We received this question from a chiropractic practice:

“I have noticed my insurance reimbursements are gradually decreasing since January 2022. I have also received a letter from one of my insurance companies that says my charges for 9894x and 992xx codes are higher than my peers. Can you tell me what’s wrong?”

As a managed billing service provider for chiropractic practices, we often come across practices that have high accounts receivables and they aren’t sure what’s the reason behind it. A few years back, the HHS Office of Inspector General (OIG) reported that 80-94% of chiropractic documentation is incomplete and/or incorrect. Most DCs aren’t deliberately and knowingly miscoding or making documentation errors. It’s a result of a lack of awareness, ignorance, or being overwhelmed.

Is your chiropractic practice sending out billing and coding red flags to auditors? Read this blog to learn how you can improve your chiropractic documentation and coding and avoid dreaded audits. You will also learn how using the right software and expert help will keep your billing in check and practice protected.

Let’s start with one chiropractic CPT code and what documentation you need for that. For instance, you’re billing a 98941. What are the requirements for that code? Use of 98941 requires a minimum of 3-4 regions of complaint and diagnosis. You need to do manipulation in those 3-4 regions. Now, let’s take, for example, you’re billing Optum for this chiropractic CPT code. According to Optum, the use of 98941 requires documentation that shows manipulative treatment was done to 3-4 regions of the spine and one of the following – validated diagnoses for 3-4 regions or validated diagnoses for two regions and one or two adjacent spinal regions with documented soft tissue and segmental findings. That takes us to the first point of how to improve your chiropractic billing and coding.

1. Understand Your Insurance Company’s Policies 

If the insurers with which you participate have specific rules and you’re not following them, you’re violating the agreement you signed with the insurance company. Most insurance companies publish Medical Review Policy (MRP) that outlines what’s expected for specific treatments, including chiropractic care. Your providers and billing officers need to know the rules in order to ensure correct coding and usage of proper documentation.

2. Chiropractic Documentation : Follow Standard Guidelines

The best way to set documentation and coding standards in our practice is to use reliable resources.

• American Chiropractic Association published Clinical (Medical) Documentation Recommendations. Refer to these recommendations for properly documenting patient encounters.
• Check your state licensing board’s website. If the state follows specific documentation guidelines, they should be listed in your on your board’s website.
• Documentation guidelines for evaluation and management (E/M) services are published by the Centers for Medicare and Medicaid Services (CMS).
• Medicare administrative contract (MAC) publishes local coverage determinations (LCD) and coding and billing articles for initial and routine visits for Medicare patients.
• If you bill 10 different insurance companies, visit the websites of each of these companies. Check Clinical Coverage Bulletin, Reimbursement Policy, Medical Review Policy, and Treatment Guidelines published by the insurance companies.

3. Stay Current with the Coding Changes

Chiropractic coding and billing information are constantly changing. Policymakers introduce new chiropractic codes, definitions, and rules for chiropractic CPT codes and ICD-10 codes. If you don’t stay current, your billing will suffer. The best way to stay up to date with the coding changes is to use chiropractic billing software that is updated automatically every time new coding policies are introduced. Just a reminder for your practice: New changes to ICD-10 chiropractic codes become effective on the calendar year of October 1, and CPT code changes go into effect on the calendar year of January 1 on an annual basis.

4. Medical Necessity vs. Maintenance Care

There is a huge difference between medically necessary care and clinically appropriate care, especially when it comes to chiropractic coding and billing. Medically necessary care is episodic care that has a clear beginning, middle, and end of treatment. Maintenance therapy is a care service that seeks to prevent disease, promote health, and enhance the quality of life. Weekly adjustments performed on a senior patient for his arthritic hip pain may help the patient feel better, but the treatment won’t be considered medically necessary if there is no documented functional improvement. Medicare doesn’t pay for maintenance care. Likewise, if you want insurance companies to pay for your chiropractic treatment services, they expect you to provide documentation of day-to-day progress. Therefore, make sure you include questions in the subjective portion of the SOAP note that aligns with the functional goals of the treatment plan on an encounter-to-encounter basis. Each patient is unique. Each encounter is unique. Make sure your documentation for every encounter with a patient reflects the necessary objective, subjective, treatment, and plan.

5. Use Modifiers Properly

If chiropractic CPT codes are billed without modifiers when it is required, the insurance company will deny the claim with justification on the EOB of clubbing with another service. Modifiers help to distinguish specific CPT codes and keep codes from being bundled into another service. While there are several modifiers, five modifiers are the most commonly used in chiropractic care:

• Modifier 59 (Distinct Procedural Service)
• Modifier 25
• AT (The Active Treatment) Modifier
• GA Modifier
• GY Modifier

Check out here when and how to use these five chiropractic modifiers when submitting a claim. Now when you know how you can improve your chiropractic documentation, let’s check out some common claim form mistakes that you must avoid to eliminate all those red flags that could lead to audits.

1. Date of the Current Accident/Injury/Illness

This date is the date when the patient presented for care for the current episode of treatment. Don’t forget to change the Date of Current Injury/Illness in your SOAP notes and field 14 of your HCFA claim forms.

2. Diagnosis

The diagnosis box number 21 in the HCFA form tells insurance companies that your provider has provided adequate support services using the applicable diagnosis. If you use the same diagnosis on every patient visit and/or on every patient, it might draw the attention of auditors.

3. Charges

Major insurance policies have allowed fees for covered and payable services. If your practice is charging excessive or outside (above/below) for chiropractic codes than what your peers charge for the same services, it could result in some types of audits/reviews.

4. Rendering provider ID

This is the NPI of the provider who rendered services to the patient. If your practice has multiple providers, they must have unique and individual NPI numbers. Make sure the claim form clearly mentions the NPI number of the provider who performed chiropractic services on the patient.

5. Diagnosis Pointers

Diagnosis pointers indicate the appropriate order of importance in relation to the services being performed. Make sure the same diagnosis code doesn’t point to multiple services. The diagnosis pointer (Box 24E in HCFA) references the line number from Box 21.

Conclusion

If you follow the aforementioned tips and avoid common claim mistakes, your practice can keep your documentation and coding on the right track. If chiropractic practices know the reimbursement policies, follow standard documentation guidelines, stay current with coding changes, and use chiropractic ICD-10 and CPT codes appropriately, they can get paid for what they’re owed. If you feel overwhelmed with insurance billing or need help with your high accounts receivables, our managed billing experts can help you. With our chiropractic billing services, you can keep billing and coding on the right track while increasing your revenue. Talk to our insurance billing expert for free.

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