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A little there, again, friends and colleagues. This is Sam Collins with the ChiroSecure. It is my privilege to be with you. And let’s cover a little bit. That’s going on. I’ve had a lot of offices recently contacted. Sam, I’m getting these letters. I’m getting them from Medicare. I’m getting them from Anthem and others, all about coding and the ratio of coding.
And is this something we should be concerned with? Is this something that I’m in pending to get me in trouble? Does it mean I’m going to be audited? What does it mean? What it means is that people are looking and you want to make sure that you’re compliant. I’m always going to start from our end of compliance.
What. Making sure we’re following along to fit within the standards of practice, whether it be by the board of chiropractic, under state, federal Medicare, and other rules, to make sure that we just fit within that. And it doesn’t mean it always has to be exactly. Cause they’re gonna always be circumstances, but we do want to see, is there anything that makes us stand out?
We’re always, of course, afraid of the red flag. Am I going to get in trouble and what I want to be careful. You getting the hyperbole where people try to get you excited and afraid oh, I’m going to get in so much trouble. So let’s go to the slides. Let’s talk about this type of compliance and what we need to do to assure that we’re fitting right within the ratios.
Now, as always I’m with the HJ Ross company, we do seminars and programs. Take a look at our site if you will, but let’s talk about. Is it something you really should be concerned with? I always say don’t be paranoid, but being mindful have you done a compliance office in your office? Have you done it yourself?
By example, if you’re billing a 9 9 2 0 3. What are the requirements for that code? And if you’re not well aware of that, it might be something you way want to look at to make sure do I fit the right parameters. But for the most part, it’s really about just making sure the information that you have in the file matches what you’ve built.
And that’s what you’re mostly going to find when dealing with these types of issues when you get them. So I’m not concerned about an audit as long as the information is there. And frankly, as much as you’ll hear the excitement of their auditing, It’s not as prominent as you think. And I’m not saying this for you to just be relaxed, but just being mindful it’s we’re about the excitability and getting everyone to do something more than to focus on.
Let’s just do what’s right. And that’s what I want to make. Sure. So let’s talk about a complete coding compliance audit that you do on your own. What things should you be looking at to make sure you don’t fit this? So being aware of code usage is critical to compliance overall. It can easily fall into a dangerous place.
What if. Every one the same way all the time saying. Frankly, I won’t say that’s necessarily wrong because what if you see a lot of the same conditions and same levels, let’s face it as a chiropractor and low back pain and you’re seeing the same types of diagnosis. Wouldn’t you expect the same type of care plan, maybe some longer or shorter.
So just be mindful that certain times there can be things that could fall into that. That doesn’t necessarily make it wrong, but do we fall into a dangerous path to where there’s an overutilization or a higher than expected usage? So let’s talk about chiropractic manipulation. We’re all aware of the codes.
Obviously there’s the one to two area, three to four. And so on what I want to place an emphasis today is talking about how do I choose the right code? When choosing these codes, it’s not about your style or your manipulation. It’s about both things, your style or your adjustment, but what you’re coding.
So the code is not determined by your technique. By example, if you’re a diversified type provider, I bet you probably adjust full spine most often, however, The code you may build is going to be based on the diagnosis, not the number of regions you adjust, because remember they must match. So whatever is the lesser.
If you’re an doctor and you diagnose all five regions, but you only adjust see one, you get a four row. And the other side of it is if you are a diversified provider and you diagnose only cervical, but adjust all 500. It’s still a four O so it’s going to be based on both. So keep that in mind. However, something interesting to look at now, I’m going to show you here.
This is from the health chiropractic, a portion reimbursement policy, which by the way, I’m a member of the optimal coding and reimbursement committee. And I want to be clear with everyone. That doesn’t mean I get paid for it, but I sit on an advisory panel and have for 20 years on the coding and billing of Cairo.
One of the things I think it’s important to note and I highlighted in red is the use of the codes. Obviously the expectation is it’s diagnosis. Diagnosis means a or patient has an area of complaint most often. So you would expect to get a four, one, you would expect a patient to necessarily have three regions of.
And I would say, yeah, that’s probably correct. However, take a look. What I’ve highlighted in red there indicating that a person could have validated diagnosed with three to four spinal regions and complaints, but notice this validate diagnosis for two regions, plus one or two adjacent regions with documented soft tissue findings.
So I want to be careful what if a patient comes in and has a cervical and thoracic. And as a consequence on palpation, you’re finding a lot of significant findings in the upper lumbar spine tenderness loss of range of motion and so forth. Would that be enough to code a subluxation and potentially instead of being a.
For one, certainly possibly I don’t want you to think to stretch that every time, but there certainly could be reasons. Now I will tell you, my father was a diversified adjuster and he pretty much adjusted full spine cause he built, he really based a lot of things on the old building blocks. And I certainly think that makes a lot of sense.
I have a friend of mine that always adjusts extremities based on the same principle, nothing wrong with that. And I think clearly acceptable and reasonable. However, when it comes to billing. Your technique or style is not the determination, but what you’re diagnosing. So notice even for a four, two, they’re saying the same thing.
If there’s an adjacent area. Now, if a person has a surgical complaint, what’s the. Thoracic. So even if you found something thoracic there that would not turn that to a 4 0 1. And this is what’s occurring where we’re getting these types of ratio outliers, the typical expected ratio for CMT. Now this is based upon Medicare.
Those are 99, 43 doesn’t fit. The expectation is probably it’s about 50 50. Between 4 0 1 4 0 1. But frankly, even Medicare indicates that a 9, 9 41 is probably going to be the higher valued or have a higher percentage of use. And that makes sense to me because of patients often have multiple areas, not just isolated to one.
So it wouldn’t be unusual to say that maybe more than half of your patients are for. So when you look at this ratio, you should fit somewhere in between here. Now, nine and 42 should be pretty small. I’ve seen some say as much as eight, but I go less than 5% and I’m not against a four two, but imagine a four, two requires direct diagnosis for all five spinal region.
I mean what the patient do fall flat on their back off of a ladder. And I’m not saying no to that, but you can see that would be a pretty hard reach to get, have that as a common code, but certainly possible. So if you’re fitting within this, you’re fine now. And 99, 4, 3, they’re indicating maybe 20 to 30%.
I’ve seen some say a little bit less, but what I would say is if you’re billing a 43, make sure the patient has a complete. To that area and specific findings to show manipulation. Don’t just have the idea that everyone gets extremities. If you always adjust extremities on every patient, that’s more your style.
And I’m not saying anything wrong with that, but without a direct diagnosis, you’re only correlating it. I’m going to say no, but again, I’m not saying against it. So make sure if you’re a full spine adjuster, it’s more about what you’re diagnosing than necessarily how you’re adjusting. And so this brings me to what’s happening quite a bit.
As part of our network service, we help people dealing with coding and billing issues. So boy, I’ve been getting a lot of these. You’ll see this one is dated February 22nd, and you’ll see here. It says claim analysis for chiropractic manipulation. So let’s blow that up a bit and you’ll notice here. It says Anthem, meaning the whole company, and this is across the us.
This is not isolated to any one area. I’ve had letters literally from all four quarters and every place in between the U S and it says here we embrace the opportunity to foster collaboration with providers to ensure proper coding. Okay. So they’re saying, we’re just taking a look. Does this mean they’re auditing?
Not necessarily, but it says here in second paragraph, we reviewed the use of chiropractic modalities treatment as part of our ongoing claim day review for claims that’s been dated between September and October of the year following. And it says fourth paragraph or third paragraph. The review indicated your average utilization of the CMT codes, particularly nine at 9 41 42 is higher than.
So that means somehow your numbers are way above. Now, I would say, take a look in your own practice. If you’re doing electronic billing, I’m sure you can do this. Just look to see what is the percentage now again, if that percentage is about 60% or so, I’m going to say, oh, okay. Even at 70, I’m glad it’s a little bit.
But probably. Okay. So long as you have a reason, because notice what it says, we are aware of many factors may impact the coding of your, if the treatment. So could you be a provider where you do have 90% of your patients with a four one? That’s possible. But is that really probable and is it practical?
And I’m not going to say no to that, but certainly if you’re doing those numbers, I’d want to take a look to make sure can I really justify it. So take a moment to do that. Don’t just assume all I’m okay. This letter does not necessarily mean they’re auditing, but if those numbers remain high, do you think eventually going to go, we want to take a look because notice here it says, please respond via email to provider team at your earliest convenience so they can.
Hey, what are you doing? That’s different. It doesn’t mean you can’t have reasoning, but they’re looking at this as a way to say, we’re not saying we’re going to audit, but we’re giving you a warning to take a look and we’re not saying you’re wrong, but you better be able to justify. So Medicare also has begun this year and they do this every three years, send out comparative bill and reports about the usage of.
And you’ll notice here. It says the provider uses modifier 80 with chiropractic manipulation codes from four oh to four, two to indicate acute or active treatment. And they’re saying here, your percentage is significantly higher. Now I’ll be very honest about that and say to me, that makes no sense. And here’s why, what are you going to build to Medicare, but corrective care.
So therefore what is going to be the highest percentage of ones that you build? A Medicare? Wouldn’t be an 80 now. Let’s remember. Could a patient get maintenance care, of course. And if they sign an ABN, would we build a Medicare? Maybe remember the ABM gives two choices. And how many times does a patient can give you a choice to say, no, I don’t want to bill Medicare.
Therefore you may not be billing any of the maintenance care because the patients have indicated no. So I find that statement kind of erroneous for Medicare, but what I have a little bit troubling for this particular doctor is that. You will notice literally every patient, this doctor sees is a 9, 8, 9 4 1.
Now the fact that it has an 80 I’m okay with that it’s corrective care, but you’re going to tell me that you never had a patient that has a four O that everyone’s a four one. This one concerns me now. I’m not saying no to that. But I’m going to say it’s very unlikely. I had one I dealt with not long ago with ChiroSecure.
Of course you have audit protection, and these are some of the things that we deal with. Cause I’m one of their experts on dealing with. When you have an audit, by the way, check your malpractice coverage. Do you have a hundred protection because we’re going to help support you for this. Now this particular one I haven’t worked on because they haven’t gotten an audit, but I’ve seen a case where a provider did something like this and they found that roughly about 40% of those four ones were incorrect.
So they were indicating that it should have been more about 60 once they dug in through the notes. So I’m not saying no to this, but check to make sure do I really have a person with a four one every single time. Now, if you told me Sam, I only deal with people that have three complaints. They never can come to me with two complaints.
I’ll go with that. They never have one, but you can see here, the odd nature of that. So that’s something that kind of does stand out to me that I would be a little bit mindful of if I get a report of this nature, because you’re going to notice here, they’re saying, Hey, it’s. Obviously, because every single patient now, the thing they do indicate here though, is their percentages of what you bill out.
Now you’re going to notice here, they’re saying your average number of visits is 22, which is higher, the expected average in your status, 10.7. Again, that’s what I may not be as concerned with. If I have the medical necessity. The significant diagnosis. Remember Medicare does coding for secondary is based on short, moderate, and high level care.
And if you have patients with disc degeneration and those types of things as is common for Medicare patients, might you see someone 22 times in a year? I think so. So that part I’m not as concerned with what I’m concerned with is just the flat out usage. Can we dictate that this patient always have three reads?
That are diagnosed that are complaints because I’m concerned that’s probably a bit on the high end, but is it just about CMT? That could be part of it. Here’s another letter. And you’re going to go, wait a minute. This looks like the same letter it is except what is this one pointing out? Ooh, we reviewed your claims and we find you’re using modifier 59 higher than your peer group.
Okay. Is that something I’m going to be necessarily concerned with maybe, but maybe. Why do we use modifier 59? We do that to indicate when we’re doing a separate, distinct service, such as myofascial release, manual therapy or massage. And is that completely reasonable? You bet. It is. However it let’s compare in order to be paid for that service.
When we put a 59, what do we actually have to do? There’s two things. It’s not just putting the modifier, but what else? You’re right. We need to have a separate region. So this would actually concerns me a little more. Can we support when we do the 59 a lot? I’m not saying no, but if someone looks, did you always do a separate region?
Now, if that’s been done, I’m clean. I have no regard for that whatsoever, but please be mindful if this comes up, there’s certainly going to say, Hey, let’s take a look at your chart notes. Let’s see if it’s a separate area, that same office I talked about that they lost on the 909. They build out about 400 massages and unfortunately, literally 90% more.
Because the massage was never in a separate region. And that’s one for hard, hard for us to fight, because it’s real clear about that separate region. So I’m not against doing and using 59, but make sure for the codes that are needed, particularly massage manual therapy, they are separate regions, but this is their way of saying, Hey, there’s something.
That may be up, but notice again, in this third paragraph, we are aware of manufacturers impacted. So they’re never saying it’s absolutely wrong. And here’s another one you’re going to note man, same letter, but what does this one talk about specifically? The use of exercise. Now, this one to me, I find frankly, laughable why they’re saying you have a higher incidence of doing exercise.
Isn’t that what the guidelines say? If you were to read the guidelines, whether it’s a. You can go back to mercy conference for that matter, or even ones from Cigna blue, cross blue shield in there, they indicate the patients should have more active care. So what is the one thing that should be combined with manipulation to really have the patient with the best outcome?
Honestly, it is exercise. So I have no issue. If you have higher utilization for exercise, I have no issue so long as you have a good purpose. Restoration of strength, flexibility, endurance, restoration of their ADL’s to pre-injury status. Obviously we’re going to move them to more of a home-based program, but I have no issue here.
Now. The good news is with exercise. Does it need to be a separate area? Nope. Does it need a modifier? Nope. What does it need that it was done? So all this comes back to if you’ve done a service document. So with exercise, what would you document? What were the exercises. How many sets, how many reps, if there was a weight involved and what’s the face-to-face interaction and the outcomes.
So again, some of these, I wonder in a way, are they just sending letters out to make everyone go, Ooh, I’m afraid I have a tendency to believe that it’s, I’m sure they’ve got a metric that shows when they send these letters providers to cut back. Now, I’m not saying that you shouldn’t necessarily cut back.
I’m saying it gives you a chance to. And if you’re doing something improper, maybe you need to make adjustments. Don’t set yourself up to be waving a red flag above yourself. But at the same token, if everything is just a. I have no issue whatsoever. And that’s really what I help them make sure that you do in ChiroSecure does you’re here to have the best practice to give the best outcomes of your patient and provide the services that are reasonable and necessary.
So if you get a letter like this, I wouldn’t panic, but I would say, take a moment to look and go let me see, do I have something that falls out of the norm? And if it does. Do I have the justification for it? If you do that, it’s no issue. So be careful of the hyperbole and getting all excited. Remember HJ Ross is here for you.
We’ve got our new section go to our site. We always going to update things there for you. No surprise billing, other types of issues. We offer a service where I become part of your office. You call me, email me, fax me, leave and zoom to make sure you’re getting paid. Here’s going to be the. Have someone that’s on your team as an expert to always make sure you have compliance and can avoid this because it’s not as complicated as people make it seem.
And we want to make sure if anything else, you’re having a good infant practice. So I’m going to say to all of you, thank you very much. I’m really happy to be with you. I’ll see you next time. This is Sam Collins, the coding and billing expert for ChiroSecure and the HJ Ross company. Be good. Everyone be helpful.