Blog, Chirosecure Live Event August 15, 2022

Documenting Manipulation Properly

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Hi friends, I’m  Sam Collins, again, your coding and billing expert for the HJ Ross Company and ChiroSecure with another episode to try to make sure your practice is always expanding, thriving and compliant. Today’s episode. I’d like to discuss a little bit about documentation. I get a lot of calls and inquiries about what should I document?

How do I document? In fact, I deal a lot. Yeah. Audits unfortunately. And what an audit happens, the main thing they’re looking at is what you billed for reflected in the records. And I want to focus today on chiropractic manipulation, because I want to make sure there’s a good, clear understanding of what are the minimum standards or the best practice standards for you to document manipulation properly, because I’ve had some offices that have had issues recently on the proper documentation.

So let’s go to the slides. Let’s take a look here at what’s going on with documentation in relation to. Manipulation. It’s one that we think might be easy, but there’s a couple of points and tips. I’m going to give you here to focus in on. So as always, here’s the company website for me as well as my email.

So you’re welcome to reach out. However, let’s talk documentation in general. And one of the things I deal with often, again, as I mentioned is. You build for three things, did you document three things? So I want records to reflect that they maintain their accurate records for documentation of the services they provide.

Make sure if you’re billing a three region manipulation, three regions are documented and diagnosed or a therapy and so forth. You should ensure that the claims of submit are supported by the documentation. This is where we run into problems, a checkoff list that says you did manipulation or any. Would not be adequate.

That is not enough good documentation practice. Of course, ensure you receive appropriate care for the patient, but also you rely on our records to see how the patient has done, how they’ve responded. It really is a legal record more than just our chart note. So it must reflect and identify the services.

So ENM services must match the build service. Of course. If I’m building a 2 0 3, did I do enough time or that a medical decision-making hit? Or how about therapy? If I did the therapy, what therapy, where did I do it? How much time did I spend if it’s time and for days for today’s purposes, I wonder if and focus on CMT.

And I want to make sure that you’re focused in on two things about it. It’s reflecting, not only the regions manipulated, but the diagnosis as well. So we gotta be careful technique is not the. So I want to focus in on a little bit on what the gold standard is of documentation. And I would say for me, this is my own opinion.

The best documentation is one that another provider, another chiropractor could read it and perform it. If I just checked a box that said I did ultrasound, would that be adequate? No, it wouldn’t because what, where did I do at what intensity and all those things have to be there. Same with manipulation.

You can’t just say I did manipulate. You have to identify well, where did we do it? And then of course it matches. So it makes sure that someone could read it. In fact, if you’ve ever seen a surgical note, I grant you when you read it, you’d be surprised how much of a cookbook it is, of how things are done.

And I’m not saying we have to be overly detailed, but have reasonable details about the services we provided. So since we’re talking CMT codes, let’s take a look directly at the CPT manual and let’s focus in because of course we are given three codes for spine, one for extremities or extra. That deal with the number of areas we manipulate.

So let’s make sure there’s a good understanding of what these are. Cause this is one that’s, I will say controversial by some, but it isn’t, it’s been set in stone for quite a while. We have five spinal regions cervical. Now remember cervical includes the Atlanta occipital joint. It is not separate. So even though you can see a diagnosis code

That includes the exhibit. That doesn’t mean it’s separate from spine for that purpose. It also includes thoracic region as it region number two, which is obvious T spine. However, remember it includes the ribs, cost of routine role costal transverse. So ribs are not separate. The lumbar region is unto itself and then we have the same.

But then the final region is the pelvis and people that will pelvis. What do we mean for the purposes of CMT? We mean the S. So specifically say grow iliac. So you can see if there’s a lot of crossover was sacraments sake, really, but those are the five regions that we have to determine which code we’re using.

You’re all familiar with these codes. Of course, they’re based on regions. However, I want to focus on here. The code is not as determined by diagnosis and regions manipulate it, not your technique. And this is one of the areas we’ve run into problems with for our profession. You might have a provider that does diversify gods.

Maybe they’re doing Merrick or any other type, including activator. And with those techniques, it is not in often that you might adjust multiple spine Aries. I know providers when they have a patient with a surgical problem, but they’re doing diversified or constant. They may adjust the knees and the hips and all those areas.

However, the code they use is going to be cervical because the diagnosis reflect cervical. So first things first with documentation, make sure your diagnosis. Matches the number of regions so that you can bill appropriately. So if I diagnosed cervical and thoracic, but you still intern adjust the lumbar and the sacrum because you want to align everything I’m in on that, but you cannot build a 99 41 because you’ve only diagnosed two regions.

So it’d be very conscientious. So not overstate based on technique. How do we know how we document and what we document? Oh, by the way, a quick note, extra spinal means anything. Extra spinal quick note on extra spinal. It is built for one unit, no matter how many areas you manipulate. So if you do the shoulder of the elbow and the.

The knee and the ankle all in the same day, it’s still just one unit. That code is limited, but remember, have to have an extra spinal diagnosis. Of course. All right. Let’s talk about the documentation part. Let’s look at what CMS says. CMS is a little bit more specific. They want to have a very specific precise level of subluxation.

So when documenting manipulation to Medicare, you must have a very specific level and it must name the spine, not just serving. Not thoracic, but very specific vertebra. So obviously the exhibit could be occipital, cervical C one to seven Atlas axis. Any of those can be named. Now, if you want to use the numbers, you can, if you want to name them, you can as well cost of routine role, okay.

Is going to be part of the recipe. Cause notice thoracic is the dorsal spine, but notice costs are achievable costs, Costco transverse, or included. In addition, it includes ribs one to 12. So again, ribs are going to be included the lumbar spine obvious the five lumbar spine, the sacrum, or excuse me, the pelvis, if you will, is going to be the joint.

And then the sacrum is the sacrum itself, but that can include the coccsyx as well. So what Medicare is going to look for though, and this is what I want to make clear when you’re documenting for Medicare, it is not enough to say. You must say C1, C2, or occiput. You could also indicate regional. You could say lumbosacral, because if I say lumbosacral that’s indicating that it’s L five S one, so a transitional area, but be very specific where I have providers run into problems for Medicares.

They don’t name the vertebra. Medicare requires the vertebrate because of course we have to document subluxation and the subluxation has to be to a particular vertebra, just simply naming. What do they require on a visit? Obviously we’re going to do a soap. We’re going to do our little history, sip and review.

We’re going to do our physical exam part. The PRT, we’re going to evaluate how the patient’s treated, but then here’s the big part that I want to make sure we’re getting for today’s topic, the treatment given the days of the day of the visit, you must indicate to Medicare the specific level of the spine.

You manipulate it, not regionally, but vertebra. Medicare, you must indicate the adjustment today was to see one and L for that specifically, and must be done each and every time. Not once. I would also caution you don’t put down later, say refer to the subluxation above, always put the areas you’re manipulating right in there in the plan or the treatment area.

Don’t refer to another area. Don’t make someone hunt for it. Put it right there. Now, what about other payers though? This is where things get a little tricky. Now Medicare says, give me the precise level. So if you indicate chiropractic manipulation to L five, that’s just fine. But notice under Anthem, and this is going to be Anthony nationwide.

They want obviously the location, but notice something specifically and I highlighted or bolded it. They want the regions adjusted. Now, wait a minute. They said regions. So what these plans except saying cervical, they would, you could say cervical or. However notice what they require, and this is taken directly from their manual.

This is not my opinion. It says technique used, wait a minute. Now that’s a little different, even for Medicare. Now, remember Medicare, honestly, you should be indicating the technique because certain techniques aren’t acceptable. Remember it has to be manual manipulation, which activator does fix that’s manually controlled.

So I’m going to suggest you can see here. Anthem is requiring technique. I’m going to suggest let’s start putting whatever technique you have used on a particular patient, if nothing else, just so you remember last time. Oh, I did Gonstead last time instead of diversified or whatever the case may be. So I want to make sure the strictest says for Medicare, they want vertebra, the strictest and their Anthem says they also want technique.

Now could you say, Hey for Medicare, I’m just going to say the vertebra, but I’m not gonna worry about that. And then vice-versa regions and, but technique. Yeah, but I would start to say, if you’re going to document, let’s do it consistently across the board and not try to remember all this is Medicare or someone else.

Now what about other plans like Cigna? I showed you Anthem. Cigna is a little bit more vagueness to it. They, of course in documentation want the data treatment and the specific treatments provided that match the procedure code. So that would mean I would take it that obviously you have to have at least regions and that you’ve manipulated, however, they don’t give any specificity beyond that.

So I wouldn’t go to the latter a little bit more relaxed type, and then of course, everything else that goes to the treatment time and other skills services, of course. So let’s talk about what are the best practices and here’s what I want to do. I want you to do something that you can and forget it. Let’s not get too caught up. Let’s do this. The best practice is let’s use the strictest definition by a few pairs, whether it’s Medicare or Anthem. I suggest whenever you’re documenting chiropractic manipulation, indicate the vertebra, get away from saying cervical and also include the technique.

Thereby would never be a problem now realize it’s not unusual that you’ll probably do on that same thing over. So you would just be repeating it. I don’t want to say cut and paste per se, but essentially repeating it, but I want to be very clear that I don’t want to have any issue. When someone looks at your notes, that it was incomplete and not having any specificity from any one that’s outside of Anthem and others, let’s take it the stricter route.

Why make it a big deal? Let’s start documenting the vertebra and technique every time I know several chiropractors that do multiple types of techniques. I know my father, myself. I sometimes adjust with them. I might do a diversified style. I’ll sometimes do activator, but I’m going to do what works best for my patient because I don’t do only one style.

So therefore I want to know, did I, what did I do with them last time compared to now? So I don’t want him to just leave it that I manipulated be very specific. Now, I guess if you said Sam, I always do the same technique, I guess so, but what, remember doesn’t matter, Anthem stills wants you to document it.

So let’s make that the best practices that way you end any controversy with anyone. If you hold to the stricter. Then it’s never worrisome for one that maybe is not as strict, no big deal, but the one that is, we know we you’re covered. So let’s end any guessing. Let’s just make it for sure. Not that hard, frankly.

However, let’s make sure remember. Also though, if you’re diagnosing only two regions, the style of manipulation will not change that to. You must have multiple diagnosis. Keep in mind. People always worry. And I’ve mentioned about audits. I don’t want you to get overly worked up about audits, but I want you to be aware of why would someone audit you anyway, audits aren’t as random as people think audits happen because they see something unusual.

And this is something I deal with our network service. One of the big things that I deal with is offices that have issues of this. With that we can defend the good news. We mostly win these. Anyway, your ratio of CMT will lead to, or not lead to an audit. These are the standard ratios as determined by Medicare.

So this is not mine. Medicare expects the most prominent code you’re going to use will be a 9 8, 9 4 1. That kind of makes sense. The bodies people are gonna have multiple areas. So in 99, 41 is going to be more than half, maybe 55 to 60% notice for oh 40 to 4,500. Four to less than 5%. You can have some, here’s what I want you to think of.

If you’re building a ratio where 90% of your patients are 41, you’re highly likely to be audited. Now that doesn’t mean what you’re doing is wrong, but it would be unusual. Why are you seeing patients like this way more than the average, you would have to demonstrate that you only deal with more complicated and patients who have more issues, be careful don’t fish.

And what I mean by this? If a person comes in with a cervical collar, That’s not going to turn into a 4 0 1. Now, if they come in with a cervical and thoracic, and there’s a third adjacent area that maybe has some soft tissue findings, maybe, but let’s not bump everyone up. Make sure it matches, but the match, because more people have multiple complaints, it would be four.

One would be higher. And just a quick note, 99, 4, 3 is not problematic unless you do it all the time. Now, if you’re a sports medicine doctor that deal with extremities a lot, maybe your ratio was. But that’s explained because of the style of practice, make sure it’s not because you went to a, an extremity seminar on the weekend.

And every on Monday, everyone gets adjusted. I have a friend, I went to school with that. He adjusts extremities on most patients because he finds, if you have a low back problem, he always finds knees things in the knees and hips. He wants to adjust. I don’t disagree with that, but without a complaint or a specific finding, I would be careful of always adding that in between.

Be defensible, make sure it’s all there and you have a reason for it to be there. One of the things, of course, I’m always going to be here to help. We always have news and updates. Here’s our latest blog and our new section from our website, HJ, Ross, how to choose a managed care network. We have lots of videos and other things here that can help you on a day-to-day basis.

Look up topics we have there also keep in mind, guess what’s going to change. October 1st diagnosis codes are updating. Our most recent seminars are covering that and we also have a service called the network. If you’re looking for help day to day, make me part of your office. It includes seminars as well, but what a great way for you to have some compliance and better coding and billing out guarantee.

If you join, we’ll make you more money. So use the QR code. I hope to see you at a future seminar. Next week’s host will be Sherry McAllister until then I’ll serve everyone. Thank you very much. Catch you next time.