Documenting Medically Necessary versus Clinically Appropriate Care
INSURANCE
Kathy Mills Chang
MCS-P, CCPC, CCCA
It is no secret that chiropractic billing has been under increasing scrutiny over the past several years. The need to "prove” the necessity of the service we’ve provided to our patients is frequently called into question by many sources. It can feel like successfully being paid by an insurance company should be cause for minor celebration when it occurs after a bill is submitted for the first time. Many realize that this little party we throw in our collections department can be short lived. The dreaded postpayment audit can happen, and has happened to many in our profession, causing us to refund hefty sums of money to insurance carriers years after being paid. Why is this happening?
Take the case of one of your favorite long-term patients whom we will call Morris Medicare. He was one of your first patients, and he has remained loyal from the very early days of your practice. Moms completely “gets” chiropractic and comes in every month for his adjustment. In fact, he has a standing appointment at 9:00 a.m. on the first Wednesday of every month. Aside from an occasional flare up once or twice a year when he needs a few extra adjustments, he keeps that appointment without fail. You bill Medicare for Morris’s monthly visits and they have been paying you for years.
One day, you get a letter from a company hired by Medicare to do an audit on a few of your files. You comply with the request and promptly submit the documentation requested. Weeks go by and finally you receive the results. You owe Medicare money. “But why?” you may ask. All of those visits when Morris came in for his monthly care were deemed to be maintenance and Medicare does not pay for such care. Did he need those adjustments? Of course, he did! The issue is that they did not fit the standard definition of “medical necessity” as Medicare defines it. There was no history or incident surrounding that monthly visit. There was nothing to demonstrate he was receiving any therapeutic benefit, and the treatment was not part of an overall care plan with the goal to restore some lack of function or improve a condition for which there was an active diagnosis. His care may have been “clinically appropriate,” but it was not “medically necessary.” Morris should have been paying for this type of care—not Medicare—and now you owe Medicare a refund. Worse, you cannot collect at this point from Morris because there was no signed advance beneficiary notice (ABN) at the time these maintenance services were rendered. You write the check.
However, you may have noticed that there is no field on the CMS 1500 form to indicate your philosophy as a chiropractor. 5 5
Another patient, Sally Subluxation, was part of this same audit request. Sally has been a patient for some time. You provide her with the only relief she has ever found for her headaches and neck pain. You properly diagnose her with cervical subluxation and headaches, and your care has always been effective. Since you are a full-spine adjuster, you always take time to check Sally’s entire spine from occiput to pelvis. If you detect any segmental dysfunction along the way, you dutifully deliver the perfect adjustment to restore proper joint mobility. You bill Medicare a 98941 for the 3-4 region adjustment you performed. Sally’s audit
results are that Medicare wants money back for her care too. Your diagnosis only gave you medical necessity for a 1-2 region adjustment—a 98940. Even though you adjusted her lumbar spine and pelvis, those areas were considered incidental findings. The adjustments to her neck were “medically necessary,” but the “clinically appropriate” lumbar and pelvic adjustments were not “medically necessary.” You write the check.
These may sound like common stories to many, and they likely grind against your view of health care and, for some, your chiropractic philosophy. However, you may have noticed that there is no field on the CMS 1500 form to indicate your philosophy as a chiropractor. We as a profession must do better to meet the standards of medical necessity to avoid such nasty scenarios from occurring.
There are many definitions and rules about medical necessity in a chiropractic office when dealing with third-party payers, including Medicare. Because Medicare’s documentation standards are more stringent than others' standards, they provide the best guidelines to follow, though:
• Be sure your documentation shows a functional deficit that, with the appropriate treatment and case management, should greatly diminish or resolve the problem.
• Create written policies for documenting medical necessity to show compliance.
• Establish Medicare definitions and guidelines as the standard for documentation and record-keeping processes in
your practice. (These help you produce clear, thorough policies that explain how you plan to create and maintain high-standard chiropractic documentation.)
Clinically appropriate chiropractic care is based on a chiropractor’s clinical expertise and his or her professional opinion that care rendered will help the patient maximize health, maintain wellness, and/or achieve peak performance. This care is within the provider’s state scope of practice. The chiropractor should document the clinical findings that led to the conclusion that chiropractic care should be rendered during that visit, even though there is no significant functional deficit to help define the care as medically necessary.
Remember, care that is not medically necessary but is clinically appropriate is the patient’s financial responsibility and not that of the patient’s insurance company. Having clear policies for handling payments from patients is critical in these situations.
Kathy Mills Chang is a certified medical compliance sPecia^lsl (MCS-P), a certified chiropractic professional coder (CCPC), and certified clinical chiropractic assistant (CCCA). Since 1983, she has provided chiropractors with reimbursement and compliance training, advice, and tools to increase revenue and reduce risk. Kathy leads a team of 30 at KMC University and is considered one of our profession ⅛ foremost experts on Medicare, documentation, and compliance. She or any of her team members can be reached at 855-832-6562 or ufoakmcuniversity.com.
