Waving the 98942 Flag in Front of the Bull
DOCUMENTATION
Kathy Mills Chang
Many DCs have heard the cautionary tale of a California-based practice that wound up with a refund request of $708,022 from the federal government following an audit. Among the practice’s most egregious mistakes: the majority of the services billed (82%) were sent in with CPT code 98942/five spinal regions (not so coincidentally, the highest-paid CPT code covered by Medicare for chiropractic services).
To put that in perspective, the Office of the Inspector General (OIG) came out with a report this past September stating that if you run your ratios, only about 10% of all chiropractic services should be for 98942. We recommend that our clients average 10%—or less.
We wish we could say that this California practice was an unusual case, but it wasn’t, and it isn’t. In Kansas, another group of chiropractors had to cough up similarly horrifying recoupments because of the exact same problem of high 98942 ratios. This multi-office Kansas provider, whose audit determined that 98% of its services were billed with 98942, didn’t have the documentation to support the code, and it was determined that they had been overpaid $773,111 as a result.
Sadly, we see this easily avoidable coding error a great deal of the time, and so does the OIG. Their most recent report stated that their prior investigations have found that almost half of all 98942s are upcoded.
We aren’t without sympathy. It’s tough to bill for and properly document a 98942 for a patient. With Medicare, for example, you need two DX codes for each of the areas—plus medical necessity established for all five. And as if that weren’t hard enough, how do you really distinguish the complaints necessitating treatment in the pelvis from, say, pain or dysfunction in the lumbar or the sacrum? It has to be distinct—from complaint to finding to diagnosis.
Many “full-spine adjusters” feel that adjusting an area automatically makes it a billable service. We teach that while there may be a primary subluxation in an area, other nonsymptomatic areas that are treated are usually secondary, or even tertiary. DCs may have to address these other areas in order to treat the primary subluxation, and that should be well documented. Even so, it doesn’t mean those secondary or tertiary areas are billable.
^Overbilling of 98942 translates to overpayments that, if captured by an audit, will have to be repaid (do you have a spare $700,000 lying around?). ï Ï
Medicare is very concerned. So are private insurance companies, and that’s why overuse of 98942 can be like waving a red flag in front of these very powerful “bulls.”
It’s relevant to note that full-spine adjusters can evaluate and treat the entire spine—even with no complaint—as long as they’re not asking a third party to pay for it. When asking for Medicare or another third-party payer to reimburse, however, it’s imperative to follow the rules.
When we work with DC s on this, we go back to basics, including the following equation: history + exam = diagnosis, which leads to the treatment plan. If there’s no history of complaint in a particular region of the spine, there should be no examination—and therefore, no diagnosis or treatment. It’s not lost on us that the spine is a closed kinetic chain, and adjusting the lumbar spine can and will affect the cervical area. But in a third-party reimbursement world, that is just not the “causal relationship” that’s often included in the medical necessity definitions.
Interestingly, DCs who focus on upper cervical adjustments have somewhat the opposite problem, and it’s still an issue. If your treatment always includes adjusting Cl, but the problem is actually lumbar, how do you code for that? CMS is scrutinizing this kind of documentation too. Its definition of medical necessity states that you must show a “direct causal relationship”
between the two regions in order for the issue to be billable as an adjustment to more than one region.
Overbilling of 98942 translates to overpayments that, if captured by an audit, will have to be repaid (do you have a spare $700,000 lying around?). In almost all cases, the OIG states that overbilling 98942 occurs because chiropractors didn’t establish adequate policies and procedures to ensure that chiropractic services billed to Medicare are medically necessary, correctly coded, and adequately documented.
The OIG also says that many doctors don’t have procedures to document qualitative or quantitative measures by which they can prove that future progression of care would demonstrate treatment effectiveness. This is when we direct providers and their teams to install OIG compliance programs. Conducting a step-by-step process of creating Medicare compliance policy and procedures, training staff, and putting together a customized OIG compliance manual that outlines precisely what the OIG wants to see can be a tremendous mitigating factor should an unfavorable audit occur. And oh, by the way, compliance programs aie mandatory now for Medicare providers—don’t wait any longer.
Where our clients get the most confused in this is when they are full-spine adjusters. They ask, “Why can’t I code 98942 all the time?”
Here’s the issue, in summary. If you’re a full-spine adjuster, there’s nothing wrong with that. The problem stems from the lack of a policy describing how you handle the billing when you adjust multiple nonsymptomatic areas versus what you bill for that treatment. What the OIG expects to see is a policy that describes how you note the treatment of primary, medically necessary treatment to specific spinal regions versus how the documentation differs when treating a compensatory area. Clarify up front with a written policy; then, an auditor or other third party can understand why multiple areas are documented but fewer aie billed.
Bottom line: 98942 is a good code, a reasonable code, and a useful code. Just tread carefully when using it and ensure that your documentation supports it, or you might find one of those bulls charging at you when you least expect it.
Kathy Mills Chang is a certified medical compliance specialist (MCS-P) and certified chiropractic professional coder (CCPC). Since 1983, she has provided chiropractors with reimbursement and compliance training, advice, and tools to improve the financial performance of their practices. Kathy leads a team of 15 at KMC University and is known as one of our profession ’s foremost experts on Medicare. She or any of her team members can be reached at 855-832-6562 or infofifKMCUniversity.com.
