The Cat Was Out of the Bag: Too Little, Too Late with Documentation

This mid-western doctor called us last summer, and the frustration in his voice was evident. He said he used to really start every day excited and ready to take on a day full of patient care, documentation, finances and quality relationships with patients. He remembered the "good old days" of leaving the office at night with a sense of accomplishment and pride in the services and healthcare that he offered to his community. He had a simple question: "How do I get back to the days where I wasn't worried every minute that someone was going to come investigate my every move in the office?" Maybe you can relate to his story. He has been running his practice for six years. His office hours allow him to be home with his family when he chooses but he admitted to always feeling not quite comfortable when he left the office for the day. He says there was always a gnaw ing feeling that things weren't ex- actly "as tight "as he felt they should be. but couldn't quite put his finger on it. This feeling of uncase interfered with his personal time, and he knew he needed to get around to "fixing" some things. He thought he was doing pretty well, and he was getting checks in the mail. Everything would be OK. right? We discussed some possible actions he could take, some training we recommended, and some stop-gap measures, including looking over his documentation that would certainly give him some peace of mind. Unfortunately, we didn't hear from him again. Until... The Inevitable Happens Three months after our initial call, he called back in a panic. He had a documentation request from one of their largest third party payers. He had that sinking feeling that the hens were coming to roost. He wasn't worried that they would find anything "fraudulent" but he was pretty dam sure that his documentation and other records were not up to par. We suggested that he allow us to help him with writ­ing and organizing case summaries to go with the records. We explained that when the records arc organized within the packet returned, with a synopsis of the case on top. it makes it easier for the reviewer to make sense of "less than perfect" documentation. He said hc"d think about it. and unfortunately, we didn't hear from him again. Until... Bad News Two months later he called us again, and this time we could hear the fear in his voice across the phone line. He received the results of that "probing" record request, and now he's being asked to pay back thousands of dollars. He faxed us the letter and these are the three points that were paramount in the insur­ance company's reasoning for the recoupment: 80% of the adjustments billed on the sample of 20 pa­tients were 98942. Since he considered himself a "full spine adjuster", he thought that was the right way to charge. All patients got a full spine adjustment regardless of their chief complaint. The consistently high percentage of 98942 codes being billed caused medical necessity red flags. The full spine adjustments were clinically ap­propriate but didn't meet medical necessity guidelines The documentation did not contain appropriate treatment plans. Quick notations of frequency, like "3X Week for 4 Weeks", were all that could be found. This payer, like all third party payers, required a much more detailed treatment plan to include goals and to justify the work that was to be performed. The doctor made no mention of treatment goals and he didn't indicate what sen ices would be performed based on the chief complaints. Although the average length of care in the twenty charts was 28 visits, there was not one single rc-cxamination. Without periodic rc-cxaminations. there can be no verification that the care provided was working, and that more care was indicated. Coupled with the fact tliat there were no measurable goals, the payer was liard-prcsscd to believe the care was warranted and necessary. The Fat Lady Had Sung There was little that could be done now. The cat was out of the bag. the documentation lad been sent in and seen and evaluated. Because this doctor really didn't have a leg to stand on. he refunded the money paid and was determined never to allow this to liappen again. He also acknow ledged tliat he would have been better served taking our advice to properly send the records in. to summarize the records in a way that would PLUS the documentation where possible. He also recognized that correcting the problem for future patient visits would be vital to his success. A Fearless Future Its easy to make plans for the future that build on the knowl­edge gained in a lesson such as this. Nobody wants to have to pay tuition to the "School of Life" in this manner. There is no skimping on learning the rules of billing, documentation, and other compliance matters. The following facts were learned the lard way by this colleague and you can resolve to work on these now rather than pay your tuition: NEVER send in requested records in a willy-nilly fash­ion. They should be organized and summarized in a way that allows the reviewer to paint a picture in their mind of the episode of care the patient is treating within, the number of visits within that episode that the required documentation points to. and other factors that will assist with the review. Consider having a professional reviewer, like a Certified Medical Compliance Specialist, conduct a mock audit of a few charts, to paint a picture of what may be seen when a third party reviews it. Forewarned is forearmed. Here arc some suggested items that can be included in a Case Summary submitted with requested documentation: Beginning date of this episode of care or this burst of chronic care: The visit(s) represent (s): ( ) Acute Treatment ( ) Chronic Treatment The intake history/exam/ADL Deficits included: Subluxation demonstrated by (if applicable): The Diagnosis codes assigned are as follows: (Complete as applicable) Region 1: Region 2: Region 3: Region 4: Region 5: Treatment Plan included the following recommended care for these regions and anticipated tissue specific responses: The functional goals at the beginning of this episode were: Total number of visits for this episode: Visit numbcr(s) of the date(s) in question as they relate to the stated episode: Dates of follow up examinations performed in this episode: Patient compliance with treatment plan: Patient discharged (or is anticipated to be discharged) from this episode on: Treatment effectiveness demonstrated by: Conclusion: While your philosophy or technique may call for a full spine adjustment, and it may be clinically appropriate, when dealing with third party payers, you have medi­cal review policy that dictates the medical necessity of care. Chief complaints must be present in the area treated, verified by examination findings, and include a diagnosis and treatment plan for that area. Look at your ratio of adjustment codes between 98940. 98941. and 98942. A great guideline to follow is that 98940 or 98941 shouldn't be higher than 60% and 98942 would be the rare exception, probably under 10%. Remember, purposely under coding the level of work you performed is as bad as over coding. Accuracy is key. The code must match the documentation. A treatment plan is a valuable and required tool in your documentation. It establishes your measurable goals, the treatment you intend to render, and the frequency and duration of care. Keep in mind that a "measurable goal" never looks like "reduce pain" but should be far more specific, like "Patient able to sit at desk for 4 hours with no pain". These arc goals you can measure and document during treatment and certainh with outcome assessment tools during re-examinations. Medicare requires several components of a treatment plan. Be sure yours include: Frequency and expected duration of care, for all the care you expect to provide, not just adjustments. You can es­timate here! Nobody expects you to have a crystal ball, but give your clinical opinion of what will be necessary until the first re-examination. Then you can re-tool. Goals, and preferably functional, measurable goals as noted above. Refrain from being overly general, with goals like "reduce spasm". After all. can that really be measured? And what if spasm isn"t present on one visit, but is the next, and then missing for three or four? An evaluation of treatment effectiveness is expected to be presented, so the third party reading your notes is able to understand HOW you will know if the patient is improving and WHY the patient needs more care. If you use Outcome Assessment Tools (OATs) this is the easy way to measure effectiveness. Score and chart the initial level of disability or the score from the tool initially, and then measure that at the mile-posts along the way. each rc-cvaluation. This can also be added to your goals. It's an easy way to show the treatment is working, and that care is justified. Periodic rc-cvaluations are a crown jewel in your docu­mentation. They are often over-looked and create both compliance risks around medical necessity, and signifi­cant missed reimbursement opportunities as well. There arc mam reported reasons about w hy these important milestones are missed, like feeling too rushed to perform the rc-cvals. lack of scheduling, and patient push back over lack of understanding and financial matters. Too mam doctors admit to NOT performing rc-cvals because the patient cant afford them. There arc mam ways to solve financial issues, but far fewer ways to prove your care without rc-cvaluation. Rc-cvaluations help you to document progress toward measurable goals and out­comes during care. Without this documentation, because of the guidelines used in most audits, care beyond 2-4 weeks. 30 days, or 12 visits, can't be justified without an evaluation and would be denied. Consider installing a system where the initial group of treatment visits are scheduled with the rc-cvaluation as the last appointment. Or. set a system in place where team members keep track and notify the doctor. Set reminders in your computer system or in the patients chart. Everyone will not go through this type of audit. Despite paying his tuition to the School of Life, this doctor is now-able to practice with peace of mind and fear-free due to his full understanding of what is required and with the help in implementing systems into his practice to make sure there is adequate time for documentation and necessary sen ices. It's easier than you may think! Knowledge and understanding, along with some strategic actions, can go a long way in helping you to know with certainty that your office is legal, compliant, and in good standing. Kalhy Mills Chang is a Certified Medical Compliance Specialist (MCS-Pj and, since 1983, has been providing chiropractors with reimbursement and compliance train­ing, advice and tools to improve the financial performance of their practices. Kathy is known as one of our profession s foremost experts on Medicare and can be reached at (855J TEAA1KMC or [email protected]