Medicare Documentation: From Active to Maintenance Care
By Kristi Hudson
Over the past several years, the Office of Inspector General (OIG) has issued reports defining critical chiropractic billing and documentation issues. For example, in 2018, the OIG work report stated that chiropractic services had the highest improper payment rate compared to other Part B services.
One area of concern is treatment suggestive of maintenance care. (OIG, 2018) According to Dr. Steve Conway, "The treatment plan is 99% of the issue and 99% of the solution for this whole Medicare documentation problem."
Accordingto Medicare, for treatment to be considered active treatment, the patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient's condition and provide reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine as demonstrated by X-ray or physical exam. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3)
Two types of conditions are outlined in Medicare policy.
Acute Subluxation: A patient's condition is considered acute when the patient is being treated for a new injury, identified by X-ray or physical exam. The result of chiropractic manipulation is expected to be an improvement in or arrest the progression of the patient's condition.
Chronic Subluxation: A patient's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3) (CMS, 2020) Dr. Scott Munsterman said that it is essential that doctors of chiropractic are good historians if they want to improve their documentation. "When taking a patient's history and review of symptoms, look at all the symptoms that the patient is presenting with that visit," said Munsterman.
Ask about areas of pain, soreness, stiffness, etc., to potentially help patients become aware of a symptom that may not have been apparent. The more detail provided in the documentation, the better these findings can have metrics or measurements attached to quantify them, allowing you to make a treatment goal(s) and objectively measure the performance of treatment effectiveness.
For effective goal setting, it is essential to correlate treatment goals to the mechanism of trauma and the patient's condition diagnosed at the initial visit. (Conway & Munsterman, 2018) Common goals to consider:
• Reduce pain (use a visual analog scale)
• Increase range of motion (degrees of motion)
• Increase function, i.e., activities of daily living (outcome assessment tools)
Once the patient stops reaching further functional improvement, it is time to discharge the patient from active care, and any additional care is considered maintenance care. Medicare defines maintenance care as a treatment that seeks to prevent disease, promote health, and prolong and enhance the quality of life, or that is performed to maintain or prevent deterioration of a chronic condition. (Medicare Ploybook) Although helpful to the patient, Medicare will no longer reimburse additional treatment. The patient will need to be notified and the appropriate ABN form signed if maintenance care is provided. {Medicare Ploybook)
When it comes to documentation for Medicare, the rules are simple. One of the easiest ways to become educated on proper documentation is to read the Medicare Ploybook by Dr. Steve Conway and Dr. Scott Munsterman. You can receive a free copy (limited to the first 100 requests) at www.chirohealthusa.com/ students/medicare-playbook/.
B Kristi Hudson is a certified professional compliance officer (CPCO). She serves as the Director of Business Relationships for ChiroHealthUSA where she has helped to educate DCs and CAs on establishing simple and compliant financial policies. You can contact Kristi at [email protected], 888-719-9990 or you can visit the ChiroHealthUSA website at www.chirohealthusa.com.
