Observations from Recent Post-Payment Audits

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Hello everyone. This is Michael Miscoe with Miscoe health law with this week’s ChiroSecure growth without risk presentation. And we’re going to talk about some risk areas based upon observations from some recent post-payment audits by blue, Cigna United and the like probably the number one thing that I want to address, because it seems to be a target in almost every audit that I’ve seen recently is.

Massage services now, fundamentally there has been some cases where you have employer self-funded plans that specifically write massage coverage into their summary plan descriptions, or there is massage coverage under the health insurance carriers certificate. Long story short, just because massage is covered, doesn’t mean that you should necessarily be billing it.

When you look at medical necessity issues, especially where you’re billing for units and massage and it looks more alike head shoulders, knees and toes, full body relaxation type massage, as opposed to a focal massage of. Specific tissues. You’re going to run into medical necessity.

The other issue that comes up with massage is delegation. We’re licensed massage therapists are used. That’s fine. In some cases, payers do not pay for services of licensed massage therapists. So to get it paid, the massage services are billed under the performing or under the supervising chiropractor.

And that is fine. Because there is a difference when a massage therapist is operating within the scope of their license, they are evaluating the patient. Determining what the massage, where to massage and how long to massage when they’re working for you as a licensed chiropractic physician there in effect a chiropractic assistant, but to substantiate.

And we’re delegation to a chiropractic assistant is permissible. You need to substantiate that you are performing the diagnose, the examination, the diagnosis, and you’re writing a specific order for the massage therapy so that they are being told what muscles to hit, how long to hit and what technique to use.

That’s gotta be in your documentation. If we’re going to salvage the delegation. The worst thing in the world is to allow your massage therapist to write soap notes, where they do subjective analysis object to the analysis and identify what muscles are tight and how the patient’s doing. And they’re in order of their own treatment that tells me.

That is not a delegated service and that would be inappropriately billed under your license because you’re not controlling the care. So in order to establish billing under your license, as opposed to the massage therapist, make sure you have a detailed order that tells them exactly what muscles is substantiated by your objective findings on your examination, diagnosis of muscle spasm.

Hypertenicity, whatever it is that you want them to work on and its specific order for what techniques to use and for how long. And normally those massages will go maximally 15, 20 minutes. Per body region, like a head neck or, neck mid back, low back very rarely going to get into extremities are finger popping or ear popping or things like that.

So just be mindful. If it were up to me, I would tell you if you’re going to do massage, make a cash, take it out of your treatment plan, especially if you’re treating those muscular issues with other therapies in your office, like stem. Manual therapy and things of that nature. So be very cautious when you’re billing massage, and don’t forget, at least we’re CCI that correct coding initiative applies massage is a component of manipulation and to bill it separately, you need to support the 59 modifier.

And if you’re doing manipulation in that region, you won’t be able to justify. And they will take that money back. So be very careful with massage, similar to the concerns with massage. I’m still running into cases where docs are still trying to separately report manual therapy. With the 59 modifier on top of their CMT.

It is a very highly audited code pairing payers know that it’s probably, especially when you’re billing 99, 41 that it’s likely not going to be justified unless it was in an extremity or something like that, issues that they pick on when they don’t bring up. The bundling issue is both medical necessity.

In some cases they find it, the therapy is duplicative of some other more cost-effective therapy, like electric stem. Second issue is delegation. Similar to massage. A third issue is the 59 modifier. Meaning if you’re performing it in the same body region, even though that’s not how the modifier 59 is defined, most payers are going to want to bundle it.

Now in a recent case of provider thought he was really smart. Because muscles that they were addressing or that he was addressing through manual therapy were attached in the region of the sacrum. He would purposely not manipulate the sacrum, even though it may be needed it in order to justify separately, reporting two units, manual therapy and therefore making much more money.

Very bad idea. We had to roll over on the manual therapy money because there’s just no documented justification for it. And the idea that we would argue to the payer. He found subluxation in the SSI or the lumbosacral joint, but didn’t manipulate the sacrum just so that he could bill for manual therapy suggest that you’re purposely altering treatment in order to bill more money, which is via contrary to the contractual requirement to perform care in the most cost-effective and least costly setting.

We couldn’t make that argument. And we had to fold on the manual therapy normally in a very hyper-technical sense because the muscles aren’t usually attached to the regions of the spine. I’m not saying that his theory was wrong. It’s just, that’s not how payers interpret it. And because. There was a 9, 8, 9, 4 1 being billed and the massage or the manual therapy was performed to a soft tissue structures.

Interestingly enough, that were also being massaged in the same region where manipulation was performed. It’s just too many Hills to climb. So those would be issues that, that you are going to run into trouble on. Therapeutic exercise. If you’re doing resisted stretching techniques to improve range of motion or, deal with hypertenicity break up adhesions, as long as it’s active and you’re doing resisted motion for the same therapeutic outcome, even though it’s not as fun for the patient, but where your documentation details, the exercise you’re performing sets reps and the time.

And it’s performed by the doctor. In most cases, that’s going to be a way that you can get paid for something other than manipulation that doesn’t create the same bundling concerns. Okay. Upcoding of manipulation services commonly when they look at manipulation, there are. Manipulations for formed outside the region of significant complaint.

So patient comes in complaining, let’s say of neck and upper back pain caused by some injury. And during the course of the exam, the doctor also be consistent with his or her training, start to asking the patient well, how does your low back feel? How does this feel? How does that feel? And they develop complaints outside the area of complaint that caused the patient to chic.

In some cases, there aren’t any complaints in those other regions at all, but nonetheless manipulation is identified on examination and manipulation is performed pretty much full spine in 9 8, 9, 9 4 1 or 9 8, 9 4 2 is built in the scenario where the complaint was restricted to the neck and the upper back.

Even though manipulation may have been performed in three, four or five regions, we only have. Justification to bill too, because payers will normally only allow manipulation in the region of significant complaint. So the takeaway from this is one don’t develop the complaint beyond what the patient picked up the phone for.

If they’re coming in for head neck pain, deal with a head and neck pain, if you want to adjust the other regions of the spine on a supportive basis, fine documented as such, but don’t include it in your claim to the insurance. And it’s not purposely down coding your service, it’s coding the level based upon the necessity justification in your records based on the complaint.

Beyond that I would say just focused when you’re billing insurance on the area of complaint, all that other stuff will be there. When you’re done, you can pick it up on maintenance care on the backend. It’s not going to significantly worsen. If your care plans are normalized, three, maybe four weeks tops.

Situation is only focused. Draw a box around the region of complaint, treat that, and it will build diversity in your CMT profile that makes you a less likely audit target. Finally not finally. The fourth thing I’ve noticed is that the way manipulation is documented. Relative to regions of the spine or the specific bones vertebral bodies that you manipulated doesn’t necessarily gel with how subluxation levels are defined and the regions are defined.

So when you think about the barriers between each region T 12 L one L five S one. The SSI joint, the regions of manipulation are defined by the articulations. So the cervical region is CS zero through C7. Okay. The articulation. So if you were to manipulate C7 it necessarily is going to influence the C6 seven articulation, the C 71 articulation.

In which case it’s a manipulation to two regions in. So when you’re documenting your manipulation, it’s recommended that you document the articulations and therefore regions influenced by your manipulation. If you’re in the middle of a SA of a region like T five, it really doesn’t matter, but when you’re at the borders.

Okay. So when you manipulate alpha, It’s going to influence L four L five, which is lumbar. And it’s also going to implicate influence the lumbosacral articulation, which that’s the sacral region, the pelvic region. Isn’t the pelvis. It’s the sacred. Iliac articulation right or left. So dropping on the sacrum hits two regions because you’re getting the sacral region between L five and S one.

And you’re getting both SSI, joints articulations at the same time. So when you remember that region is defined based upon the articulation, not the. And you document your regions appropriately consistent with your levels of subluxation, then you should be avoid confusion by the payer that we have to sort out in post-payment review.

The next thing is treatment orders. Oftentimes, payers complain and want to deny care as being not sufficiently documented to establish the necessity of the services based upon the lack of detail as to how a service was performed. So say you document east end for 15 minutes. It’s not a time-based code.

15 minutes tells me it was performed long enough to do something, but what kind of Eastern. So document the protocol, the area where it was applied so that they can validate that there’s objective findings in that region. And that there’s a condition that you’re actually treating with the electric stimulation alternate.

Take your pick any therapy, therapeutic exercise. You need to specifically detail what you’re doing, where you’re doing it. And in some cases, especially with procedures who is doing it that will also touching back on the delegation discussion we had earlier. It will also help you with delegation because when you establish a precise order and I don’t want to offend any chiropractic assistants that may be listening to this, when I was an assistant, I used to think of it in terms of write me an order that Mike, the monkey boy can follow, turn the knob here, do this there, do this therapy here, do this many sets of this exercise.

So many reps you have to tell an assistant who’s unlicensed exactly what to do so that they’re not exercising decision-making because as soon as an assistant who’s unlicensed exercises that decision-making. The service no longer becomes billable under your name and NPI number. Finally, the last issues, medical necessity.

Payers cherry pick cases, if they’re doing probiotics and in the last series of cases that I’ve been through they cherry pick the cases very carefully, and they picked all the cases for patients that have been coming for years, similar problems in there on ad hoc scale. Meaning they present once a one and done here, two and done there, or they’re presenting predictably once every three weeks or four weeks or fill in the blank once every and a medical necessity argument for those kinds of cases is almost impossible because.

The patient is going to be no better at the end of care than they are at the beginning of the care. At best, we could argue that the care is palliative. And the only thing that was salvation in some of those cases is the payer didn’t clearly articulate the basis, the correct basis for their medical necessity concerns.

So it gave us something to argue in lead towards a settlement, but. You have to remember when a patient has a air quotes, significant health problem causing significant impairment. These are patients that you don’t have to convince to come three times a week. They’re coming because they can’t live without it.

And when they don’t need to come three times a week, it’s over. So you want to develop a profile where you’re doing short, deliberate courses of care with good outcomes. Don’t forget the document. The actual changes to the objective problems during the course of care and do yourself a favor when you switch them over to maintenance care at the end, which you should or dismiss them at your call or the patient’s call write a discharge summary that indicates what you accomplish with the treatment.

That is your best salvation. If you’re not tracking objective changes throughout the course of care that’s the way you save a case where you specifically indicate the motion benefit, the changes in the severity of subluxation or ridiculous or whatever the problem is, that that summary at the end indicate that you made recommendations for maintenance care, fine patient. Agreed. Didn’t agree. That part I don’t care about so much. I mean you do, you want to convert these patients to maintenance for cash, so you keep them in your circle. At the end of a course of treatment, it’s got to end and it should have a definable land and it shouldn’t be an end that is dictated by the patient when the patient quit.

Quits showing up prior to the end of your proposed care plan. It suggests to me and most auditors that the patient didn’t need to be there in the first place. And that the only result obtained was palliative care. And you leave a door open for a payer. To beat you up on medical necessity for that reason and for the docs.

I know what you’re saying. So I’m going to lose a medical necessity case because the patient self terminates. Yeah, you will. And unfortunately the patient is often the biggest impediment to establishing medical necessity to care. And when they’re not showing up because, oh, I have a hair appointment.

I can’t come today. That means they don’t know. Covered treatment in the first place. So keep those things in mind. I hope this was helpful. And I look forward to seeing you again at on a future topic next week. You’ll have another presentation. I don’t know who the presenter is, but I’m sure it’s going to be awesome.

So be sure to go check it out. I think it just showed up on the screen. So see you next time.