Specific Documentation Issues Bridging Your Treatment Plans

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Hello everyone. My name is Mike Miscoe with Miscoe Health Law, and I apologize for my casual attire today. But we had a little bit of a power outage and I had to go fight with a tree. Anyway, we’re following up on our presentation last week with the ChiroSecure Facebook Live presentation that we did relative to treatment planning issues, relative to COVID. And based upon questions that we got, we thought it might be useful to go through some of the specific documentation issues that will help you deal with bridging your treatment plans, where that’s possible for cases where treatment was interrupted due to this COVID issue.

One of the most important things in any case is that when you have a disruption in a care plan, COVID-related, not COVID-related patient went on vacation, whatever. You have to understand that, that a payer that looks at that analysis and they’re reading your documentation and then there’s this break in care, whether it’s two weeks, two months, whatever it is.

And when the patient comes back, the note picks up like nothing happened. That’s a telltale red flag that the care from that point forward is probably going to be denied, is not medically necessary for a number of reasons. And in the most important reason is, is that medical necessity from a commercial payer perspective relies on a patient having a “significant health problem.”

Well, how significant could their problem have been if they were able to operate and function without care for a number of weeks or even months. So the note picking up today, Mike entered the office complaining of and you do your same as last treatment note, and it’s all the same stuff. I mean that’s obviously not going to work. And when you look at the documentation guidelines for evaluation management services, you realize that the history once a patient is an established patient, you have to address what happened since the last encounter in terms of the progression or non-progression of the patient’s symptoms.

Now to have an argument to justify re-initiating a previously terminated or interrupted plan of care, you’re going to have to very carefully document from the last encounter what happened. I mean, why weren’t they coming to care? And it’s because we had a closer office down due to COVID. Well, did the patient just not come? Did their symptoms continue? Did they regress? Did they actually get worse? That would be helpful for justifying a re-initiation of care. Did you attempt home care managements?

Maybe some of you did telehealth or phone-related instructions to patients and you gave them some guidance relative to home exercises to help bridge the gap. But what has happened relative to their symptoms during that period is critical to get into the documentation. Because you have to bridge that treatment gap, so that a payer or more importantly a payer auditor understands the why the patient wasn’t there.

And more importantly, why this condition is still a problem such that it continues to present functional impacts, limitations? Maybe do a new revised, an updated outcome assessment. Show the worsening of from when they left to when they came back to establish a basis for re-instituting the plan of care. Outcome assessment data is very good. But make sure you reference it. Make sure you talk about it. It’s not enough just to throw a form into the record and expect the reviewer to kind of look at the old and look at this one and say, “Hey, the patient’s worse. And therefore, yeah, I get it.”

They’re not going to draw those conclusions. You have to lead them and you use your documentation through your history to do that. I don’t care to see a big blown out, extensive review of systems or re-review of the past medical, social family history because none of that’s probably changed.

And if it hasn’t, there’s no real need to go into that. But what has changed and what is important is, is hopefully if there was a progression especially regression of the patient’s symptoms and functional abilities because they weren’t able to get in for care, then that is very critical information to record. And then, like I said, use the comparative outcome assessment and demonstrate that because of the disruption of the patient’s care plan, you know their outcome assessment score increased from say 40 to 62%. And then of course you’re going to have to reestablish goals for where you want that to be when you’re done.

But nonetheless, it establishes the basis for re-instituting care. But we can’t leave it at just the history. Because payers predicate medical necessity oftentimes on what they call objective measurable goals. We have to evaluate the status of the objective problems, subluxation, cervical neuritis, sprain, strain, ligament laxity, whatever the problem was. And if the status when care was interrupted was say five out of 10 if you’re using that methodology to establish how you’re impacting those conditions with treatment, which you should be.

Then if the status worsened objectively, then again, you’re building an argument for reestablishing the need for care. And then you have to remember decision-making is what sells the care. So given these changes in the patient’s subjective and objective status, while the diagnosis codes themselves may not change, certainly the severity of those conditions should change. And you should numerically assign a status value zero to 10, so that you have some way going forward as you did before, hopefully to indicate what impact your care is having.

So maybe after two weeks you can say, “Hey, subluxation is now, it was a seven, now it’s a five. And neuritis, it’s not as severe as it was.” Whatever provocative tests you’re using to identify those conditions, you know you can evaluate as a licensed provider how severe condition is. But understand it’s the changes that are important when you have an interruption of care, hopefully for medical necessity billing purposes, not so much for the patient and understand you have to worry about them, I don’t. I have to worry about you.

But for those patients whose conditions have actually worsened, that’s what we need to see. I don’t need to see I did this test and it was positive and I did this test and it was positive and all of the same stuff that you did before, and it’s all still positive. That doesn’t tell me anything. It just tells me they still have the same problems they had before. But again, if I can’t see any difference in the findings before and the findings now, then nothing’s changed in the patient doesn’t need to continue with the care.

But if instead of telling me the test, tell me about the problems and what changes your exam revealed in the status or severity of those problems, then you’re building an argument that their condition has actually regressed absent treatment. We’re going to re-institute care. Here are my revised goals, here’s my revised anticipated discharge date, here’s my I’m going to re-institute the prior treatment order because it was working before the termination, and here’s what we’re going to do for each problem.

And you lay out a methodological and logical argument for why you’re putting this patient back into treatment. Absent that, my concern is, as I explained in the last call, is that payers are going to see these breaks. There’s going to be no explanation as to why. Maybe they’ll figure, “Oh, it was about that time they, everybody was staying home with COVID. Yeah, maybe I get it.” But if the patient survived without care for two months, then they didn’t need the care. And that is a very compelling argument and when I’m defending these cases, what am I supposed to say? They were worse.

Well, the documentation doesn’t show that. We can’t assume that. You have to tell that story and you start it with a history. You do an exam, but rather than tell me what you found, tell me what changed relative to the status of each objective problem. And that helps you build new goals and build a plan of care that makes sense. And keeping you within the causing significant improvements of the patient’s condition or capacity to function in a reasonable and generally predictable period of time.

And if you read enough medical necessity policies, you’ll see that language over and over and over. It is pretty durable concept among payers and whether their medical policies are exquisitely clear or not. It’s the way they all look at these medical necessity issues. So from that perspective, that’s how you solve the COVID problem.

Now understand you’re not going to be able to solve that problem with everybody. Some people are going to have this interruption of care and they’re going to be fine. In which case you got to tell them, “Look, we can continue to treat you, but you’ve been doing fine. Let’s put you on a palliative preventive supportive, whatever care program. It’s cash. And if you fall out of a tree or something or you trip over the cat and do a head plant into a wall and you sustained some significant injury that gives us an argument to build a new treatment plan and start based upon a new injury, then fine.”

But absent that we just don’t have the juice to bill or to make the representation to your insurance company that this re-institution of care meets their standards of medical necessity. And of course if you bill it, they’ll probably pay it. My concern is, is that on the backside when they start looking at this, they’re going to notice these patterns and mark my words, there will be a lot of post-payment activity to follow this as carriers try to recover as much money as they can because that’s their job.

So be mindful. You got to watch out for yourself because no one else is going to do it. And if you follow those documentation tips, at least you’re given, if they challenge it, you’re giving yourself an exceptional argument to explain for the cases where you re-instituted a plan of care, why you did it and why it made sense.

Speaking of money that people are going to try to take back, I’m going to spend a couple minutes, something that just popped up yesterday. Medicare has been issuing payments to providers who bill Medicare and who receive payments from Medicare in 2019. And it’s a free money. Shows up in your account.

It looks like free money and these payments are going to show up and in a short period of time, these are COVID relief funds that are being sent to providers. But be very, very cautious about accepting and keeping this money. Following receipt of this payment, providers who get this money are going to be asked to sign an attestation that they comply with the qualification and documentation requirements associated with these payments.

And to be very brief, the relief funds, when you do that attestation and you would do this attestation through an electronic portal, you are a testing that you are currently providing diagnosis, testing or care for individuals with possible or actual cases of COVID. Now I understand how chiropractic treatment can improve patients general level health and immune response and whatever, but that’s not what they’re talking about, care for COVID.

So you’re not going to meet on that element. You’re not terminated from Medicare. You’re not excluded and all that other stuff and that’s usually not a problem. You’re also certifying that the payment, the money that they actually sent you will be used to prevent, prepare for and respond to coronavirus and will reimburse you only for the healthcare-related expenses or lost revenues due to the coronavirus. This is where the documentation piece comes in.

So even if you could successfully argue that you’re using the money to diagnose and treat coronavirus or potential coronavirus, the documentation side of this is, is that you have to maintain documentation that that money was only spent for coronavirus-related expenses or losses. And my concern is, and the concern among the healthcare bar, is that there is going to be significant post-payment and/or false claims act liability associated with improper retention of these monies.

Your best bet is if you get these monies and you are concerned that you either don’t meet the qualifying criteria or that you don’t have the ability to justify retention of the money based upon actual expenses in response to coronavirus. And let’s face it, put the qualification criteria aside for a minute. Expenses, things that you have to do to clean your tables. Maybe you have extra staff to clean tables and do all the coronavirus safety precautions and whatnot in the office. You may have actual expenses that you can document.

My concern about the qualification remains, however, in terms of your ability to keep this money. But a false attestation can get you into serious hot water because that’s like making a false claim. So your best bet is if this money shows up, do not do the attestation unless you’re absolutely certain that you understand exactly what you’re attesting to, and you meet both the qualification and documentation requirements for the expenses.

Otherwise, if you don’t do the attestation, they’ll ask for the money back. Then you give them their money back and you maybe earned a few pennies of interest on it in the interim. But be very, very cautious about accepting this money. Because like all things with the government, it isn’t free.

So I just wanted to pass on that a little piece of information, so that nobody gets trapped thinking that they got free money and that there aren’t a significant number of rules associated with it, which of course there are. That’s all we have time for today. I hope that was helpful for you. Thanks to ChiroSecure for creating this platform for us, so that we can get this information out to you and I’ll look forward to seeing you next time.

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