February 26th, 2015
By Michael Vocu, CCCPC
Director of Communications, ChiroCode
In my 20 years of professional bull riding I have had many highs and lows. There were times when the rankest of bulls couldn’t throw me and times when I couldn’t ride a rocking chair. When in a slump, what always worked for me, and for the number of young bull riders I now coach is, “When in doubt, return to the basics.” There are basic skills that every beginning bull rider learns. They are the simple foundation which your riding is built upon. As you move away from these basics, your riding suffers. When you reincorporate them, things improve.
As with bull riding, there are some simple basics that pertain to chiropractic billing as well. Take a minute and share with your staff this wonderful “Basic Guide.” It is from our friends at Core Products, with the help of Dr. Ron Short. This simple guideline will help you stay focused and ride this rank bull that we call “insurance.”
Billing Success Depends on More than Just the Proper Code
- Before providing a service, verify that a patient’s individual agreement with their insurance carrier will cover that specific service. As an example, Medicare will not pay a chiropractor for a service outside of the adjustment performed. The other carriers will cover additional services, including things like lumbar sacral orthosis. Everyone has a different insurance contract, so even though two people might have coverage from BCBS, it does not mean that their policies cover the same thing. Insurance reimbursement is contingent upon the state scope of practice, patient’s coverage, proper documentation, and finally, the proper billing code.
Documentation is Vital to Appropriate, Proper and Successful Billing
- Documentation needs to be consistent.
- Medical necessity must be shown.
- Diagnoses must show that the condition is interfering with the patient’s activities of daily living.
- Diagnoses and services rendered must match. For example, if the doctor has diagnosed the patient with lumbar degenerative disc disease, then he has to have a lumbar x-ray and an x-ray report in the patient chart that clearly states the patient has disc thinning in the lumbar region.
- Make sure a plan of care is made and outcome assessments are administered. Outcome assessment questionnaires cn be very helpful in establishing the need for care.
- Medical necessity, diagnosis, plan of care, outcome assessments, and services rendered must match the patient’s prescribed course of care and chief complaint.
- Allow the patient to “OWN” their course of care. (Have patient signatures on documentation showing they understand their diagnosis, plan of care, outcome assessments and services rendered and agree to them.)
- All of the above documentation may need to accompany submission for insurance reimbursement.
Factors That May Reduce Reimbursement or Create a Denial of Payment
- Does the patient’s insurance cover the service you plan to provide?
- In-network discount (Are you in an insurance net work that requires you to accept a discounted reimbursement rate?).
- Reimbursement rates will vary based on state scope of practice and individual carriers. (What is your rate and fee schedule?)
- Was medical necessity proven?
- Did the diagnosis match the service rendered? (Patient complained of neck pain yet a lumbar orthosis was prescribed?)
- Was proper documentation turned into the insurance company?
- Form filled out inaccurately or incompletely.
- Inappropriate billing code selected.