Mechanism of onset
  2. Subjective complaint
  3. Objective findings
  4. Diagnosis
  5. Treatment plan
  6. Progress

For example, for the cervical region a record showing medical necessity might include the following:

  1. Slip and fall while working in the yard over the weekend.
  2. Neck pain with radiculopathy to the right arm.
  3. Painful, limited cervical range of motion (passive), palpatory tenderness in suboccipital muscles, mild edema in cervical region.
  4. S13.4XXA - Sprain of ligaments of cervical spine, initial encounter
    M99.01 - Segmental and somatic dysfunction of cervical region
  5. Cervical manipulation two times per week for four weeks to improve range of motion 50% and reduce pain reporting 50%.
  6. After four weeks range of motion is 50% improved and pain is 50% improved.

In other words, you would want to find all six of these elements in the other four spinal regions if 98942 was billed. While some of the six elements may overlap regions, such as the mechanism of onset, many of these must be uniquely noted in the record. For example, all five regions must have a complaint, objective findings, and a distinct diagnosis. 

If you audit chiropractic records, learn to use the six criteria outlined here and become familiar with Medicare LCDs and private payer policies. They can help one to become proficient with chiropractic’s unique audit challenges.

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