Blog, Chirosecure Live Event December 18, 2021

Top Ten Metrics that Drive Post Payment Audit Scrutiny

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Hello everyone. This is Michael Miscoe with Miscoe Health Law with this week ChiroSecure, present Growth Without Risk presentation. Today we’re going to talk about what I would call the top 10 metrics that drive. Polo’s payment audit scrutiny and having done as many post-payment audit defense cases have over my career.

There’s a number of common themes that come up. Providers asked, why me? How did I get picked? And I can assure you, it has nothing to do with randomness. They pick you out of that. It’s not that at all. Data analytics are what drive post-payment audits, and it’s a number of things that they look for when they analyze billing and receivables data oftentimes it can be driven in general based upon increases or rather.

The change in the slope of a curve relative to exposure where their history suggests that they’re paying for a certain thing at a certain amount. And then all of a sudden there’s a spike. Sometimes that’ll be what starts the process. But then as they look deeper into those numbers, there’s a number of things that they identify in terms of picking who to audit.

So with respect to that, Let’s start with the first one. And these aren’t in any particular order. So I don’t want you to think that these are a prioritized list. It’s just a list of the top 10 things that I find driving a post-payment audit scrutiny for doctors of chiropractic evaluation you management utilization.

Is a big issue, especially where and what they do is they count the number of ENM codes per patient visits. And when that ratio gets a little too high there’s an expectation of maybe one in 12 visits. Although some providers bill, an initial evaluation, then they do a report of findings and potentially build a time-based TNM for that.

And while that would be. Is technically justified. It’s going to drive your profile in that respect and potentially could generate some post-payment scrutiny that may or may not. Ended up being about the ENMs at all. I have seen cases where providers have attempted to build evaluation management services on every visit especially visits where they’re not performing chiropractic manipulative treatment or a CMT code.

And that becomes a little difficult to defend. But watch your utilization there. If you’re if your utilization is one in five, one and eight, one in 10, one in 12 you might get a look. But certainly if it’s I know you’re trained to do re-evaluations every 12 visits, I would only build a re-evaluation when it actually led to a change in diagnosis, change in the plan of care.

And a re-evaluation due to an exacerbation maybe, but again, it’s not enough just to say there was an exacerbation. You need to finish the thought process and document the impact on the diagnosis. So under the new ENM coding roles, if you’re coding your ENM based upon medical, decision-making make sure you update the classification of the condition as being.

Acute with exacerbation or due to exacerbation indicate whether it’s complicated or uncomplicated identify any comorbid factors, whatever, but there’s gotta be evidence that the exacerbation. Caused additional decision-making to make that evaluation management as a separate service more sellable without it, just to simply say that the patient suffered an exacerbation ho-hum and you have the same exam finding same treatment, same diagnosis and nothing changes.

That’s going to be a little bit of. To sell to a payer in post-payment analysis number two utilization of your various CMT levels. So when you cluster code around 9, 8, 9, 4 1 that certainly Has in the past caused some concern. If you cluster code around 9, 8, 9, 4, 0, I’ve seen docs under code or always code and 9, 8, 9, 4 0.

Thinking that they’ll fly underneath the radar. It’s the consistency. Of using a particular code level that draws the attention. And certainly as you might imagine if you have a high utilization of 9, 8, 9, 4, 2, you’re just begging to get looked at because while I will agree that most many of you manipulate full spine, it’s very unlikely that the patient.

Has conditions and complaints at each level of the spine that caused him to seek treatment. No doubt a patient that comes in with neck pain. You evaluate that in the history and then you ask about how’s your low back, feel your mid back. And while the patient may have some occasional complaints there, that’s not why they’re there.

So let the primary complaint, the complaint that caused the patient to pick up the phone, let that drive your analysis and you will get. CMT utilization profile. Generally, I look to see 55 45 four out of four, one or vice versa, depending, if you’re in a blue collar area, you’re going to deal with more low back conditions where I would anticipate 9, 8, 9, 4 1.

Occasionally you might have 9, 8, 9, 14. For a patient that did in fact injure the entirety of their spine. But just remember, as you get into that case, one of those regions is going to drop out. In which case your four to may, throughout the course of care, become a 4 0 1 and eventually a four O before they’re ultimately dismissed.

Unfortunately, what I see is it starts out at four, two on all those areas, continue to get adjusted until all the areas are done or until the patient’s complaints are stabilized. And usually. In the records, it looks like at least. They all progress on the same rate and that’s very rarely true. So watch that as well.

Extremity CMT usually I would anticipate a five to 10% utilization as a percentage of total patients and visits. The patient either has an extremity complaint or they don’t. And if they do, you need to do an extremely. History of present illness and extremity exam, have an extremity diagnosis and have a plan of care for the extremity.

Now, if you’re doing extremities because the extremities are connected to the body and they influence a spine those are all going to get denied and post-payment review as not medically necessary because if the patient doesn’t have a source complaint in the extremity, like the patient presents with knee pain or ankle pain or shoulder.

And also just, if they do report with solely and extremity complaint, don’t feel like you have to make up a reason to treat their spine because that’s what you do. It’s very possible that the patient will only be treated for the extremity, if that is the entirety of their complaint. So don’t let your your training lead you into a.

Pattern that you won’t be able to justify and post-payment review. So I would expect to see extremity CMTS about 10%, and I would expect to see in some cases where the extremity would be the only region treated Code pairs CMT and manual therapy. We’ve addressed this many times. And while there’s very hyper-technical rule that suggests that it shouldn’t bundle as often as payers think it should.

Nonetheless, it is a code pairing. When you bill a spinal CMT along with manual therapy with modifier 59, that is a code pairing that is going to get a payer’s attention in a very big way. So they can audit a 59 modified codes as a way of identifying that and look for the code pairing when they see a lot of it.

You’re for sure. Going to get audited. In some cases, providers, bill massage services performed by massage therapist on their either 9, 7 1 4. Oh. Or 9 7 1 1 2 neuromuscular reeducation depending on the order and the technique as to whether we can justify that billing at all, because it’s usually built under the DC.

But the coding aspect of it, when does massage become manual therapy? Tricky analysis. And it depends on the order which hopefully exists in the record. Oftentimes it does. It’s never going to be neuromuscular reeducation. That is a type of rehabilitative treatment for a patient whose primary condition is a neurologic injury.

Or disease. And you need to be very careful with the use of that code. It just like manual therapy, massage neuromuscular Riyadh is considered a component of manipulation. So you’re not getting around any bundling rules by changing your coding, but 9 7 1 1 2 as a highly audited code.

With respect to CMT, usually because that’s not what the doctor’s doing. There’s some like proprioceptive, neuromuscular, facilitation trigger point techniques that are erroneously coded as 9 7 1 1 2. So you need to be very careful in your use to that code. If you’re doing occupational therapy type neurologic rehab, if you’re a DAC and or something like that, then maybe.

But, that re Hab is designed to wake up the nerves and get the nerves to fire. You’re not, re-doing proprioceptive changes in a joint that are associated with normal joint dysfunction. That’s 9, 7 1 1 hour five, three O type rehab. Direct one-on-one units build per day is another common analysis where they will analyze the number of times.

Time-based service units that you bill and to identify providers who are potentially either delegating contrary to the payers policies regarding delegation and, or you’re just you’re billing. Services performed in a group setting as if they were one-on-one bottom line one-on-one is really easy to understand one provider, a one patient, and your attention is solely focused on that patient.

And it has to be skilled intervention. You can’t just simply watch them. You have to interact to ensure that they do the time-based service appropriate now with manual therapy in some of the hands of. Types of techniques like a resist of stretching techniques for . You really can’t do those other than one-on-one.

But for patients who are using exercise equipment, balls, bands, machines, whatever there’s a tendency to have more than one person out there on your rehab floor supervised by one DC. And that is technically group therapy, 9 7 1 5. So if you’d never ever build group therapy that would be an indicator to me that there’s a potential one-on-one issue.

And then depending on the number of one-on-one units, you’re billing, maybe we bring that issue up or we don’t. Now when you’re using auxiliary persons to assist you in rehab, let’s assume your license permits you to do that. That’s fine. Just understand that if you’re supervising, let’s say three rehab assistant.

CAS certified, like whatever your state board requires that may be appropriate. It’s just, you’re going to be generating a lot of units under one provider from a billing perspective. And it will get noticed at some point visits per patient. And we look at visits per patient per year visits per condition.

And they oftentimes correlate that analysis. Especially on the visit per condition side, based upon the diagnosis. So if you’re wimping out on your diagnoses and you’re just documenting a symptom like neck pain and a subluxation those conditions really don’t justify. A really long treatment plan.

Now, if the neck pain is due to cervical radicular, Titus, you would be much better off to report the actual condition, especially if it is something that’s relatively complex and severe to treat and it will help you at least explain superficially, why the care is taking three, four or five weeks potentially.

So you can mitigate some of the risks here. Properly diagnosing the nature of the patient’s condition that you’re treating and its complexity. But just remember even it’s not a process of just throwing a diagnosis down. It has to be supported in the record. And don’t diagnose everybody with the same thing because that in and of itself would create a pattern that would be easily recognized in these computer data analysis is average.

Average visit frequency is an analysis that payers do to identify potential palliative maintenance wellness type care. A optimal visit treatment plan. If you’re billing the services as if they’re medically necessary restorative services, I would expect to see a two to three times a week visit schedule and only a two to three time a week visit schedule.

One of the interesting things is a traditional chiropractic management. You start off three or maybe even more times for a week. And as the patient’s condition stabilizes a little bit, then. Drop the visit schedule to twice a week, then once a week. Once you break down your visit schedule, you’re pretty much indicating that you’re manipulative care is becoming supportive rather than restorative.

When you’re billing, you want to build a nice tight two to three times a week plans to care until the patient stabilizes, then they’re done, and then you move them off to cash. When your visit Per week, average drops below two or worse yet drops below one. That is a big indicator that patients are coming either episodically for palliative care or Getting once a week or once every fill in the blank maintenance type care.

And that is what generates audits. Usually those patients, their care goes on for a long time. So not only is the number of visits per week in issue, but the total number of visits per condition or per year trips you up. Number eight services dollars per visit. If it takes more than one CMS 1500 form to account for all the services performed in a visit that’s bad.

Usually manipulation one to two therapies is justifiable, but if you’re throwing everything at them, but the kitchen sink you’re likely going to get audited Inclusive of that be mindful of 9 7, 5, 3 5. That is a code that as physicians, you should never bill because it’s counseling services, it’s part of your ENM.

It may or may not justify a separate ENM, but counseling of the patient should be included on your exam day. Especially when you’re billing on the basis of time. You shouldn’t try to bifurcate that, and bill that code just because you gave the patient a home exercise. Where that happens.

All of that money usually goes back because we have no legitimate argument to defend it. DME especially, braces, tens unit, very highly audited tens units. If a patient has really severe pain and you need some. In the early phase of care to give the patient relief between visits, that’s fine.

Rent the unit. Okay. It’s a short-term need once the patient’s condition stabilizes, they give the unit back, you treat them and you’re fine. Now if the patient at the end of. Has continuing pain and they refuse a referral for medical management or possibly pain management services like injections.

Then you can consider the sale of a tens unit, but make sure you’re making the case that, conservative care was attempted. Partially successful. The patient has continuing ongoing pain, continued chiropractic care was offered, on a maintenance cash basis refused. And the patient then can be ordered, attends.

Do. An application of tens, make sure that you’re documenting that the patient has obtained significant relief, at least 50% short term. Make sure you lay out a schedule. And then you’ll have to deal with the resupplies monthly on an ongoing basis with braces. Make sure you look up your carrier medical policies.

And if you don’t have one look to Medicare’s policies relative to especially LPSOEs, knee braces, ankle braces, and whatnot. Usually they’re compensable only in certain circumstances but make sure that it’s not a welcome. That everybody with back pain gets a back brace and everybody with ankle pain gets an ankle brace.

Yes, you can make some money off of DME, but be very careful because everybody knows that you can make money off of DME. A lot of people over-utilize it, they get audited. They get to pay all the money back and by the way, The DME backs. So the fact that, you had to buy the DME too bad. You get to eat that.

Those are audits where it’s more than the value of your time. You actually have an out-of-pocket expense to purchase this DME, to give to the patient and you will not recover. The last thing I’ll bring up is consistency in your care plans? I realized I had an orthopedic surgeon tell me one time.

He said, when all you have in your tool box is a hammer. Everything looks like a nail. And there is. There are protocols and physical medicine care chiropractic, certainly, but be cautious that you’re not always doing like manipulation stem and traction, or you’re doing the same therapies on every patient, every visit.

I would expect to see some. In your coding profiles if no, other than in your treatment orders, there’s variants in the type of stem, the location of stem, the type of traction, the location of traction the conditions being treated. If you’re doing rehabilitative exercises, Patient specific exercise protocols.

Now, granted, I understand rehab is not rocket science, there’s upper kinetic chain protocols. There’s lower kinetic chain protocols. And there’s progressions to those protocols and it’s fine to start with those. But they shouldn’t feel. A consistent pathway from patient to patient. Like for the first week we do these exercises.

Then the next week we do these exercises, I expect there to be some analysis as to when the patient can progress and see some variants there. Long story short, too much consistency in your billing, coding, whatever is going to be easily identified by payers. Watch out for the troublesome code pairs CMT with extremity CMT with manual therapy or massage or neuromuscular reeducation and be cautious about passive modalities for too long.

Visits per week, all of that stuff, because these are the things that payers look at to identify who they’re going to audit. If you manage your profile correctly and you keep an eye on it, to make sure that you’re doing truly patient specific care. And you’re not getting too lazy in that respect you can probably avoid.

Or at least mitigate the likelihood that you’re ever going to get be the subject of a post-payment audit. So hopefully that’s helpful for you next week, Dr. Sherry McAllister’s up. And she’ll have an engaging presentation. I am certain. So until the next time everybody enjoy your Christmas holiday or whatever holiday you intend to celebrate, have a happy new year and we’ll see you next.