by Wyn Staheli, Director of Research
February 26th, 2018
The OIG recently released a "Portfolio" regarding chiropractic service which stated (emphasis added):
This portfolio presents an overview of program vulnerabilities identified in prior Office of Inspector General (OIG) audits, evaluations, investigations, and legal actions related to chiropractic services in the Medicare program. It consolidates the findings and issues identified in that work and discusses recommendations from prior reports that have not been implemented or have been implemented ineffectively.
In other words, the OIG is not pleased with the way that CMS has handled their previous recommendations and so they released this portfolio summarizing their findings and recommendations. In the portfolio, they go as far as to say, "chiropractic services that are not reasonable or necessary can potentially harm Medicare beneficiaries." So just what is in this portfolio that doctors of chiropractic need to be aware of? Mostly it reiterates the ongoing documentation and maintenance care issues. However, there are some things to note such as prior authorizations and caps on CMT.
Role of the Date: This new portfolio reiterates the prohibition on maintenance care as well as the importance of using the "date of the initial treatment" on the claim. That isn't new, but what is interesting is that it states (emphasis added) that "By entering the date, the chiropractor affirms that all documentation required by Medicare is being maintained on file." Basically that was in the Medicare manual, however, it is now clearly spelled out that they expect the documentation to include either the date of the initial treatment or the date of the exacerbation of the existing condition. Also clarified is that this date is necessary to establish that the type of treatment being provided is medically necessary.
Prior Authorization Requirement: Last year, a program was implemented to require pre-authorizations for providers whose billing patterns were unlike their peers or those who have a high denial percentage (85th percentile). The portfolio pointed out that this program will continue and it sounded like they wanted it to expand because, according to their reviews, many chiropractic claims are incorrect for even those whose billing patterns were not 'aberrant'.
Inadequate Training: The portfolio also cited the low number of views of CMS' training video as proof that chiropractors are unwilling to change their policies and procedures. We have viewed the video and there is nothing there that we have not been teaching for years and also included in the ChiroCode DeskBook. To have the OIG state that this is a problem does not give credit to the providers who have been attending more comprehensive documentation training like that provided by ChiroCode.
Increase Medical Reviews: The OIG has called on CMS to conduct more medical reviews but MACs responded by stating that they haven't done more because they don't have enough staff to do so, and because the costs of chiropractic care are relatively low compared to other services. With this push by the OIG, it is possible that MACs will begin to increase the number of medical reviews of chiropractic claims.
Establish Thresholds: Another recommendation is the establishment of a threshold for chiropractic services. The OIG stated that other types of services such as outpatient physical therapy already have thresholds and that "CMS could set a threshold for the number of chiropractic services that a beneficiary may receive per year and require medical review for services in excess of that threshold." In support of their recommendation, the OIG stated that in their reviews "services in excess of 30 per beneficiary per year were all unallowable." Exactly how these thresholds would be established was not stated, but there were several ideas listed such as limiting visits, medical reviews for claims exceeding a set amount, and/or pre-authorizations. CMS seemed to disagree and responded "that the objective data required to implement a national cap did not exist." However, with the OIG pushing for this change, it is likely that MACs will pay more attention to the episode of care model and some type of thresholds may be coming.
New Modifier: CMS stated they might consider a new modifier to indicated the beginning of a new episode of care because simply requiring modifier AT has not solved the problem. In fact, one biller they interviewed stated that their software automatically added modifier AT on all claims. That is fraud. Be sure that your billing software does NOT add modifier AT unless you tell it to.
In summary, there will be a continued focus on chiropractic care with some interesting proposals for changes. Be sure that your organization has taken steps to ensure proper documentation protocols and carefully review your LCD to ensure compliance. Take advantage of ChiroCode's webinars and review Chapter 4 of the 2018 ChiroCode DeskBook for comprehensive information on correctly documenting patient visits.