Blog, Chirosecure Live Event April 10, 2023

Get Claims Paid The 1st Time You Submit Them

Click here to download the transcript.

Disclaimer: The following is an actual transcript. We do our best to make sure the transcript is as accurate as possible, however, it may contain spelling or grammatical errors.  We suggest you watch the video while reading the transcript.

Hi everyone. This is Sam Collins, the coding and billing expert for chiropractic, the HJ Ross Company, you, and of course, with ChiroSecure as well. Here to give you another one on let’s make claim forms. Let’s make your life simpler, easier, get paid. Let’s allow you to do what you like to do, which is do chiropractic.

Let us focus on getting the billing right, getting you paid correctly. Today what we’re gonna talk about is common claim denials. Let’s go to the slides. Let’s start talking about this. What happens in our profession? Why do claims get denied? What are some of the common things that occur? How can we fix them?

How can we prevent them? And frankly, how do we get paid? What’s going on is commonly what we have are claim form errors. There’s several things, but I’ll start with this one. Claim form errors. What goes on in our claim forms that causes our claims to get denied? And this is something we can fix our.

Obviously we’re gonna have issues with diagnosis. Okay? That could be an issue of why claims are denied improper C P T codes. We’re missing a modifier. There’s modifiers that are gonna be needed for different scenarios, and frankly, just coverage of the patient’s plan is something we have to think of. Do we have and understand, does this patient actually have acupuncture, or excuse me, chiropractic benefits, and of course, the insufficient documentation.

That’s not so much an initial. But it’ll follow up when they look at it. And I don’t want you to panic over that and don’t feel like they’re gonna audit me, but just make sure is what on the bill. in the notes, make sure that everything is there sufficiently. Again, it’s not hard, but you have to know the specific things they’re looking for.

Let’s talk first about claim form errors. And this is something I deal with day in and day out, and as offices have been around for a while, you think, oh, I got that down pat. Not always, because there’s always a little bit of new staff for people that come in, but do make sure the top part of the form is correct.

This actually is pretty. at the top part of the form. You’ll notice it’s patient information. You’re thinking what could go wrong there? Here’s what goes wrong. Possibly you’ve transposed the number. Okay, that’s just a clerical error. But here’s a common issue. The patient’s name is Patricia. That’s what it says on her card, but she says, call me Pat.

And so you get in the habit of just putting Pat pat is not what’s on her insurance card, and therefore may cause a denial. So do make sure the name. Matches exactly as it is on the. Do not put any additional abbreviations, anything else, and sometimes that name is very unusual, so therefore, put what’s on the card.

Also, keep in mind, sometimes the insured is different from the patient, particularly with the child. Potentially, maybe the parent’s name on the card do make sure that the patient may be listed here in this section, but the insured, meaning the parent, would be over here. So make sure that matches. That’s one that you might not think too much about, but I do run into that quite a bit.

Now the other error, and this is one where we really run into some issues, is this, on the claim form block 14, people think what do I have to put there? Generally we’re gonna put date of. or data first symptoms. So what about a patient that goes, I hurt myself five years ago. What date do I put in?

I’m probably not gonna put a date five years ago cuz I no longer will think we’re dealing with the injury that happened then. But probably the current chronic exacerbation of it. So if it’s a very old, like I’ve had it for years, the date I we’ll put here is the date they first. Or the date they felt the symptoms most recently, but not necessarily a date of injury.

So do keep in mind that’s something that’s unique, but here’s something even more unique. What about Medicare? Now, for health insurance, that’s always gonna be the date that they’ve had an injury or first symptom. But with Medicare, it’s the date of the first visit. So this is a very common era for a Medicare patient, for block 14 for Medicare.

I don’t care when they hurt the. . I do, but what I don’t care on the claim form is because on the claim form you’re gonna put the date they first visited. So even they may have hurt themselves six months ago, a week ago, the date in block 14 is going to be the date that they first visit. So make sure on a Medicare claim form, block 14 matches the first visit that they’ve come in.

Now here’s something unique though, cuz you’ll notice there’s this other thing that says other date. Does this ever come into. Let’s take a look. This is Anthem. Anthem, and Anthem says they do want in block 14, the date of injury. So literally, what’s the date they hurt themselves? What if they didn’t have a trauma?

What do you put the date of the first symptom, if you will. But here’s something they also want though, is the initial treatment date. So notice they say in block 15, they want the initial treatment date in block 15, and you’re gonna put with it the number 4 54 as the qualifier. So let’s go back here.

You’ll notice it says, and qualifier. So 4 54, I think you see this a lot. If you’re in Texas, Illinois, particularly those Anthem policies are very strict about it. So make sure you’re including that. And again, you might think, how are they denying this with improper date? It’s for this reason, and that’s why I wanted you to see it directly from their guidelines.

So it wasn’t something that Sam made that up. I want you to see there are plans that do that. Now would I do that with a Cigna or a United Plan? No, that’s an anthem only. Here’s another common problem, and I get this one quite a bit as well. The claim came back and it says, we don’t recognize the provider.

And you’re thinking, what do you mean you don’t recognize the provider? Let’s keep in mind your name that goes in Block 32 and 33 must match the M P I number. So what if you’re billing as a. or you’ve incorporated yourself as a business person, you’re gonna have to have that name matching this mpi.

So do make sure, like same thing as applies to patients, if you later decide to, you’re calling yourself something different, but you register the insurance under a different name or under a different format if you will. Make sure it matches. Exactly. And do keep in mind the NPI number goes in 33 A and that matches the billing.

if you happen to be billing as a corporation, the billing provider goes here, meaning the corp number, but then the individual mpi, number of the provider of service goes in 24 particularly in the multi-doctor office. This is pretty common, this can occur even if there’s only one doctor. One doctor could be incorporated, where you’re gonna have two MPIs, the group or Corp mpi, as well as the MPI number.

You as the individual who’s doing the service. So again, little nuances like that on the claim form will cause things to be denied. The other area that we like to look at is let’s talk about up here. What about diagnosis? My diagnosis of the claim? Diagnosis, what you’ll hear is you have to have a code.

That is complete and you’re thinkable. Of course, Sam has to be complete. What it means though, is it complete with a number of digits. Remember, codes can be as little as three or seven characters, and I will tell you, many of you have a common code list and that makes sense. You should have a common code list.

However, do make sure that common code list is up to date. Have you gotten mine recently? Frankly, make sure codes that have changed, you have updated. I can’t tell you how many times I’ve had a per, in fact, this just happened. Someone coded M 50 32, and as soon as I saw that, I thought, oh my God, when’s the last time they coded this?

That code’s been updated. It’s M 53, 2 0, 3, 2, 1, 3, 2 2, and 3, 2, 3 depending on the level of the spine. So do keep in mind, do I have the actual correct code? Look at your list and make sure it updates. Remember, we update codes once a year every October, and there’s always changes. Remember when the changes for low back pain occurred?

How about the changes for myalgia? Those all were important, and if you have the wrong. , it’s coming back. Here’s another area. You’ll notice it says, this is from United, a recent one. It just says invalid claim and next steps. It’s saying we need a new claim, and it says, diagnosis code, or is invalid or missing.

So that just simply means you use the wrong code. Do you also make sure it’s a code that’s payable? Remember, what codes do chiropractors get paid for? Neuro musculoskeletal. So do make sure you’ve got the proper codes. So keep in mind, do I have the right codes? Here’s an example of a Medicare claim.

Notice the subluxation code is first with the secondary. So for right coding, remember, depending on the states you’re in, some states require the subluxation must be M 99 0 1 through zero five, but in other states it could be M 99 0 0 through zero. and still in other areas. It could be M 99 0 0 through zero five, but also include M 99 10 through 15.

So do know your Medicare administrative carrier for your state. If you’re not familiar with it, join our network. I’ll help you. I’ll make sure you’re doing well there. But do keep in mind improper coding. Remember, for Medicare, you have to have subluxation and second. However, there are some states that use national government services that you could just simply put the subluxation.

You have to have the secondary in the notes. So it’s knowing those nuances that can often cause you to be denied. But also what codes are payable. When’s the last time you looked at your Medicare list to assure you’re using the codes that are covered, or for that matter, the codes that are covered with other payers?

And I’ll give you an interesting one here, the company Aetna. Will not pay you if you use the code for thoracic strain, not sprain strain. That code is S 29,020. A thoracic muscle strain. They won’t pay it. It’s not on their list, by the way, are familiar with their list if you’re not. Get a chance to come to a seminar with me or join the network, we’ll be helpful with you and say, here are the codes they pay for.

Often it’s just a lack of knowledge that I didn’t know was covered. So let’s make sure we understand the coverage of that coding. Another error we run into is, what about coding like this? Take a look at this one. You look at this and go, Hey, there’s subluxation, there’s pain, there’s this, there’s subluxation.

You’re thinking, that seems okay. Do you know it’s not? This claim was actually denied. And the reason it was denied is because they’re using codes that are excluded, codes that cannot be billed together that will cause an automatic denial. These are specifically called exclude ones or codes that can never be coded together.

And what they are surprisingly is you cannot code pain of the spine with disc. Now you might think that’s crazy. Here’s what I’ll tell you. Why are you coding pain if you have a disc? Isn’t it inherent? If you have a disc, it’s probably painful. Think of it. Would you ever code ankle sprain and go, oh, by the way, it also hurts.

I don’t think so. You’re probably just gonna code ankle sprain. Pain is a throwaway. So keep in mind the same thing as a simple rule. Never code any spinal pain. with a disc code. Otherwise, you will definitely get this type of denial where it says it’s coming back or because of it in this way. So I’ll give you a simple rule.

Never put spine pain codes with a disc code ever. Just don’t never code multiple muscle codes. If you were wanna code mial. , great, but don’t code muscle spasm with it. Don’t put two muscle codes. They’re gonna counteract them and don’t combine neuro codes. Don’t combine, for instance, cervical radiculopathy with outlet syndrome, if you will, or any other radicular complaint.

I have a list of these. If you’re a member of the network, please reach out to me for that. Or if you’ve come to the seminar, you have them, but they’re a list of exclusive. If you’re not familiar with them, you better start looking at the code. You commonly bill to see is there any code that’s. when I build with this, here’s an interesting one.

Sprain of the lumbar spine cannot be coded with a disc. You just code the disc only, and again, I You’re going, wow, I’ve never heard of that. Insurance companies are becoming increasingly more adept at looking at it, I think cuz they use computers to adjust claims. So you really wanna make sure that, am I using co combinations that make sense and aren’t gonna get denied because they considered and exclude.

Here’s another issue just with coding. C P T, coding and diagnosis. You’re all familiar. There’s codes we have to put modifier 59 in chiropractic. When you do manual therapy massage in order to show it’s a separate area how does the insurance know? We’ve done a separate area. This is how you use diagnosis pointing and denials happen cuz they’re gonna say we don’t see it.

Cuz what if you didn’t show that you did a different area? Notice diagnosis A and B are cerv. Diagnosis, C and D are lumbar. Do you notice 90, 89, 40 references a. 9 7, 1 24 references C and D. This is how you point to show they’re separate. Now you do have to make sure your chart notes show that separation as well.

Don’t adjust the area that you’re also doing manual therapy, but diagnosis pointing helps resolve that. So modifiers are used for that reason. That’s the specific 1 59 for it. You can also use Xs if you’re familiar. That one does the same thing. But here’s a modifier and I, this is one that pops up cur a.

Modifier gp, that’s G as in George, P as in Paul. And that modifier means an always therapy. You’re thinking, why would I use that? Certain payers require it. So whenever you’re billing to UnitedHealthcare or Optum, or frankly any affiliated of United, You have to put gp if you don’t, automatic denial and it’ll come back and just say you’re missing a modifier.

And if you call ’em and say what modifier am I missing? They’re gonna say, oh, we can’t tell you that. So that’s why I’m here. Use modifier gp. You also require it if you’re billing VA claims, if you’re billing Anthem policies, they also require requirement Blue Cross of California though. And this is for California specifically.

So keep in mind, California divides Blue Cross and Blue Shield for Blue Cross. They require for Blue Shield. They dont. , because you might be thinking Sam, if these companies require gp, why don’t I just blanket and throw a GP on everything? No, don’t do that. Because if you put a GP for a company like Aetna, they’ll kick it back because they don’t require the modifier.

Now, this may seem frustrating and hard, but once you learn it, not a big deal. And that’s why we’re always here, ChiroSecure myself, the expertise to give you these simple nuances and tools to just make sure your claims get paid simply. You know who also requires. Medicare, you think? Sam, come on.

Medicare doesn’t pay for therapies. No, you’re right. They don’t. But what if you have a secondary that’s going to pick it up? Then of course you need the GP so that Medicare gives the proper denial. So it’s not just the gp, but also the GI for an excluded service. So do make sure, do I have the correct modifiers?

Think of it. What if I’m doing. , a locum tenons. What modifier do I use there? How do I do it? That modifier BQ six, by the way. But again, common denials will happen because we just don’t have claim form. Proper modifier is the things and the nuances they need. Remember, what’s a common one?

Modifier 25. Why? Because you need to have it separate from your exam, meaning the treatment and exam are separate. If you don’t put the modifier, it comes back. But also make sure, do my notes really. To make sure that exam is seen as separate. But again, do not just blanket and start throwing modifiers and everything.

Don’t put 59 s. Know the modifiers, what are needed, and here’s one that’s always is frustrating. Take a look here. This person’s billing out neuromuscular education, other services, and it says, not supported. The submitted medical records did not include detailed description of the specific neuromuscular education performed.

So denials happen because you just didn’t describe the service. You can’t check off neuromuscular educat. You have to tell me what type of neuromuscular education did you do? Did you do a bosu ball? Did you do a wobble chair? What was it that you did? Did you do balance training? Anything like that. And then, of course, the one-on-one time.

So do make sure they match up to scrutiny. That’s what we do. We’re here to make sure we can help you. The American, the, excuse me, the HJ Ross Company, ChiroSecure here to support you. Your success is ours. If you ever really need some help, and you can see just from these courses we’ve done with you, you’re thinking, why don’t I have someone I can call like this?

I can be your expert, part of your team. Take a look at our site. I will tell you we’re here to help you make sure you’re getting paid. Make your life easy. Until next time, everyone, thanks very much.