August 30th, 2012
In May, 2009, the Department of Health and Human Services’ Office of Inspector General (OIG) released a reported entitled “Inappropriate Medicare Payments for Chiropractic Services.” This followed a similar report issued in 2005. Both reports were critical of the way chiropractic handled documentation and coding. According to OIG, Medicare inappropriately paid $178 million for chiropractic claims in 2006, representing 47 percent of claims meeting the OIG’s study criteria.
The American Chiropractic Association immediately countered the study, protesting that it used a flawed data set (chiropractic claims for beneficiaries receiving more than 12 services from the same chiropractor.) The ACA also took issue with the timing of the study, claiming that the data were taken on the heels of a previous study, before the industry could react.
Here is what the OIG said it found:
“In 2006, Medicare inappropriately paid $178 million (out of $466 million) for chiropractic claims for services that medical reviewers determined to be maintenance therapy ($157 million), miscoded ($11 million), or undocumented ($46 million). These claims represent 47 percent of all allowed chiropractic claims that met the study criteria. Claims representing $36 million had multiple errors.
“Efforts to stop payments for maintenance therapy have been largely ineffective. CMS, carriers, and program safeguard contractors (PSC) use a number of strategies to deter inappropriate payments for maintenance therapy, including use of the AT modifier to indicate active/corrective treatment, provider education, frequency-based control edits (caps), and focused medical review. Despite these efforts, carriers and PSCs continue to report high errors for chiropractic claims. Carrier staff, PSC staff, and medical reviewers for this study agreed that the AT modifier did not prevent inappropriate payments for maintenance therapy because chiropractors continued to submit claims for maintenance therapy with the AT modifier.
“Claims data lack initial visit dates for treatment episodes, hindering the identification of maintenance therapy. To identify active/corrective treatment and thereby distinguish it from maintenance therapy, it is useful to identify the start of a new treatment episode. However, claims data do not indicate when an episode begins. Thus, we asked sampled chiropractors and the medical reviewers to identify when an episode began and ended. Overall, only 50 percent of all treatment episodes remained active/corrective throughout the treatment episode. In addition, 78 percent of those treatment episodes that became maintenance therapy did so by the 20th visit. The Comprehensive Error Rate Testing (CERT) paid claims error rate used by CMS is based on a review of a single claim, which limits its ability to detect maintenance therapy and may underestimate errors in claims for chiropractic services.
“Chiropractors often do not comply with the Manual documentation requirements. Separate from the undocumented claims counted as errors above, 83 percent of chiropractic claims failed to meet one or more of the documentation requirements. Consequently, the appropriate use of the AT modifier could not be definitively determined through medical review for 9 percent of sampled claims, representing $39 million.” -Inappropriate Medicare Payments for Chiropractic Services, Daniel R. Levinson, Inspector General, Office Of Inspector General May 2009, OEI-07-07-00390.
The medical reviewers also indicated that treatment plans are an important element in determining whether the chiropractic treatment was active or corrective in achieving specified goals. Of the 76 percent of records that reviewers indicated contained some form of treatment plan, 43 percent lacked treatment goals, 17 percent lacked objective measures, and 15 percent lacked the recommended level of care.
As a result of these findings. OIG recommended that the Centers for Medicare & Medicaid Services strengthen its enforcement policies, and ensure that chiropractic claims are not paid unless documentation requirements were met. Obviously, this is not a plan of attack that most chiropractors would agree with.
How Did It Come To This?
As required by the Social Security Act, Medicare pays only for reasonable and necessary chiropractic services, which are limited to active/corrective manual manipulations of the spine to correct subluxations. A chiropractic service must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.
The Centers for Medicare & Medicaid Services (CMS) “Medicare Benefit Policy Manual” (the Manual) allows chiropractors an opportunity to produce functional improvement or arrest or retard deterioration for subluxations within a reasonable and generally predictable period of time. When further improvement cannot reasonably be expected from continuing care and the services become supportive rather than corrective, the services are considered maintenance therapy. The Manual provides that maintenance therapy is not considered a medically necessary chiropractic service and is therefore not payable under Medicare.
Many of the infractions uncovered by the OIG center on the transition point between active care and maintenance care. It has been indicated that part of this problem is that 1) Chiropractors did not document the date services began, and 2) The survey methods used in the study did not look forward sufficiently to insure that a data of initial service was missing from the documentation.
This illustrates the reason Chiropractors should be serious about documenting the date of initial service. However, Medicare has estimates of how long a given illness should require treatment. They will be looking for outliers. For this reason, it is very important to track as well dates of exacerbation, backsliding, re-injury, or the occurrence of new injuries which support a continuation of service as active care rather than as maintenance care.
What do we mean when we say “electronic health records”? Simply stated, electronic health records are concerned with storing patient information in a way that keeps it private, and allows the information to be shared easily with others who may need it to perform their functions, such as insurance companies, CMS, and consulting practitioners.
In spite of many doctors’ desire to “keep things simple” and avoid altogether electronic patient recordkeeping, the option to do so may be expiring. Some states already require such records. The federal government is offering incentives to practices that adopt electronic records early. In a few years, the feds will penalize offices that do not adopt these technologies because processing and auditing paper records will cost the government and the industry more money.