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Hey, greetings everyone. It’s Sam Collins, Your coding and billing expert for ChiroSecure HJ Ross Company, and of course, you and the profession. Today’s program, I’m gonna speak about audits. I know everyone kind of hates that term and they get nervous. In fact, I. I think you’ve probably seen a lot of people like myself, I’ve been doing as an educator for chiropractic now for 25 years, and a forensic expert when it comes to coding and billing, and I’m contacted by all types, whether it be attorneys, state boards, the insurance companies themselves.
In fact, as you all know, I’m part of the Optum Health Coding Reimbursement Committee. This makes sure that everyone knows I don’t work for them. This is an applied position that I’m appointed, but it gives me an insight onto what’s going on when we look at these types of things. And the one thing I think I’d want to be careful with is often notice the people who are telling you to be afraid of an audit.
Are trying to scare you and they’re scaring you because they want you to buy what they’re doing. So there where you can fix their problem, and it’s not to say there isn’t a little bit of purpose behind that, but a lot of that is hyperbole. So we wanna be careful and I wanna talk to you today about what is really going on with audit.
Should it be something that’s going on. In fact, you always hear people . Oh my God. They’re auditing by Medicare or they’re auditing by any, for those that have been around a long time, remember when Medicare used to send those pink sheets and you would get, you would go, and people are always scared. You should never honestly be afraid of an audit.
All audits do is verify what you bill. Did you do? So if you’re afraid of an audit, then I would be concerned that, did you just not document it? It’s not to say no one likes to be audited. Who wants to be audited by the I R S? But if everything that you said was true on there, it’s not a big deal.
So I wanna be careful because one of the things we deal with, and this is the one thing, if you’re not insured through ChiroSecure, you should be, and here’s why. They protect you. Now, obviously it’s malpractice and that’s everyone. Everyone thinks it’s malpractice insurance, and I get that. That’s certainly the main thing for it.
But the truth is, chances of you having a malpractice suit, frankly, are pretty low. And it’s not that you shouldn’t have it, ’cause you always have it just in case. The bigger factor you’re gonna run into is what if someone makes a complaint about you, whether it’s a complaint to an insurance that may trigger an audit or an insurance company looking at something.
Did you know that ChiroSecure. Has audit protection, meaning they bring in a person like myself as well as legal people that help go back and defend it. What I wanna be able to do is give you today what can trigger one, and then what to think of when one happens, how do you deal with it? But more importantly, how do you probably pr probably prevent it, but also have the mindset that if you’re doing something that may trigger one big deal if you’re doing it properly.
So let’s get away from the hyperbole and the fear. What is an audit? Really? An audit is nothing more than reviewing a file or several files for services. So by example, if you build out a 9 9 2 0 5, would that be something that may trigger an audit? Generally no. But if you did it a lot, so here would be my takeaway.
So what if you do a lot of 9, 9 2 0 fives very high level e and m? If you’re doing it on every patient, that could be problematic. But what about when you have patients that have really severe conditions, they’ve been to multiple doctors and or they just have such a history or things that you have to gather on the first visit.
It just takes a lot of time. The key is if it is with every patient, I had one doctor that billed out 9 9 2 0 4. 9 9 2 0 5, almost always. And when you see that, you’re like, my goodness, what could this chiropractor be seeing that’s life and death? It wasn’t necessarily life and death, but you know what?
He did a lot of work with surgeons who referred him patients after or pre-surgery to see what he can do to work with them. When you’re dealing with a patient that is an absolute surgical candidate, would that tell you that’s a little bit more complicated than a run of the mill strain sprain.
Absolutely. So when you’re billing an e and m code, the one thing I will tell you is in an audit, what they’re looking for is someone that bills high level e and m codes, two oh fours and two oh fives very frequently billing a few here and there are no big deal. But if you bill it a lot, they’re gonna go, Ooh, that looks weird.
So what triggers an audit are things that will come up as . Unusual. Every insurance company uses algorithms as everyone does. Now they have artificial intelligence that just looks at coding patterns. So if your coding pattern is one where you have 9, 9 2 oh fours, two oh fives very frequently, chances are someone’s gonna eventually go, oh, let’s make sure this fits for typical things.
Chiropractors. See, that wouldn’t be common. So therefore you wanna make sure if I’m billing them, Do I qualify them? So the one thing to keep in mind, if you tell me every patient is a 2 0 5, I’m gonna say that’s probably not true unless you have some unusual circumstances that may go along with your patient base.
But ultimately, even if you do, we have to make sure, did I qualify? So let’s say you’ve billed a 9 9 2 0 5. I want you all to think right now what is required. To qualify for a 9 9 2 0 5, what do I need to do? What do I have to justify that? There’s two ways of doing it. You have the medical decision making, which means the severity or the amount of time.
Now, time is relatively easy. If you have a patient that has a very complex, complicated, long history of issues that’s chronic, it certainly may take you an hour to do that. Now, would that be typical? A patient takes an hour for an experienced doctor who takes an hour, but there could be times for it. So if it doesn’t meet that type of criteria, what does it require?
A 9 9 2 0 5 is pretty significant. That requires almost a life, death, or severe disability. So I would suggest that for most chiros, unless you’re seeing that patient that’s a surgical patient and or long-term disability or lifetime, chances are it’s not a 9 9 2 0 5 unless you meet the time factor.
So one of the things to do is go back in the archives of what I’ve done in these programs to show you what does qualify if you get audited for it. I don’t care. If you qualify for it. I have doctors all the time that I get information from, they say, let me see. One of the things that I do beyond just these programs is I do seminars of course, but we also offer a service that’s called The Network where I work with you one-on-one.
I prefer that to be beforehand. One of the things you should all do is audit your own file, that if someone were to audit you, would there be a problem? Have you checked to make sure, hey, if I’ve billed a 2 0 5. Did I qualify? Same would apply with a 2 0 4. Certainly a 2 0 4 may be a little bit more common, a little bit greater severity, maybe a severe trauma with long-term disability might fit, but otherwise it’s 45 minutes.
So keep that in mind. If you are getting audited, what triggers it? High level e and m codes. Codes that would be atypical. Not to say that they’re absolutely not used, but atypical. If your run-of-the-mill patient is a 2 0 5, I’m gonna say that’s probably not right. And if you do that a lot, someone’s gonna look and go back and say, Hey, that was improper.
We want our money back, or we’re gonna downcode it. So be conscientious there. What about e and m’s? This way though? Providers often bill them very frequently. I’ve had offices say I bill them every two weeks. I would go, why? Why every two weeks? The standard for a billing of an e and m code is every 30 days.
So if you’re billing them every two weeks, what would trigger it in two weeks? Why not 30 days? If you’re doing it sooner than 30 days, and here’s the trigger, sooner than 30 days on a lot of patients is a trigger for someone to look, because again, the algorithm shows, wow, 90% of doctors bill ’em every 30 days.
Why are yours every two weeks? There could be reasons. What if a patient had a new complaint? A new injury. That certainly could justify a sooner than 30 days, but make sure it’s there. So one of the key factors is just look at your coding pattern. Are my s very high? Are they very frequent? And I’m not saying they can’t be, but if they are, you better take a better look at your notes to make sure they’re justified.
Does my notes back up what I’ve billed? What’s one of the other triggers that happens for audits that people get all concerned? You’ve all probably gotten a letter like this at some point, whether it’s from Medicare for that matter, but also all the general insurers. I’d say Aetna, Cigna, Optum the Blues all send these out that says, oh, your frequency and the use of 9 8 9 4 1 or 9 8 9 4 2 is higher than what we would expect.
Now you may wonder what are the expectations with that? I, is there something that expectations of a four oh or four, one, this will surprise many people. Do you know? Even Medicare indicates that more than half of your patients would be at 9, 8, 9, 4, 1 more than half. So therefore, if you’re billing 50 to 60%, four ones, maybe even a little bit higher, that would be considered normal.
In fact, I can tell you Optum will scold you if your four O’s are too high. ’cause they’re going, you’re probably not diagnosing this properly. This is based on when a person comes in with a complaint. How often is it Multiple areas. And when you have multiple areas, there’s often an adjacent area. So it’s not unusual to have more patients with a four one than with a four.
Oh. So something to keep in mind. What’s gonna trigger it? What if 90% of your patients, 80% are four ones? That is a little weird. That doesn’t mean it’s necessarily wrong, but does it justify? Now we have to be careful. Remember, as a chiropractor, we often adjust full spine based on philosophy, which I understand and I get.
I do diversified as well. However, if my diagnosis is only cervical, regardless that I may adjust some other regions because my diagnosis is cervical, it’s a four zero. So be careful. Don’t allow your technique to dictate your coding by example. Where I run into issues here with audits, and this is one that I get commonly, is the provider is billing out 80, 90% of his claims at a four one.
And while I’ll expect that to be the case to be higher, just not 90% invariably, and I’ll tell you honestly what I found. I’ve not yet to see a chiropractor that’s billed 80, 90% of four ones that it was actually justified. Now that doesn’t mean the majority isn’t. If you told me it hovered in the high sixties even, or at 60%, I go, oh, okay, but not 90%.
’cause at 90% you’re saying everybody comes in and no matter what, they have three areas always of complaints. And that’s probably not true. Here’s what the percentages are. Average. What should be normal? Honestly, 55, 60%, four. Ones probably about 40%, maybe in a little higher. Four. Four ohs with a very full small percentage of four twos.
A four two honestly is unusual. It doesn’t mean you won’t see it, but imagine you have a person not only with complaints, but significant findings for all five spinal regions. It happens, but I would say keep it under 5%. Now, if it’s higher than 5%, okay, tell me why. Now, again, if you have a patient here or there, no one’s gonna have an issue with that.
It’s the higher than average. So keep in mind C M T codes. At a higher frequency for a four, one or four two then goes outside the norm means you’re audited. Now, being that someone requests records doesn’t mean you’ve done anything wrong. They’re just looking going, Ooh, it’s unusual. We wanna see that it’s justified.
I will tell a doctor in a minute, I will defend you backwards and forwards always. If the justification is there, so be it. If you see those types of patients, if we can justify it, it’s there again. Would I consider it to be typical? No, but there certainly could be some . Instances where it may be a bit higher.
Now what about 9 8, 9 4 3? That is one that will trigger an audit also, if you bill more than 25%, now you go, where’d you come up with these numbers? These are based on insurance companies. The numbers they see more than 25%. Sounds like it’s a technique by example. I. I’ve had doctors. You can always tell when a chiropractor is gone to a weekend seminar for extremities.
’cause on Monday everyone’s getting an extremity adjustment. And while extremities are important and certainly significant, we’ve gotta be careful that you’re not correlating, oh, everyone with a low back has a drop, Tice or something else. I have a friend that he adjust ankles and knees with every low back because of the basis of the balance of the body on the pyramid, if you will.
While I understand that Chiropractically, philosophically, that’s more based upon his philosophy of that area, and so it correlates to the spine. It’s not separate. So unless you have a distinct complaint for extra spinal, be conscientious of the justification of it. Now, what else can trigger audits happen when things are unusual?
What’s unusual? Long-term care for seemingly uncomplicated conditions. So be conscientious. Am I treating everyone? 30 visits, no matter what. You can always tell a provider, they’ll find a plan that says the plan allows 30 visits a year. And what does everyone get on that plan? 30 visits a year. Now, I won’t say that’s impossible, but improbable.
Shouldn’t there be some people that get a little less or a little more? Why does everyone get 30? Part of that problem is people like chiropractic care. Obviously it’s the one doctor people want to go to, compared to no one says, oh, I’m looking forward. I’m gonna the medical doctor on Monday. I’ll guarantee for chiropractors.
There’s someone on your books right now that can’t wait to come in ’cause chiropractic feels good. So patients begin to choose and say if I get 30 visits a year, I want to use all 30. I’m not against that. But do we have the justification for that number? So does the diagnosis meet that level of care?
And if everyone with a simple diagnosis to a complex diagnosis is getting the same. Doesn’t that appear unusual? Now, that doesn’t mean it can’t be justified, but it’s obviously gonna be harder to justify why someone with a very simple back pain problem compared to one with a very complex, seem to get the same types of services, especially for length.
So keep that in mind. Notice what I’m pointing out is audits happen because it’s unusual, but more importantly, when someone audits, did they find anything? Was it justified? So let’s talk about. Long-term care, but also just number of services. Some doctors, no matter when the patient comes in, they get the exact same service.
They’re gonna get a little heat, a little stim, a little this, that it’s always four or five things. Again, not necessarily anything wrong with that, but shouldn’t the services be based upon the condition, the complexity. Now, when you see someone with a low back strain, I would certainly believe many of you are gonna do the same types of protocol with each patient.
Of course. What may vary is length, ’cause some strains are a little bit more severe. But what I’m pointing out is that if you always have everyone treating a very long time or with a greater number of services, it’s going to trigger someone looking. Now, that’s when we have to justify why do we do it?
Did the diagnosis match, did the complexity, why did we do the same service throughout the whole course of care? Think of the purpose of what we do. Passive care is pain management, swelling, muscle spasm. So if we’re still doing that six weeks into care, I would start to think, I don’t think that’s working.
The one thing that fits throughout care, though, the adjustment, the beauty of chiropractic is your care, meaning a chiropractic manipulation fits during any phase of care. But think of modalities. What is the purpose of exercise? That’s rehab. Now we can start it sooner than later, but if you’re telling me that someone’s still getting heat on visit 20.
Why So again, there’s gotta be a justification and why would I bill heat anyway, it’s so inexpensive. Focus on the active care. The other one it comes to treatment is just plain old number of services. As a person gets better, there’s an expectation that some services would drop off. I’m not gonna say necessarily the number ’cause I believe in rehab.
If you look at a standard insurance carrier protocol, they talk about active rehab being something that we should do with our patients. Why? Musculoskeletal problems are always gonna cause a deterioration in strength, flexibility, deconditioning, you gotta rehab it. So exercise certainly should be a part.
And maybe the initial you don’t do as much ’cause a patient can’t tolerate. But then we drop some of the passive things I. Focus on the active, so the number might be two, three units of that key factor here is if you’re billing three units of services per visit, that’s within even four, but it’s when you’re getting to six, seven, or eight, it’s now if you tell me a very severe auto accident or something, that nature, that might be justified for some period of time, but I’m getting back to a trigger, is something unusual. If your pattern fits with them, and again, if there’s a outlier here or there, let’s say your average patient visit is 11 and you 11 visits meeting, but you have a few patients that come in 30 or 40 times.
I would go yeah, because that is something that we’re gonna see. But if you tell me every patient, for every patient that does 30 or 40, you probably should ask them to take two or three. Let’s face it, some people should get a little bit better. So keep in mind, don’t be as afraid of an audit in the sense of did you or can you justify what you did and why, and did you do it?
Most importantly, invariably I find when offices are audited, it’s sent to me, whether it’s ChiroSecure or others. I look first to say, Hey, what can we justify here? Let’s make sure it’s all there. If it’s all there, I’m in. Defend you backwards and forwards. We don’t lose those. So one of the things I require when someone joins our network is I audit your office.
I wanna audit files to see whether or not, hey, let’s just take a random look. Everything you billed for, was it done? And you should do the same. Have you ever thought of, do I do a self-audit? By the way, that’s part of HIPAA and compliance, self-audit. Am I really justifying what I’m doing? And I would say be particularly conscientious when you are a higher than average utilizer.
If you bill high level e and m codes, you do a lot of services. Begin to look a little bit more critically. Don’t be afraid, I. Be proactive. Your care is good. Let’s demonstrate it. So let’s give a summary. Let’s go to the slides here. Let me give you a little bit of a breakdown of what to do if you have high level e and M codes.
That is something I want you to be conscientious of. Can I justify it? What if your e and m frequency is above every 30 days? Just make sure, why did I do it? What triggered it? So you don’t have someone coming in going, Hey, there was no reason for it. Your C M T codes, what is your percentages? You should see higher than 50% for four ones.
But if you’re building at 90%, take a critical look and see, am I doing this based upon my technique? Let’s face it, if you’re an activator type doctor, you may well do a five region adjustment plus extremities every time. I’m not gonna down that type of technique. However, the use of that technique does not justify you in a four, two and a four three every time.
What about greater than four units or four services? That’s something I would look at to see the why do I justify I’m doing that. In fact, if you’re doing very passive care with active care at the same time, that seems a little bit weird. Why? What about just long-term care for uncomplicated conditions?
Okay, simple diagnosis, getting the same as something more complex. Take a look and figure out why are there unusual circumstances? Can I justify it? So here’s what it comes down to. Make sure your documentation meets the level that you’ve done. If you’ve not done a class with me or looked at it, please look, do I fit the medical decision making or time?
And let’s remember, time is not just face-to-face time, at least when it comes to an exam. Does your diagnosis meet the C M T? Be careful. Often, I’ve seen doctors say the patient came in with a cervical complaint, but I’m justifying a four one. You can’t. Now. Certainly if you told me there’s a cervical complaint and you saw something adjacent in thoracic, I would say yes, I get it.
There could be another diagnosis there, but what’s adjacent to cervical? Thoracic, there’s no adjacent to lumbar, so be conscientious there. Does the care plan. Match the severity and complexity. Think of your diagnosis. You want to create something that doesn’t cause an audit. Give me a proper diagnosis.
What is the difference to someone treating for back pain, to facet syndrome or radiculopathy? There’s a big difference. I. So here’s the thing. Help me help you. We offer a service that does that. This gives you a little thumbnail scratch of it. Take a look. Our seminars are coming up. We’re gonna have all the new codes that are happening for next year, but in addition, we go through how do we help you?
And that’s really the one-on-one part I’m gonna say to all of you. Don’t be afraid you’re giving good care. Don’t be scared of an audit, but be proactive to look, to make sure, am I there? Let me be part of the team. We can do that. Until next time, everyone, I wish you the best. .