How Not to Get Some Zs
DOCUMENTATION
Kathy Mills Chang
ZPIC audits, that is. Recently, a client came to us because they were hit by a Zone Program Integrity Contractor (ZPIC) audit. The practice is a large, multidisciplinary business with multiple practitioners. Since it is located in an area popular with retirees, about 75% of the practice’s patients are on Medicare. The reason they were targeted? Mostly, it was due to overuse of code 98940, chiropractic manipulation, which they were using 44% more than their peer practices in the state. In other words, they were flagged for being an outlier.
The results of the audit were even worse. None, repeat, none, of the audited claims from a five-month period passed muster with Medicare. This would be bad news for any chiropractor, but for a practice that specializes in Medicare patients, it was a true nightmare.
The report found the following sloppy—and easily avoidable— billing errors in the documentation. Read carefully because these ai e some of the most common documentation mistakes in the profession. According to the 01 G, as many as 80 to 94% of you ai e making them.
• “Medical records contained an inadequate plan of care.”
This statement, taken directly from the report, is actually generous. Not only were plans of care “inadequate,” but they were missing altogether in many cases. Remember, if it is not written down and documented, then it never occurred at all as far as Medicare or a private insurer is concerned.
• “Certification of the plan of care for physical therapy lacked the required date/signature by the physician/ non-physician practitioner who agreed with the treatment plan.”
One of the most commonly overlooked details we—and third-party auditors—find is a missing or illegible signature. The second most common is no date. These are such simple things, but a staggering number of DCs overlook them.
• “Treatment notes lacked the required timed code treatment minutes and local time.”
While it may seem obvious that a treatment tied to a timed code, such as most physical therapy, actually needs to have the time listed in the documentation, this is yet another frequent mistake. If the code requires 15 minutes of the practitioner’s time, then the document has to reflect that the practitioner was indeed standing there from X o’clock to Y o’clock without fail.
• “There were no discharge summaries written by the clinician to summarize the episode of care.”
Ouch. Without an appropriate discharge from the episode of active care, there is no way to establish a new episode of care the next time the patient comes in with a new injury or complaint. This does the practice and the patient a grave disservice.
• “Several encounter notes for chiropractic manipulation and physical therapy were missing from the charts. The records did not support that treatment was rendered.”
Didn’t write it down? Again, then it didn’t officially happen, and if it didn’t happen, the claim can’t possibly go through for reimbursement. You can expect to see claims with missing encounter notes bounce back or be denied. If you submit enough of them, you can expect to see an audit notice.
• “Documentation did not support medical necessity for chiropractic manual manipulation of the spine as covered by the Medicare program.”
You would think that a practice with a patient roster that is 75% Medicare recipients would know Medicare’s rules, but the sad truth is that this practice is far from alone in this. Medicare covers chiropractic manipulation only, and only when the treatment is medically necessary, which is
a totally different beast than clinical necessity. There must be a beginning, middle, and end of care, and there must be a reasonable expectation of functional improvement from active treatment.
• “The provider did not document the patient’s response to ongoing treatments.”
Similarly, if you’re not actually documenting your patients’ progress, you can’t possibly justify medical necessity, which is tied directly to the expectation of improvement.
• “The physical therapist did not perform a re-evaluation as would be expected when a patient is getting continuation of therapy after several weeks to support progress and medical necessity.”
See the above bullet point. In order to qualify as medically necessary care, the treatment plan must be described clearly and followed, with any progress (or lack of progress) noted. Do you think the government is going to simply take your word for it? That would be like submitting your tax forms without detailing your deductions and hoping the 1RS will simply believe you when you guesstimate an approximate figure.
The consequence ofthat client’s ZPIC audit was that the practice was placed in prepayment “rehab,” so to speak (i.e., required to create case summary packets of episodes of care for all patients, all to be reviewed prior to Medicare reimbursement). In the meantime, they also got our help with Medicare and documentation traming, and now have ongoing programs and procedures in place with a customized OIG Compliance Manual. Once they’ve earned back Medicare’s trust, they’ll be back in the driver’s seat.
Rehabilitating your reputation with Medicare or a private insurer isn’t impossible, but it is incredibly time consuming and comes with no guarantee of a positive outcome. So the choice is really up to you: spend the relatively small amount of time up hont to make sure that your documentation is accurate, complete, and supports your diagnosis, coding, and medical necessity; or spend a great deal more time and an mcalculable amount of shess later jumping through postaudit hoops.
The best practice is to do everything you can to avoid the Zs, and all of the other potential audits out there. It is the best way we know to sleep easy at night.
Kathy Mills Chang is a certified medical compliance specialist (MCS-P). Sincel983, she has been providing chiropractors with reimbursement and compliance training, advice, and tools to improve the financial performance of their practices. Kathy leads a team of 14 at KMC University and is blown as one ofour profession ’s foremost experts on Medicare and documentation. She or any of her team members can be reached at 855-TEAM KMC or infofifKMC University, com, www.KMC University, com.
