Blog, Chirosecure Live Event December 11, 2023

Chiropractic Malpractice Insurance – Are Your Exams Being Denied and Not Paid?

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Hi everyone, it’s Sam Collins, the coding and billing expert for Chiropractic, the H. J. Ross company, ChiroSecure, and of course you. We’re always dealing with issues, changes, things going on, obviously 2024 is coming, there’s going to be RVU updates and other things, but one of the things we have to deal with, and this has come up quite a bit recently as an expert.

Lots of questions related to this. I’m getting denials or I’m having problems with my evaluation and management codes. I want to make sure I’m getting paid and this is even for the seasoned doctor because there’s some things going on we want to start to address. So let’s go to the slides. Let’s talk about evaluation management or E& M codes and specifically for chiropractic coding and payment.

What do we need to do? What’s going on with E& M’s, our exams? Obviously the first thing I’ve been running into is sometimes we’ll get denials where they’ll come back and say The examination was not within scope or not covered. Let’s first talk about that. Would it be [00:01:00] reasonable for a doctor of chiropractic to treat someone without examining?

It’s a requirement to determine what’s wrong. Can you imagine? Patient just comes in and you say, I don’t care what’s wrong, lay down and let’s adjust you. Obviously, there’s legal and ethical requirements to do so to evaluate a person. So there is a requirement. So whenever you get a pushback on something like that, unless you have A contract that says otherwise.

And this is where you do have to be careful. What if you join something that says, we’re bundling everything in? By example, if you belong to UnitedHealthcare under OptumHealth. They’re going to bundle the exam into the treatment, meaning you’re going to get 60 visit, 60 a visit, regardless of an exam, x rays or otherwise.

I’m talking outside of that. There otherwise, of course, is a requirement for an exam and it should be payable unless it’s contracted otherwise. However, something we have to consider is, are we using the right codes? Remember, the codes are updated, and in fact, they’re changing a little bit for 2024. You may want to get to a seminar with me to get that.

But nonetheless, we’re going to [00:02:00] have new patient codes, 99202 205, and established patient codes, 99211 215. Remember, these codes have two components for use. Are you choosing the code based upon severity, medical decision making, something simple like a 202? Or something very highly complex, maybe life threatening with a 205?

Or someplace in between? The key factor is it’s going to be one of these. And when you use this code, what you are indicating is that you’re doing an exam. And this is one that’s going to be above and beyond what you do on a day to day basis. And that’s the big reason for why you have to use Modifier 25.

And this is the issue I see time and time again. I’ll get someone to contact me and say, Hey, Sam, I got denied for an exam. And I’ll say, okay, let’s talk about that. Did you bill with a modifier 25? And particularly for a new doctor, they often say, what do you mean by modifier 25? Let’s remember modifier 25 is a requirement when billing an exam with treatment to [00:03:00] be put on the exam, to demonstrate that this exam is above and beyond what they call the pre.

Intra and post service evaluation. If you don’t put that modifier, it’s an automatic denial. You’re basically stating to the insurance, don’t pay me. Let’s make sure we’re putting on there, pay me, and that’s what the 25 does. Remember, the 25 does not change the price. It just indicates it’s a separate and distinct evaluation.

Let’s get into that a little bit. When you treat someone on a day to day basis, let’s say it’s the second visit. You’re probably going on the second visit. Ask them, Hey, how are you feeling today? Is that a little better, a little worse? Maybe do some objective evaluation, leg check, palpation, range of motion.

That part of an evaluation is embedded into the treatment or the manipulation code. So for that reason, we have to demonstrate to the carrier that the exam is above and beyond that. That’s the reason for the 25. It’s the sole reason you don’t bill an [00:04:00] evaluation every day. Why don’t you? You do one every day, but remember there’s a small portion of it that’s embedded.

So what you’re doing with the 25 is saying, no, this is above and beyond. So realize the first visit A lot of information is going on. History and exam and so forth. On the follow up visit the next time, not so much. You’re just doing a review. However, after 30 days, would it be appropriate to do an exam again?

Sure. What we have to assure though is, does the exam correlate to something above and beyond the day to day visit? And that’s going to be important because putting the 25 is what’s going to show to be paid. Here’s an example. Notice this is a patient getting an adjustment, massage, therapeutic activities.

But notice 25 is on the exam code. to demonstrate that it’s separate and distinct. Again, not a change in price, simply showing it’s separate and distinct. So be mindful. The number one reason exams are denied is lack of the modifier. The other factor, though, could be, did we demonstrate [00:05:00] that it was separate?

Now, sometimes people get confused and say does it require it? So I want to show you, this is a picture, this is from the 2024 CPT manual. And I’m going to highlight here, it says, the chiropractic manipulative treatment codes includes a pre manipulation patient assessment. Additional evaluation management services, including office or outpatient visits, and it names all of them, including home visits, it says may be reported, and I’ll go right here, may be reported separately using modifier 25 if the patient’s condition requires a significant, separately identifiable E& M service above and beyond the usual pre service and post service work associated with the procedure.

So you can see here, even in the manual, so if you ever get a pushback saying, oh, it’s included. You’re going to point out, that’s the reason I put the 25, because it’s separate and distinct and above and beyond. It isn’t what you do day to day. The day to day of how I get, but the one you do after 30 days certainly is beyond that.

Remember, when you do a re exam, [00:06:00] it must be a re exam. Make it appear so, right on that date. Re examination. Go through all the details. It’s not the simple day to day one. When you have that in place, now we have a place to defend. I had an office defend say I did do a re exam. It was after 30 days, but if you looked at the notes, unfortunately, the evaluation that day was no different than what they did the visit before.

So make sure when you do a re evaluation, you can defend that it was above and beyond significantly separate. It’s appropriate every 30 days, no question. That’s under CMS rules and adopted by most carriers. Can it be sooner? Yeah. What if a patient comes in today, neck pain? And then after a few treatments, they come in and go, Oh my goodness, I fell down and I hurt my low back last night.

Would it be appropriate to do an exam to their lower back? Absolutely! Now, is it going to be a very high level one? Probably not. They’re an established patient. But it would be appropriate, even though it’s sooner than 30 days. But what do we have to demonstrate? It was significant, separately [00:07:00] identifiable, above and beyond what we do day to day.

So I’m always going to say push back on this. If they’re telling you it’s inclusive, send a copy of your exam. Point out, this is page 871 of the CPT manual, by the way, for the 2024 edition, that shows clearly according to the guidelines it is. Just be careful. Don’t bill an exam just because it’s 30 days.

But because it’s separate, distinct, and above and beyond. The reason for the 25. Don’t be caught in a trap of thinking you’re just gonna bill one because, but significant and separate. And of course the use of the modifier. As always, ChiroSecure, H. J. Ross, myself, we want to make sure you’re doing good work and getting paid for it.

Are you always up to date? Realize we’re keeping you up to date always as a network member. I give you one on one help where we can dig in. I’ve got letters that deal with this that you can adjust a little bit for your situation, but ultimately defend why you’re doing it, highlighting the rules and the regulations.

Your goal, do good care for your patient. My goal, make sure you’re getting paid [00:08:00] for it. Get to a seminar, come to a network service with us. We’ll be there to help. Thank you and see you next time, everybody. Wishing you the best.[00:09:00]


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