Blog, Chirosecure Live Event February 6, 2024

Chiropractic Malpractice Insurance – Getting Paid with Timed Series Documentation

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Hi everyone. It’s Sam Collins, the coding billing expert for ChiroSecure and Chiropractic with another episode. I’ve been watching a lot of podcasts lately, and I realize. People spend way too much time on the intros. So let’s talk. What we’re gonna do today, we’re gonna talk about time documentation for chiropractic.

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How do we make sure that we’ve got the right information in the file so there’s no loss of revenue? Let’s go to the slides. All right, so for time documentation, I’m sure you are all familiar with time documentation has a 15 minute protocol. People often say, what does a 15 minute mean? Is it full 15? Not quite.

Let’s get into it. However, before we get there, let’s talk about what’s going on with chiropractic and documentation period. Now, as some of you may know, I’m part of the Optum Health Coding and Reimbursement Committee, and one of the things we do in some of our meetings is to talk about. Where chiropractic audits are happening, what’s they’re looking for and what’s the issue?

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Here’s something that goes back a couple of years, but it’s the latest information we have. I’m expecting some new information coming up shortly, but nonetheless, it shows that for chiropractors, we have a 28% failure rate of our documentation not supporting our services. Now, before we get all oh my God, 20 percent’s not very good, please notice PTs about 38%.

So it shows that we gotta do a better job still, but we’re not the only ones. In fact, sometimes the chiropractors are the worst. Not true at all. Let’s look at where we fail though. If you go back, some 10 years ago, you can see some of it was illegible documentation, things of that nature, and really bad, 64% on some things.

But look at where we’ve changed. Notice illegible documentation is pretty much nil. And I think mostly ’cause of electronic health records, thankfully. But notice the area of timed P-M-R-P-M-R stands for physical medicine rehabilitation. So your PT services, if you will, those are the ones that have 15 minutes.

And of course, notice we had a very high level of almost 70%, whereas now it’s about 22%. That’s still really high. So how is it that, eight outta 10 times we’re okay, but there’s the two outta 10 we’re not. What’s going on? What are we not understanding when it comes to time documentation? As you’re familiar with the physical medicine codes do have time.

Here’s a list of the common ones, but I wanna focus in on timed services. So you notice here under therapeutic procedures, by the way, this would also go for the attended modalities, like ultrasound, but I’m gonna leave it here where it says physician or therapist. Meaning the chiropractor required to have Direct One-on-one contact with a patient.

This means being in the room. It doesn’t necessarily mean touching. But being in the room. So you’ll notice here it says therapeutic procedure one or more areas, and then I put the star around the 15 minutes. So we’re all familiar with, of course, yes. It’s 15 minutes. So we have to spend time in order for this to happen.

So what’s happening here is I. We’re not documenting it. And I’ve seen lots of ways doctors have documented time. That’s just not gonna work. And I’m hoping today to give you a short primer on saying, what do I actually have to write down? What needs to be in the file to do this? And by the way, I don’t care if you’re doing cash or insurance, it doesn’t matter.

Proper documentation is important for any aspect. So let’s talk about this time, the 15 minutes. What does the time actually include? And I think this is where a lot of people miss out. By example. There’s some time you do that’s beforehand. So notice it says Pre-service time assessment and management. Now, some of that may be have done with your adjustment, but let’s face it when you’re going to do an ultrasound, is it the time that the ultrasound is on or is there some pre-work you have to do for that?

Of course there is. So long as you’re making contact for the ultrasound service directly, that time would count. Then there’s of course, the intra service time. That includes doing the service, obviously. But then notice post-service includes assessment of treatment effectiveness, taking a look at the area, making sure the patient’s feeling, realizing all of that is a component that’s part of it.

Now, once you move on to another service, no, but I wanna highlight it’s not just physically. Okay, start, stop. Think of it in many ways. Have you ever had an hour massage? And I’ve gotten a full hour of massage. Or is it around 50, 55 minutes? Because there’s some work in between that the person’s doing of course.

So this comes from what we call the eight minute rule. And you’ll see here it says units, unit number of minutes, and it talks about that the time of a 15 minute code. It actually does not need to be 15 minutes for one unit. So long as you spend at least eight minutes of time, you may build a unit. So it’s more than 50%.

Now, where it gets tricky, that’s easy enough. A lot of people wonder good. So if I do one service at eight minutes, if I do another service at eight minutes, would that count as a unit? The answer to that would be no, because time is cumulative. ’cause notice one unit can be eight minutes, but as much as 22, the second unit doesn’t begin until eight minutes into the next unit.

Hence why it’s 23, 15 plus eight. So in order to build two units. It has to be 23 minutes or eight minutes into the second one, or notice for three units, eight minutes into the third or 38. So let’s make sure when you’re documenting time services, you document how much time you’re spending. The face-to-face time, that’s a component of that service that includes a little pre intra and post.

Now, let’s be careful. Don’t tell me it took 10 minutes pre-service, but at the same token, two to three minutes would be probably pretty reasonable. So document that entire time. I think the difficulty is. How do we make sure to document the time itself? Let me get one more factor out here though.

When we talk about time-based services here at the bottom, it says only one time-based service may be reported at a time, and it means that services are cumulative. So if I do 10 minutes of say exercise and then 10 minutes of massage just to say, two services, what’s my total time? 10 plus 10 is 20 minutes.

Does that equal two units? You can see here, no, Sam, if I’m only doing 20 minutes, that’s one unit. So can I not bill both? No, you cannot bill both. Now the good news is you can bill one of them and it’s the one that’s the more expensive of the two. Certainly one higher rvu, but not both. But keep in mind, what if you did 11 minutes plus 12 minutes for a total of 23?

Would that be appropriate to Bill? The answer would be yes. It would be. So again, just make sure we’re documenting time. I think where we run into problems is what is acceptable, how do we document time? And I wanna give you the definitive, this comes from. The American Medical Association, American Physical Therapy Association, and adopted by the American Chiropractic Association.

You can disagree with all these groups, but I’ll tell you frankly, I don’t care because that’s the rule. Whether you agree or disagree with the speed limit doesn’t change the speed limit. So let’s understand. This is what we need to do and if we disagree with it, I’d say let’s work on making some changes.

But until then, I. This is what we have to follow. So notice it gives two methods that are accepted. It says a specific number of minutes. So if you tell me, Hey, I spent 15 minutes, 18 minutes, 22 minutes, perfectly acceptable, you, what you wanna say is, I did 15 minutes of manual therapy, including deep tissues, soft mo, deep tissues, or soft tissue mobilization to the shoulder in deltoid in let’s say infraspinatus.

I dunno, I’m throwing out muscles and I spend 15 minutes. Would that be adequate? Absolutely. Tell me the time. Tell me the where or you can list from in two time. Now notice there’s two options. You either put the exact number of minutes or you put from in two time nine 30 to 9 45 by example. Now, some people wonder, is one better than the other?

Technically no. However, I’ve noticed a few carriers, particularly Anthem, appear to say they prefer from in two times. So if that’s what someone prefers and that’s what’s gonna be the easiest path, why not just get in the habit of that? So when I’m teaching at chiropractic colleges, now I am telling ’em, just put from and two simpler.

Now, technically you can do either, but why not have both? And here’s what I’ll take away from it. Have you ever had what I call the 10 minute rule when you go meet someone they say, Hey man, meet me someplace. Oh yeah. It takes 10 minutes. Do you ever notice? It never takes 10 minutes. It’s always like 20 because it’s 10 minutes.

When things are perfect, there’s no rain, there’s no traffic, or whatever the case may be. So I would prefer to say how much time did I actually spend? ’cause often when I think we put 10 minutes, did we really mean 10 or was it 12 or 13? So I think from in two times certainly works better. However.

Either one works and you can certainly defend it on either because that’s written in the guideline. However, notice what is unacceptable documenting time in term of units. Remember the old days conversation, I did two units, that’s not gonna work. Or how about this one saying a range? This one to me is funny.

Like saying I spent from six to 12 minutes. Huh? How could you spend from, you either spent six or seven or eight and so on, so no ranges. You obviously can’t just say, Hey, I did exercise times two. What do you mean two exercises? So it has to be time, and then you can’t simply circle, remember the old forms we used to get from Parker?

You could circle, I did exercise, I did this. If you’re gonna do a billing for your billing person to look at it and just code, but the documentation, really, that’s not acceptable. And to give you further light of that, look at what UnitedHealthcare is just published. For any time-based procedure, the duration of services must be clearly documented in the medical record.

If a duration of time-based services is not clearly and properly documented in the record, the service is not supported due to incomplete documentation. This is where I’ve run into tons of denials. I work a lot with chiropractic in general, whether it’s malpractice carriers like ChiroSecure and others.

But dealing with attorneys in courts and the testimony, the one area that I can always defend you is if you put time, but if you don’t put time down, it’s gonna be a problem. So you’ve gotta make sure time is listed. But notice they say if more than one procedure is in that time, in order to fully support all the services, that time must be separately documented for each, and it must match.

But notice it gives five things. And notice I just did the one through A M, A-A-A-C-A, and so forth. You can’t say documentation of time-based codes, you can’t say units. You can’t say a range you have to do in quantity, but not specifying measurement or increment and in no time mention all. So gimme time.

It’s not very hard. No. You know what I think happens? We’re used to being quicker and easier. We all want that. I wanna be able to document in five minutes or two minutes, and that’s not gonna happen. Certainly it shouldn’t take 10 minutes, but realize, do you know documenting the service. Counts towards it, as long as you’re doing it with the room with the patient, so you know how you’re finishing it up.

That last note, that certainly could count towards that time. If it’s part of that service. What I want from you, just document time. Don’t let it be an issue. If you’ve done two units, I wanna see at least 22 minutes and as much as 37. So keep in mind, keep your time there. If you do, you’ll never have a problem.

We wanna make sure you’re getting paid. The HJ Ross Company, the network, me specifically, that’s my job. If you wanna have some one-on-one help where we can work. One-on-one, ask me direct questions. Deal with issues that come up in your office, not just some fantasy about someone else. Do that. We offer a service called the Network and we want to be here to help.

I’ll say to everyone, go out and be well. Have a very good day and see you next time.


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