by Wyn Staheli, ChiroCode Director of Research & Dr. Evan Gwilliam, Clinical Director PayDC Software
April 23rd, 2018
In August of 2017, a Brooklyn chiropractor was ordered to repay $672,805 to Medicare because the reviewer found that 100% of the claims reviewed (from 2011-2012) did not meet medical necessity requirements. The chiropractor enlisted help from two reputable experts who disputed the findings of Medicare’s Professional Reviewer (MPR). However, the OIG maintained that the findings of the original auditor were valid.
Even though we do not have access to the original documents, there are some very important things that all chiropractors can learn from the unfortunate outcome if this particular audit. Since none of us have ½ million in cash just laying around, it is essential to learn, understand, and make changes where appropriate to help audit-proof patient documentation.
Problem: OIG stated that “allowable payments occurred because the Brooklyn Chiropractor did not have adequate policies and procedures in place to ensure that chiropractic services billed to Medicare were medically necessary. Specifically, the Brooklyn Chiropractor did not have any written policies or procedures and indicated it used the Medicare guidelines to obtain information on how to document and bill chiropractic services.”
Solution: Every provider should have an official, office Policies & Procedures manual! Not only is it a necessary component of compliance, but it also helps protect the practice and enables them to defend themselves, to some extent, when they are audited. It may have helped the Brooklyn Chiropractor to simply have a statement in place such as “It is our policy to follow CMS guidelines as outlined in the Medicare Benefit Policy Manual, Chapter 15, Section 240. We will only submit for reimbursement for services which meet the criteria of medical necessity as outlined by CMS or other private payor.”
Don’t forget to include the protocols and techniques that are utilized in your practice. For example, have a policy that says that you typically do diversified technique for chiropractic manipulation. However, for the sake of audit protection, be sure to also include that information in the patient documentation.
Problem: The MPR stated repeatedly that the records were not legible.
Solution: Providers have the responsibility to make sure that their records are legible and also include a legend of abbreviations when records are requested. Don’t make it difficult for the reviewer to find important information simply because they cannot read your records.
Problem: On a significant number of claims, the MPR stated that required documentation elements were missing. The experts reviewing the same claims refuted that and stated that the information was in the documentation.
Solution: Clearly identify important elements. While this may not stop a reviewer from finding issue with your documentation, it can help when you dispute their findings. Be sure that you are using P.A.R.T. to support medical necessity. One of the new things included in the 2018 ChiroCode DeskBook is the inclusion of two concepts we call “Chain of Medical Necessity” and “Episode of Care Journey” which outline important documentation requirements.
Problem: The MPR stated that a specific chiropractic technique was not mentioned.
Solution: Even though this is not a requirement of an LCD or NCD, to avoid miscommunication and potential problems, be sure that the technique typically employed by your practice is included in your Policies & Procedures manual as well as in the patient record. For example, instead of stating “Subluxation of the spine was treated with manual manipulation”, state “subluxation of the spine was treated with diversified chiropractic manipulation”.
Problem: The MPR stated several times that the patient was not reexamined - sometimes even only 2 days after the initial exam.
Solution: Since we do not have the original documentation, nor the MPRs report, the solution depends on whether the critique related to a CMT or an Evaluation and Management service.
CMS refers to the P.A.R.T. protocol as the physical exam to determine if the patient has subluxations, which is required to establish medical necessity. Therefore, this problem may have been avoided if the provider had simply made it clear that the elements of P.A.R.T. were revisited frequently enough to re-establish the existence of the subluxation which justifies the CMT service.
A more complete examination, such as one that justifies a significant and separately identifiable Evaluation and Management code is not a covered service by CMS and CMS offers no guidance or direction on the frequency of this service. However, the generally accepted standard is that no more than 30 days should pass between re-evaluations. However, if the MPR was referring to the CMT service, then if P.A.R.T. was documented for each patient encounter, then there was a re-examination.
Range of Motion Requirements
Problem: The MPR stated that there were no degrees for the ROM.
Solution: ROM testing supports the “R” in P.A.R.T. when establishing the existence of a subluxation. A statement of increased or decreased ROM may be sufficient, but specifically mentioning the number of degrees would be more accurate. Despite the fact that there are no requirements to do so, visually determined ROM might best be documented as “estimated” to distinguish it from instrument assisted ROM. While it is important to include ROM information as part the CMT service, there is not a documentation requirement for this portion of the service to include degrees. Stating there was an increase or decrease when performing CMT is sufficient. However, if performing the initial exam or re-exam or ROM service (95851-95852), then degrees would be essential.
Problem: The MPR stated that “there was no review of trauma information related to the initial injury or the date of service provided”.
Solution: Trauma is not a requirement for medical necessity. While it is necessary to document the mechanism of trauma when it is applicable to the patient encounter, not every encounter bbegins with trauma or injury. However, the reason for the initial encounter DOES need to be clearly identified in the documentation.
Problem: The MPR stated that “there were no outcome assessments, functional index ratings, activity of daily living or completed physical examinations to prove that the treatment would result in an improvement of the patient’s condition.” Lack of treatment goals was also mentioned.
Solution: All payers want to see measurable progress. Coverage only exists when there is a reasonable expectation of improvement and that can only be proven through quantifiable means. Treatment plans demonstrate that there is a plan for progress. Outcome Assessments demonstrate that things are progressing in relation to the Treatment Plan. See See Chapter 4.4 — Treatment Plans & Outcomes Assessments in the 2019 ChiroCode DeskBook for more information.