Blog, Chirosecure Live Event September 30, 2023

Does Your Documentation Match Your Services?

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Hey, greetings everyone. Welcome back. This is another edition of Chiro Secure’s. Let’s get your office practicing better, doing better, making more money. That’s what we do with my service. The HJ Ross network is to make sure your office is compliant. Compliance always equals money. What we’re gonna focus in on this program is gonna be chiropractic documentation.

Something we all hate to talk about, but it’s something we have to have. And you wonder, well, why do I have to have it? I’m at all cash office. I don’t need to document, or at least not as much, or if only if I’m billing insurance or Medicare. And that frankly is not necessarily the case. There’s documentation requirements regardless of how you’re being reimbursed for your services.

So let’s dig into that. Let’s talk about chiropractic documentation. Let’s go to the slides. For chiropractic documentation, I want you to think of it this way. I want you to assure whatever you’ve done with the patient, whatever you billed them for, is within the notes. And this is where we often run into problems.

We have to make sure that everything that was done appears in the notes. And you’ve probably heard this statement before. If it’s not documented, it didn’t happen. And that’s very, very true. If it’s not written down, it didn’t occur. So we gotta think. If we have to have things written down or documented, I won’t say you have to hand write it anymore.

Most people are using electronic records. But do the services that we bill for, do the services that we assure the patient had? Are they in the file? And so what we do is we have to look here. Oh, I lost my, uh, Here. There we go. Who tells us we have to do this? This is one of the things I think often people get frustrated and they think, well, no I don’t because I don’t bill insurance.

Well, who says you have to do it? And the why? Board of Chiropractic. The board has standards that the services that are being provided must be documented adequately within the file, whether it’s gonna be exam, diagnosis, the treatment you provided. It doesn’t matter whether or not it’s being billed to insurance, the board requires it.

Well, who also requires it? In fact, I’m losing my, um, . Spot here. There’s gonna be, of course, state and federal regulations that are gonna require it as well. That’s gonna certainly fit. What do you mean by the state? Well, that’s the board. The federal’s gonna be under the federal government, if you will, under standards of hipaa, if nothing else.

But realize there’s city and county rules that may apply as well as just community standards. And this does involve insurance, if you will, but also your peers. But more importantly, the patient. What if the patient comes back and says, this doctor did not perform these services, or, I felt he charged me too much.

How do you defend that? The services you were done? It’s what you’ve documented. So again, I wanna get away from the whole insurance thing. I don’t care. I wanna make sure everything that we’ve done is in the file. What if the patient makes a complaint that something improper happened in the visit? Here’s a good example.

What about a patient that complains? I felt dizzy after the visit. What did you document at the end? One of the things you should be in the habit of is when you’re finished with the visit, asking the patient how they feel and how they felt at the end of the visit. Because if you don’t indicate it, that means the patient will say, well, I didn’t feel anything, or I felt horrible.

I want to know that to document that, to make sure that if anyone comes back later and says, this patient felt dizzy, you’re gonna highlight, no, they did not. In fact, at the end of the visit, we inquire with the patient and document. Now it’s not to say maybe they didn’t feel it sometime later. But they cannot say it was felt there and we documented that information.

Well, you may wonder, what does the state board say? This is their board of chiropractic examiners for California. I want you to realize I’m using California just as an example. I don’t care what state you’re in, you’re gonna find a lot of the same things here. You’ll see things, it talks about doing insurance fraud, unlicensed practice, sexual misconduct, all those bad things.

I wanna focus on really kind of the first thing it says here, insurance fraud. Now, forget insurance. Billing for a service not rendered. Now, you may say, well, of course Sam, I rendered the service. I charged the patient. Not if you didn’t document it. If it’s not documented, it didn’t happen. So always think of there’s a requirement to document the services, to make sure that if someone comes back and questions what was performed that day, whether it’s gonna be just a question of the patient or something where they’re making a complaint, we’re gonna have information there.

Here’s one, you can see this is an insurance one. And of course everyone think, well, I don’t bill insurance. But look at what it says here. I think it’s interesting. The objective of this audit was to see whether or not the doctor’s records indicated what was done. It says here, for 11 members, dated for about a year.

It says, upon review, it was found that 96% of the services were coded and paid inappropriately while 3% were paid appropriately. So in other words, 97% error rate. What happened here that we didn’t have it? Well, here’s what it says. It says it recommends improvement in documentation compliance modality not identified partially or fully cloned medical records.

This is where you have to be careful. Electronic health records, of course, is what you should be using, but be careful of certain aspects of just cloning information over and over. Says the same thing. If you were telling me I did ultrasound to the right patellar tendon for eight minutes and that were called, I’d say, yeah, that sounds reasonable.

Now, obviously, will that change a little bit day to day? Is it always gonna be exactly eight minutes? Maybe not. But nonetheless, there could be certain aspects, but please be careful. Don’t clone subjective and objective data over and over. It doesn’t make sense. That’s not how a patient talks. By the way, does your patient actually ever say, I felt pain 51 to 74% of the time?

Who in the world says that? Give me information what the patient really says here and says, service bill not rendered. I don’t think the service probably wasn’t rendered, but it wasn’t documented or no documentation is received. So these are the types of things I deal with all the time. I deal with a lot of issues, whether it’s gonna be board or insurance, where doctors get themselves in a little bit of trouble.

Remember, ChiroSecure protect you in audits, but one of the best things to do is protect you before it happens. So that making sure if someone looks at your records, no big deal. Everything is there. Well, I’m part of the UnitedHealthcare Optum Health Coding and Reimbursement Committee, and one of the things I do within this committee, by the way, I’m not paid by them.

I’m an appointed member. These are the things for chiropractic claims that they show that we have failure rates. Now, you’ll notice. Illegible documentation went away in 2015, or at least a large amount of it. Probably ’cause we’re using electronic records, but you’ll notice service not documented 6%.

That’s not too bad, but that’s still higher than I’d like to see. But you’ll notice the biggest issue that we have is there’s no timed services that are documented properly. 22%. So that’s a pretty large amount. So we wanna make sure what things are we making sure are documented is time. Time documentation for chiropractic, particularly for time services is a big issue.

Thinking yourself. Did you actually document time? Did you tell me how many minutes or did you tell me from? And two, I don’t care. Which, by the way, just do that. That’s not hard. Not at all. In fact, I’m showing this for chiropractic, but take a look here. Everyone says, oh, chiropractic documentation is horrible.

Well, let’s see. Based on their audits, you’ll notice who has the highest level, not chiros. PTs 38% of the time, chiros are at 20%. Now, I’m not proud of that. That means three quarters of the time we’re not doing a good job of making sure we’ve adequately documented the services provided. So let’s fix that a little bit.

Here’s what part of the problem is. You’ll see here it says, out of the 22 patients reviewed 22, lack supporting documentation that validated the services built. So what does this mean? Well, here it shows documentation to support the medical necessity of manual therapy for spinal regions was not there.

We need to have very specific things. Notice it says description of the manual therapy technique, which may include one or more of the common manual therapy techniques. Realize trigger point therapy, manual attraction. Any of that’s fine, but you have to say it. Don’t say, I did manual therapy. Too broad.

What type of manual therapy, where did you do it, and how much time? And I see this time and time again. So let’s start with the first place. We often run into problems, exams, when you do your evaluation and management. You’re familiar with these codes, new patient, established patient. But let’s talk about what level of code am I appropriately billing.

So by example, if I’m billing a 9 9 2 0 2, A 9 9 2 0 3. How am I choosing that code? Well, let’s go back. You’ll look at each of these codes. A 2 0 2 says 15 to 29 minutes. A 2 0 3 says 30 to 44. So one of the aspects could be how much time is spent, and actually you can use time, realize what are we documenting?

The time we spend on exam should be documented if you are using time as the value. Let’s face it, sometimes you can have a patient that doesn’t have a very severe problem. But because of their past history, complicating factors, use of pharmacology or use of drugs or prescriptions, that exam meaning history may take an extended amount of time.

So what if I spend over 30 minutes? But if the problem is relatively simple, well it happens ’cause I have to have all that information properly. If it takes over 30 minutes, I’m gonna bill a 9 9 2 0 3. Now if it takes, say from 15 to 29, I’m gonna bill a 9 9 2 0 2. Now you may say, well, Sam, what about if I spend less than that?

Well go back here. You’ll notice that 2 0 2 says 15 to 29. So you might ask yourself, well, what code do I bill if I only spend 10 minutes? And that can happen. Let’s face it. Some of you can be very efficient. In fact, all of you. We’ll be very efficient on how you perform an exam and the way you performed exams when you first started to now are big difference.

It doesn’t take you as long. However, if the problem is of a severe enough level, the medical decision making may bring it there. So I’ll give an example. What if you have a patient with a sprain or some type of trauma and that exam only takes 10 to 12 minutes? Could that still qualify for a 9 9 2 0 3?

Absolutely. The reason why is the medical decision making of that type of complaint or injury lends to a 2 0 3. So here’s what I’m getting to. What am I documenting? I need you to, in the notes, whenever you have done an exam and you bill for that level. Have some indication of why did I bill this exam because I spent 30 minutes, or was it because I had medical decision making that fit?

That type of complaint. Probably one of the easiest ways to see this is just looking at the codes from a time value. Here you’ll see the 15 minutes, 29, and so on, but you’ll notice the medical decision making, and this is often confusing. People wonder, well, what do you mean by medical decision making? Now I’m kind of making this a little bit simplistic, but it still fits.

If a patient has one simple complaint, even if you spend five minutes on the evaluation on the initial, would that still qualify for an e and m? You bet it does. It would be a 2 0 2 notice, one self limited or minor problem. Now, here’s where a lot of people miss the boat. You know what A 2 0 3 equals when someone has two or more complaints?

How many patients come in your office with two complaints? I mean, several will come. Oh doc, my neck is hurting, but how many come in? Oh man, my neck, it’s going in my shoulder. You know, I’m feeling a bit in my mid and low back. Well, that’s two or more complaints that automatically makes it a 2 0 3. But notice what also does that is an acute injury, so any trauma.

We’ll jump you up to a 2 0 3 because chances are, if there’s trauma, are you ordering extra tests such as X-rays? So I wanna highlight when you’re documenting here to make sure that if you’re billing a 2 0 3, I want you to be the first person to know. I know it’s a 2 0 3 because I spent 30 minutes, or there were two complaints or trauma.

It is that simple, but you gotta make sure it’s in the notes. Remember, not documented, didn’t happen. How about an acute, complicated injury of pretty significant trauma on a PI case that has radiation down the legs or something? I call that a complicated case. That means that 2 0 4 fits that. But what if you don’t spend 45 minutes?

Well, that’s okay because of the injury itself. Not always. It’s time. Think of it, medical doctors often don’t use time at all. Because they’re looking at something that may be severe but can do it within a short amount of time. Chiropractic was always pushed back on that, that we couldn’t bill a higher code.

But you can. But we have to make sure that if we’re billing a higher code, justify it. It’s gotta be documented. What is it? Time or medical decision making now? 2 0 5. Probably we don’t get for medical decision making threat to life. But you ever had a patient that spent 60 minutes, that happens. I won’t say it’s typical.

But it happens. So here’s my point. When you’re billing an e and m code, make sure it’s separate and distinct from the evaluation associated with treatment. Then of course, make sure whatever level you’re billing it fits the code, meaning by time or medical decision making. By the way, 2 0 2 to 2 0 5. These same parameters fit for 2 1 2 to 2 1 5.

The only difference time is a little shorter. Here’s my point. When you’ve documented an exam, don’t make anyone ever say We don’t see a separate exam. Yes you do. It’s separate, distinct, above and beyond what we normally do. And I’ve indicated time, I’m gonna tell you, chances are you should do both, because sometimes you may think something’s gonna take a short time.

Before you know it, you’re like, oh my God, that took much longer. Or sometimes it doesn’t. Keep in mind, time doesn’t just equal. The time with the patient. When it comes to these services, the things you do before and after on the same day as an exam can certainly count as well. Now, what’s another big area of documentation?

You have to make sure you’re compliant. Of course, our adjustment. It’s the thing you do. Now, your chiropractic manipulation should be documented. Where did you manipulate? Of course. But remember that codes you are using has to match, not based on your style of adjustment. . But on the regions you’re manipulating and the diagnosis.

So by example, if you’re doing a Gonstead, or maybe Gonstead is a bad example, maybe you’re doing a diversified or activator style, you might adjust multiple areas of the spine to aid in correction of a cervical diagnosis. Perfectly fine. However, you cannot bill a 9 8, 9 4 2 just because you adjust all five regions.

It’s gotta be based on diagnosis and the regions manipulated and they have to meet. So by example, if you do only upper cervical, even though you’ve diagnosed five regions, you still get a 9, 8, 9, 4 oh because you’re only manipulating one. So keep in mind, documentation much match. So if you’re billing a 9, 8, 9 4, 1, did you document a minimum of three regions that you have diagnosed?

That you’ve manipulated them. Now, a quick note on documentation. I’m assuming most of you’re familiar when it comes to Medicare, it does require you indicate specific vertebra. So you must indicate I did C two and C five by example for other insurances. You don’t have to be that specific, you have to indicate the region.

However, I will warn you, I’m not sure you’re aware. Do you know Anthem? And I’m talking all Anthem. I don’t care what state you’re in. Anthem requires you indicate. Not only the region, but your technique. So to make it easy, you know what I would think to do? How about we just get in the habit to make sure that we always put in vertebra and technique.

That way we satisfy the fullest amount. Now if you say, Sam, it’s not a Medicare claim. I don’t worry about it, and you give me region, I’ll say, that’s okay, but make sure it’s documented. Now let’s talk about, Hey, forget insurance. Sam, what about a patient that says, I didn’t receive an adjustment today, and your chart notes don’t make any clear indication of where you manipulated the type of manipulation.

Please be specific so that way there’s never a question about what you do. And remember, therapies, keep therapies simple but documented. Make sure, in fact, here’s my golden rule. If you can read a chart note and based on that chart note could perform the service, I would say the documentation is adequate by example.

If I said I did infrared heat, would that be adequate? Well, if I told my staff to infrared heat, what would be the question they ask? Wear a doc. So when you document, you need to make sure specifically the what and the where. So here’s some examples. If I’m gonna do mechanical traction, let’s say indicate where you’re doing the traction, what type are you doing it with?

The harness. What’s the weight? In other words, make it so that when someone reads it, they can perform it. Notice infrared heat to the lumbar spine. E-stim to the traps. Four pads at what intensity Or ultrasound? We can’t just say knee. What part of the knee? The knee’s. A big structure do you mean? Popliteal, fossa.

Lateral side. Medial side. Whatever the case may be. Indicate it and keep it simple. Golden rule. Be able to read it and perform it. What if I’m doing a exercise therapy? What if I said I did exercise for 20 minutes? Okay. What exercise did you do? Oh, we did . Curl ups five times 25. We did Supermans four times 20.

We did bird dogs three times 20, and it took us 22 minutes. That would be the documentation. Don’t create and make yourself upset like I have to write so much. Actually, you don’t Just make sure that when you go back to read it, you can exactly see what you did and how you did it. If you’ve done that, you’re safe.

Realize, don’t over complicate it, but also make sure that you have the simplest things there. In fact, always think oman’s razor, the answer is almost always the simplest. Can I read the note and see what’s performed? Don’t be caught with this. This is one of the things I deal with continuously.

ChiroSecure, of course, covers you for audits. If someone audits your file, they’re gonna protect you. They’re gonna fight back. You know who they’re gonna use me, they’re gonna bring it to me. Hey Sam, let’s look at this. Can we defend it? Sometimes I can say, oh my God, this insurance is off their rocker.

Whomever’s requesting. It could be a state board, it could be a patient. Or sometimes I’ll say, uhoh, let’s not make yourself the uhoh. Look at your notes critically and see whether or not they’re there. That’s what I do with the network service. If you’re a member, guess what you have to do. Send me samples of your notes yearly so I can verify whether or not you’re compliant.

I want to correct it beforehand. ’cause if we’re doing something that’s not quite good, we can fix it, and that’s really what we’re looking for, that compliance. Saves you every single time. So keep in mind, that’s what we do. Kyro Secure is there to help. So is HJ Ross, go to our website, take a look. You wanna have expert help day to day.

A place to always go to learn how to make sure claims get paid, how to make more money, whether it’s prepaid plans or otherwise, come and see me. Thank you everyone. See you next time. .