YOU MIGHT HAVE HEARD OR READ ABOUT THE RECENT ANALYSIS from the Office of the Inspector General concerning Medicare payments to chiropractors. The overwhelming feel of this 38-page report is that the majority of chiropractors arc billing Medicare for medically unnecessary treatment. We shall not categorize the OIG report as negative; rather it is serious, challenging, critical and objective. The only way to avoid a hard cap for this profession is to improve documentation. Otherwise, if we continue to fail in documentation, it is just a matter of time until Congress will place a cap on coverage. According to the analysis, their objective was "to determine the underlying causes of, and potential ways to reduce, vulnerabilities associated with Medicare payments for chiropractic services." Again, according to the analysis, "to gain a deeper understanding of the underlying causes of these vulnerabilities (maintenance care) and ways to reduce them, we selected a simple random sample of 400 Medicare services (total al- lowed amount = $12,638.38) submitted by chiropractors and allowed in 2001." Below are the Results of Their Analysis: • Maintenance services were the most common type of non-covered chiropractic service that Medicare paid for in 2001. • Supporting documentation for chiropractic services rarely met all Medicare Carriers Manual requirements. • Carrier controls to prevent over utilization arc inconsistent. All of these findings have a global theme. The OIG feels the majority of the claims submitted were for maintenance care. All of these problems centralize on the theme of documentation. It is the same theme you hear with your commercial carriers as well. The Recommendations of the OIG: • Ensure that chiropractic services comply with Medicare coverage criteria. • Require that its carriers educate chiropractors on Medicare Carriers Manual requirements for supporting documentation. Both of these arc essentially the same statement. It is all boiling down to the same issue: DOCUMENTATION! The OIG is recommending that the Centers of Medicare and Medicaid Services (CMS), formerly Health Care Financing Administration (HCFA), consider putting a cap on the amount of visits a patient can receive for chiropractic. They are saying this will help to control the amount of non-covered services that Medicare has been paying for. It is obvious how this would affect all insurance carriers. The past has shown us that, when Medicare makes a new rule, many private insurance carriers start looking to see if they should make the same type of changes. If Medicare puts a soft or hard cap on their visit allotments, you will start to see more and more private carriers doing the same. This analysis talks about the chiropractic profession's not documenting accord- ing to the Carriers Manual. This manual lists exactly what Medicare is looking for in your documentation. The reality of the situation is that chiropractic is actually saving the government billions of dollars every time you treat a patient. You help to keep patients out of surgery and get them off overpriced drugs. In the Carriers Manual, Part 3, chapter II, under Coverage and Limitations, in section 2250, it states, "The term 'physician', under part B, includes a chiropractor who meets the specified qualifying requirements set forth in 2020.26, but only for treatment by means of manual manipulation of the spine to correct a subluxation." This is important, because you need to understand that Medicare is telling you that they will pay for the visit, if you are correcting a subluxation. On page four of the OIG analysis, it states, "Several records we reviewed would have appeared legitimate for any one particular day of service; however, that day's documentation was repeated verbatim for the entirety of the patient's treatment." It is not the actual documentation of the visit they are looking for. In section 2251.2, they define a subluxation as "a motion segment, in which alignment, movement integrity, and/or physiological function of the spine are altered, although contact between joint services remains intact." Knowing what they mean by a subluxation helps you understand how to better document. On page 42, you will see a list of documentation requirements from the Carriers Manual. The information is laid out just as it is in the Carriers Manual to allow you to use this article as a resource for your office. To demonstrate a subluxation based on a physical examination, two of the four criteria mentioned under "physical examination" arc required, one of which must be asymmetry/misalignment or range of motion abnormality. Notice how specific it is and how simple this is to document. We have always been and will continue to be an advocate for Computerized Range of Motion and Muscle Testing. Not only do the AMA Guides to the Evaluation of Permanent Impairment, 5th Edition, speak of duel inclinomctry, but Medicare is doing the same. If you arc going to continue to bill any form of insurance, you will have to document, objectively, your patient's range of motion and muscle strength, using some form of the evidence-based technology available to you today. Also, in your patient's recorded history, symptoms must bear a direct relationship to the level of the subluxation. The symptoms should refer to the spine (spondyle or vertebral), muscle (myo), bone (ossco or osteo), rib (costo or costal) and joint (artho) and be reported as pain (algia), inflammation (it is), or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, ann, shoulder, and head problems as well as leg and foot pains, and numbness. Rib and rib/chest pains are also recognized symptoms, but, in general, other symptoms must relate to the spine as such. The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited. A statement on a claim that there is "pain" is insufficient. The location of the pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined. But, if you look deeper into the analysis, you will see they are not just asking for documentation of the subluxation. This has been the problem with the chiropractic profession; we have been focusing on the wrong part of the problem. What the OIG and CMS arc looking for is how the care you provide is going to impact the overall function of your patient. In section 2251.3, part A, the necessity for treatment states, "The patient must have a significant health problem in the form of a ncuromusculoskelctal condition necessitating treatment, and the Carriers Manual Section 2251.2 Documentation of Subluxation-A subluxation may be documented by an X-ray or by physical examination, as described below. 1. Demonstrated by X-Ray: An X-ray may be used to document subluxation. The X-ray must have been taken at a time reasonably proximate to the initiation of a course of treatment. Unless more specific X-ray evidence is warranted, an X-ray is considered reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of a course of chiropractic treatment. 2. Demonstration by Physical Examination: Evaluation of musculoskeletal/nervous system to identify: a. Pain/tenderness evaluated in terms of location, quality, and intensity; b. Asymmetry/misalignment identified on a sectional or segmental level; c. Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and d. Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament. The history recorded in the patient's record should include the following: ■? • Symptoms causing patient to seek treatment; • Family history, if relevant; • Past health history (general health, prior illness, injuries, or hospitalizations, medications, surgical history); • Mechanism of trauma; • Quality and character of symptoms/problems; • Onset, duration, intensity, frequency, location and radiation of symptoms; •Aggravating or relieving factors; and • Prior interventions, treatments, medications, secondary complications. Documentation Requirements: Initial Visit-the following documentation requirements apply whether the subluxation is demonstrated by X-ray or by physical examination: 1. History, as stated above 2. Description of the present illness including: a. Mechanism of trauma; b. Quality and character of symptoms/problems; c. Onset, duration, intensity, frequency, location and radiation of symptoms; d. Aggravating or relieving factors; and e. Prior interventions, treatments, medications, secondary complications; f. Symptoms causing patient to seek treatment. 3. Evaluation of musculoskeletal/nervous system through physical examination. 4. Diagnosis: The primary diagnosis must be subluxation, including the level of the subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named. 5. Treatment Plan: The treatment plan should include the following: a. Recommended level of care (duration and frequency of visits); b. Specific treatment goals; and c. Objective measures to evaluate treatment effectiveness. 6. Date of the initial treatment Documentation Requirements: Subsequent Visits—the following documentation requirements apply whether the subluxation is demonstrated by X-ray or by physical examination: 1. History a. Changes since last visit; b. Systems review if relevant. 2. Physical Exam a. Exam of area of spine involved in diagnosis b. Assessment of change on patient condition since last visit c. Evaluation of treatment effectiveness 3. Documentation of treatment given on day of visit. manipulative services rendered must have a direct therapeutic relationship to the patient's condition and provide reasonable expectation of recovery or improvement in function. The patient must have a subluxation of the spine as demonstrated by X-ray or physical exam, as described above." This is what has been lacking in your documentation. Most chiropractors do not set goals of functional improvement. The profession has been basing it on pain or resolution of a diagnosis or nothing at all. The chiropractic profession will reach its pinnacle through objective documentation by the setting and achievement of functional goals. This infomiation should encourage you. Make sure you know the rules; play by the rules, and you will win by the rules! Understand that, even when you start documenting this way, you will probably still have some problems with Medicare. Be assured that, if you begin to document the way we have laid it out, you will be able to succeed in getting paid. Bharon Hoag. a Certified Profession Coder, is the Founder and President of Hybrid Management. Inc. He is an expert in the area of coding and documentation spending the last five years studying and teaching across the country. He is also a consultant to Myo-Logic Diagnostics and Spinal-logic Diagnostics. He can be reached at hharon(ahvbridmanai;ement.net. 740-398- 3611 or visit www.hybridmanagement.net. Dr. Harold McCoy is the founder and owner of Myo-logic. He can be reached by phone at H00-76K- 7253. Ext. 2: by e-mail at [email protected]; or visit www.myologic.com. www. spinallogic.com. or www.bulletproofseminars.com. |JQJ|
