Strategies to Improve Record Keeping, Coding & Compliance

Marty Kotlar, DC, CPCO, CBCS

Question:  Dr. Kotlar, “My recordkeeping, coding, and collection systems are outdated. I’ve been documenting the same way for the last 8 years even though I’ve added more services and products. I am seeing more patients but not collecting more money. Can you share some tips to help me improve?”

Answer:  Yes, here are 5 ways to improve coding, compliance, and reimbursement:

1. Billing:

Most insurance carriers cover evaluation and management (E/M) codes (e.g., 99202, 99203, 99212, 99213).  Unfortunately, Medicare does not cover E/M codes when performed by a chiropractor.  Covered chiropractic manipulation treatment codes include 98940, 98941, 98942 and 98943.  Modalities such as mechanical traction (97012), unattended electrical muscle stimulation (97014/G0283), ultrasound (97035) and therapeutic procedures such as therapeutic exercises (97110), manual therapy (97140) and therapeutic activities (97530) are often covered by many insurance companies and personal injury carriers.

Many insurance companies also cover x-rays when performed by chiropractors. Below are radiology CPT codes added 2 years ago that relate to chiropractic:

• 72081: radiological examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine (e.g., scoliosis evaluation), 1 view.
• 72082: radiological examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine (e.g., scoliosis evaluation), 2 or 3 views.
• 72083: radiological examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine (e.g., scoliosis evaluation), 4 or 5 views.
• 72084: radiological examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine (e.g., scoliosis evaluation), minimum of 6 views.
• 73501: radiological examination, hip, unilateral, with pelvis, 1 view.
• 73502: radiological examination, hip, unilateral, with pelvis, 2-3 views.
• 73503: radiological examination, hip, unilateral, with pelvis, minimum of 4 views.
• 73521: radiological examination, hips, bilateral, with pelvis, 2 views.
• 73522: radiological examination, hips, bilateral, with pelvis, 3-4 views.
• 73523: radiological examination, hips, bilateral, with pelvis, minimum 5 views.
• 73551: radiological examination, femur, 1 view.
• 73552: radiological examination, femur, minimum 2 views.

2. Good Financial Policies:

Have a good financial policy in place for insurance, personal injury and cash patients.  For insurance reimbursement, call to verify coverage prior to submitting bills.  Some insurance plans (in and out of network) have high deductibles, so even if chiropractic is covered it may take 20-30 visits to get past the deductible.  For patients with high deductibles or if you’re out-of-network with a plan that only covers in-network providers, offer an affordable, good quality cash plan. Whether you like it or not, most patients that enter your office have some sort of insurance that covers chiropractic.

Situation:  You’re a cash practice and non-par with all insurance plans including Medicare.

Question:  What do you give patients that want to get reimbursed by their insurance company?

Answer:

1. Have patients sign a form acknowledging that certain portions their care may not be covered by insurance.
2. Patients must understand and agree to pay for all services and products at the time the services or products are provided.
3. Give patients ample opportunity to ask questions about their financial obligation, other treatment options, and right to refuse care.
4. Use standard CPT codes such as 99203, 98940, 97012, 97110 for medically necessary services and insurance billing.  CPT codes are not needed if a cash patient needs a simple walk-out receipt.
5. For wellness/maintenance examinations, consider using ICD-10 code Z00.00 (encounter for general adult examination without abnormal findings).
6. For wellness/maintenance adjustments, consider using HCPCS code S8990 (manipulative therapy performed for maintenance rather than restoration).  Do not use S8990 for Medicare claims.

3. Use Appropriate Diagnosis Codes

If clinically applicable and justified in your documentation, use longer term diagnosis codes such as disc herniation, sciatica, cervical radiculopathy, ligament sprain, etc. as your primary codes followed by pain, stiffness, spasm.  I also recommend the M99.01-M99.07 subluxation codes and using complicating factor diagnosis codes to paint the most compliant patient clinical picture.  Examples include chronic fatigue syndrome (R53.82), diabetic neuropathy (E08.40), pins and needles (R20.2), anxiety/depression (F41.8) and dizziness (R42).

4. Avoid Denials

Make sure you know what constitutes “medical necessity.”  According to the CMS medical necessity is a service, treatment, procedure, equipment or supply provided by a physician or other health care provider that is required to identify or treat a patient’s illness or injury and which is, a) consistent with the symptom(s) or diagnosis and treatment of the patient’s illness or injury; b) appropriate under the standards of acceptable practice to treat that illness or injury; c) not solely for the convenience of the participant, physician, or other healthcare provider; and d) the most appropriate service, treatment, procedure, equipment, or supply which can be safely provided to the patient and accomplishes the desired end result in the most economical manner.

If you’re getting denials based on the patient reaching maximal medical improvement, use good “fight-back” letters.  You should respond and appeal improper denials, especially on medical necessity.  Examples of what good appeal letters include are the following:

• The patient went from being in pain 80% of the day to only 30% within the first month of care.
• Pain levels went from 9/10 to 5/10 over a 30-day period.
• Bending and lifting abilities improved approximately 30% over the past 6 weeks of care.
• Lumbar flexion range of motion went from 40/90 with pain to 65/90 without pain.
• The patient needed pain medication due to the exacerbations of joint pain and discomfort.  Part of the care provided in this office was to try and help the patient reduce the amount of medication taken.  The patient reported that due to the care in this office, he/she now takes less medication.
• Use scores and grading scales to prove care was beneficial.
• Use orthopedic/neurological tests, pain questionnaires and outcome assessment tools.
• Include radiology results, MRI findings and any other diagnostic test results to the patient records and try to connect those findings to the patient’s signs and symptoms or to the inability to perform certain normal daily activities of living.  Example, at the present time, due to the patients radiating pain, numbness, and stiffness in his right leg, which stems from a herniated disc in his low back, he cannot play on the floor with his children and cannot put on his socks and shoes without assistance.

Use the following for Medicare:

• You are allowed to and should be collecting normal fees for exams, x-rays, and therapies.
• Make sure you are enrolled in Medicare and have an active Medicare provider number, otherwise STOP seeing Medicare patients. You are required to bill Medicare for spinal manipulation. If you are not billing Medicare for spinal manipulation, because you think you do not have to, then STOP what you’re doing and contact your state association as soon as possible.
• Proper use of ABN is very important. If you’re not enrolled in Medicare, you are NOT allowed to use the Medicare ABN form. Email info@targetcoding.com for a sample completed ABN form.
• You do not have to accept assignment on secondary/supplemental plans (unless under contract).
• Chiropractic spinal manipulation for maintenance therapy is not payable by Medicare.  According to Medicare, maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive, the treatment is then considered maintenance therapy.

5. Documentation

Create a chiropractic treatment plan for every patient.  Make sure functional improvement is evident in chart notes.  Document levels of subluxation adjusted.  Do regular re-exams to establish medical necessity and conversion to wellness/maintenance care.  Have a HIPAA Notice of Privacy Practices form filled out on every patient. Email info@targetcoding.com for a sample HIPAA notice form. For minors, have a consent to treat minor form on file.

Address the following to ensure documentation compliance:

• Document specific levels of subluxations treated.
• Make sure your notes are legible.
• Document progress towards goals.
• Provide planned re-evaluations.
• Have a valid signature that services were performed.
• Document time spent in therapy and for each exercise.
• Supply worksheets indicating the specific exercises done.

Dr. Marty Kotlar is the President of Target Coding. Over the last 12 years, he has helped hundreds of chiropractors, acupuncturists, physical therapists and massage therapists with compliance as it relates to billing, coding, documentation, Medicare & HIPAA. Dr. Kotlar is certified in compliance, a certified coding specialist, a contributing author to many coding and compliance journals and a guest speaker at many state association conventions. He can be reached at 1-800-270-7044, website – www.TargetCoding.com, email – drkotlar@targetcoding.com.