Chiropractic Top 10 Audit Triggers

Why is there so much emphasis on chiropractic audits? Mainly because Chiropractors dont fight back, they give in out of fear. Once a chiropractor gives in, it's taken as an admission of guilt - not necessarily of fraud, but more often as evidence of sloppy office practices or inadequate understanding of billing codes and documentation. The Chiropractic Profession is not proactive. It's much harder to get money from a medical doctor because they keep good records. It's much easier to get money back from the Chiropractor. Many Chiropractors "assume" that as long as the insurance carriers are sending reimbursements, they are coding and billing properly....a dangerous assumption. A computer makes the payment, but people conduct the audits, which means payments are often automated. Every carrier profiles your claim history. If the size of your claims, billing codes, visit frequencies, treatment durations or other indicators fall outside of an accepted parameter (defined by them), your billing pattern may be questioned and an audit triggered. Usually the pattern relates to coding issues, the date in item #14, or "documentation" requests. If your coding, etc., is different than your peers, you may be flagged for an audit. However, If you have a well-documented case, justifying your recommendations, recording functional progress and your documentation shows medical necessity, this should be nothing more than a temporary annoyance. These are the top 10 Audit Triggers: 1. Improper Use of Modifiers. Depending on which procedure code you use, a modifier may be appropriate. In Medicare, for example, you need to indicate whether the service represents Active Treatment (using the modifier -AT) or it will not be paid. Similarly, performing Manual Therapy (97140) on the same visit as an adjustment will also require a modifier to be present to signify that it was a separate and distinct service (Modifier 59). 2. Billing Same CPT Code for Every Patient. Billing for a 5 region adjustment (98942) on every visit just because you are a full spine doctor will not sit well with most insurance companies. 3. Routine Use of Full Spine X-rays. If other practitioners all take x-rays in a wide variety of anatomical regions, but every one of your x-rays is a full spine series, then you suddenly stand out from the rest of the pack and are essentially inviting an auditor to investigate your billing and coding practices. 4. Billing for an E/M Code on a Daily Basis. Some shady chiropractic "coaches" and practice management gurus advise their clients to increase services through the repeated, routine (or even daily). Unfortunately, anyone with knowledge of proper coding practices will tell you that this is not warranted and will just lead to big trouble when the insurance company catches on.

5. Billing for all New Patients With a High Level E/M Code. Certainly, high level E/M codes such as 99204 or 99205 reimburse the most. But there are probably few (if any, in

certain chiropractic offices) times when an exam truly meets the criteria of these codes. To simply bill these codes in hopes that it will fly under the radar is foolish and misguided at the least and possibly fraudulent as well. 6. Over-utilization. Once a patient has been seen for a period of time, it is considered customary to begin tapering off treatment, with the goal being patient discharge. Recognize that in many cases workers' compensation and motor vehicle insurances reimburse only up to the point of maximum improvement, not up to when the patient completely feels better. 7. Duplicate claims. Its not entirely surprising that some claims could be submitted more than once by mistake, given how long processing takes. The common mistake is rebilling the claims without first contacting the carrier to find out why your initial claim went unpaid. This practice of re-billing may be seen by the carrier as you trying to get paid twice for the same date of service. 8. Passive versus Active Therapy. The long-term use of passive therapies (application of ice/heat, stim, etc) without being able to demonstrate any significant impact on the patients functional improvement may also trigger an audit. The patients treatment plan should reflect a transition from passive to active therapy which could include exercises. 10. Financial Planning. Routinely offering discounts, free services or financial inducements to begin care can be a cause for serious penalties. Whatever you offer one patient as a discount, you must offer EVERY patient that same discount. You may not offer any Medicare patients free services. Dual fee schedules are a definite No-No. Many chiropractors live in fear of audits and as a result, inhibit their revenue opportunities by not billing fully for their services. Instead of billing, coding and documentation properly for their services, they would rather bill safely, which affects their bottom line. It also affects the Chiropractic profession as a whole. With the proper knowledge, there is no conflict between the two, and a more substantial revenue stream is the direct result. The answer lies in being preventive, rather than reactive. The key to avoiding audits in the first place is preparation - making sure you can support the claims you submit. That entails:

A clear understanding of the codes; How the coding system works; How to use it to bill for maximum revenue; How to safely bill "outside the norm;" How to demonstrate medical necessity; How to present your documentation; and Having a system in place that supports your billing

Please be sure to check out my Squidoo Lens and my very popular website The Chiro Buzz where I provide tons of FREE and valuable content that you can use to improve and grow your chiropractic practice. KMK Consultants Jacque Keil Email: Jacque@kmkconsultants.com Phone: 866-933-1381