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Orthopedic Tip of the Week

Orthopedic Tip of the Month

A Challenge to the Chiropractic Profession 

Consider this article a calling out of the Chiropractic profession on all compliance related matters.  After reading this article you may choose to remain reactive or become proactive.  You can continue to let apathy be a silent killer of your practice, or your interest will be peaked and you will acquire a hunger to make 2009 a record setting year.

We as a profession are facing turbulent times with the downturn of the economy resulting in patients losing insurance coverage leading to more individual financial responsibility for chiropractic care.  But even worse behind the scenes Medicare and other third-party payers are scrutinizing your billing and coding policies thus leading to increased post-payment audits on a level never seen before in healthcare.  Because of negative outcomes of these audits, large repayments will be demanded from unsuspecting chiropractors causing for some to leave the profession.  A thinning of the herd so to speak, that will leave excellent physicians looking for another career, patients looking for another doctor, and insurance carriers smiling.

Not Enough Bloodshed

Compliance consultants, I myself included, have attempted to educate the profession for well over two years since the National Provider Identifier (NPI) came into play.  We recognized that the NPI would be used to gather data (profiling) on your practice, which could very easily then turn into a full fledge audit.  Has the profession listened to what has been forecast?  On the whole no!!  There exists a minority of savvy chiropractors who got it and retained the services of a compliance consultant.  However, as one of my fellow consultants stated, “There has not been enough bloodshed yet for the rest of profession to get onboard”.  By bloodshed, he means repayment of monies, and or loss of practices.  So, I ask you reading right now, “What will it take”?

The Office of the Inspector General (OIG)

Still skeptical, and under the assumption it will never happen to you?  Well, take a look at the 2009 OIG workplan.

Medicare Payments for Chiropractic Services Billed With the Acute Treatment Modifier

We will review chiropractor billings with acute treatment (AT) modifiers to determine whether they comply with Medicare coverage criteria and documentation requirements. The Social Security Act, § 1861(r)(5), defines physicians as including chiropractors, but only for treatment by manual manipulation of the spine to correct subluxations of the spine. Chiropractors must use an AT modifier to identify services that are active or corrective treatment of an acute or chronic subluxation. Federal regulations at 42 CFR § 410.21(b) further limit Medicare payment to treatment of subluxations that result in a neuromusculoskeletal condition for which manual manipulation is appropriate treatment. The Social Security Act, §§ 1862(a)(1)(A) and 1833(e), provides that Medicare pay for services only if they are medically necessary and supported by documentation.

A prior OIG review of services allowed in 2001 found that 40 percent of chiropractic services were for maintenance therapy and thus did not meet Medicare coverage criteria, potentially costing the program and its beneficiaries approximately $186 million in improper payments. We will determine the appropriateness of Medicare payments for chiropractic claims identified as maintenance therapy.
(OEI; 07-07-00390; expected issue date: FY 2009; work in progress)

Chiropractic Under Attack

Why wouldn’t they look at us?  We stink as a profession in our documentation, and now they are coming to collect.  I am not going to hold back and sugar coat this problem, because our profession is under attack and most chiropractors do not even know it.  Other carriers are following Medicare’s lead and are recouping thousands of dollars paid for services deemed not medically necessary.  They have spoiled us and lulled us into a false sense of security and now they are calling in the markers.  They are using our own chiropractic philosophy against us in a term called Medical Necessity.

Medical Necessity

 The best definition that will cover Medicare and other carriers is a patient must have a neuromusculoskeletal condition and there exists a causal relationship between the symptoms and a subluxation.  The patient’s symptomatology is also affecting their normal activities of daily living.  The treatment must in the shortest duration possible, decrease, eliminate, or stabilize the patient’s symptoms and increase or return to normal their activities of daily living.  Anything else is either unreasonable and not necessary or classified as maintenance/wellness care.

Medicare’s Definition of Maintenance Care

 Maintenance Therapy Under the Medicare program, Chiropractic maintenance therapy is not considered to be medically reasonable or necessary, and is therefore not payable. Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to 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 rather than corrective in nature, the treatment is then considered
maintenance therapy. For information on how to indicate on a claim a treatment is or is not maintenance, see §240.1.3

This definition is the very foundation and core of our chiropractic treatment philosophy, and now it is being thrown in our face with a demand for repayment for those services that seeks to prevent disease and promote health.

Ready to Fight Back?

Do I have your full attention now?  Ready to become proactive and take back your practice?  It must start with the retaining of a compliance consultant and the implementation of a compliance program.  But before sprinting to Google and typing chiropractic compliance consultants a word of caution, we have arrived at this predicament, because of trying to take shortcuts in our billing, coding, and documentation policies.  This is a direct result of improper education and misinformation being disseminated in the profession on billing and coding topics.  In the past two years, there has been an increasing amount of so-called experts in compliance hit the field and profession.  While I am sure most have good intentions, or they a post-payment audit victim, you need to check credentials when choosing a compliance consultant.

What to Look For

There should be a minimum of at least five years experience in the chiropractic field or profession.  They should hold advanced credentials or working knowledge in the areas of CPT Coding and ICD-9 topics.  Preferably they hold a Certified Professional Coder or CPC designation through the American Academy of Professional Coders (AAPC).  Other certifications include Certified Healthcare Compliance Consultant or CHCC, and Certified Independent Chiropractic Examiner or CICE.  You want someone who has invested in obtaining advanced degrees or certifications in order to give you the most accurate and current advice.

Time to Take a Stand

I love this profession and have seen the wonders of chiropractic throughout the years in clinical practice.  Two years ago, I left practice to focus solely on compliance consulting because I saw a dangerous foe on the horizon.  It is time for every chiropractor and chiropractic office to retain a compliance consultant and implement a compliance program to ensure correct billing, coding, and documentation policies.  We need to bolster the profession and draw a line in the sand stating no more will we lose revenue due to incorrect coding, no longer will we have individual doctors struggling to stay in practice, no longer will we be the laughing stock due to poor documentation, and no, we will not allow post-payment audits to be the scourge of the profession. 



CONA Ortho Tip of the Month is designed for educational purposes only and is not engaged in rendering medical advice. The information provided through CONA Ortho Tip of the Month should not be used for diagnosing or treating a health problem or a disease. It is not a substitute for professional care.  If you have or suspect you may have a health problem, you should consult your health care provider. The authors, editors, producers, sponsors and contributors shall have no liability, obligation or responsibility to any person or entity for any loss, damage, or adverse consequences alleged to have happened directly or indirectly as a consequence of this material.

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