The Most Common Billing and Coding Mistakes Chiropractors Make
DOCUMENTATION
Kristi Hudson
As the healthcare industry evolves, chiropractors must navigate complex billing and coding systems to ensure accurate reimbursement and compliance with regulations. Despite advancements in technology and resources, billing and coding errors remain prevalent, often leading to denied claims, reduced revenue, and potential compliance issues. Errors can significantly impact the financial health of chiropractic practices, making it crucial to understand and avoid them. This article explores the most common billing and coding mistakes chiropractors make in 2024 and offers strategies to prevent them.
Incorrect Use of CPT Codes
One of the most common mistakes in chiropractic billing is not using the right codes to describe the procedures and services provided.1
Common Issues:
• Undercoding: Failing to code for all services provided, leading to lost revenue.
• Overcoding: Using codes that indicate a higher level of service than provided, which can trigger audits and penalties.
• Miscoding: Using incorrect codes that do not accurately represent the services rendered.
Solutions:
• Empower Your Billing Staff: Provide staff with regular, comprehensive training on the latest CPT code updates and guidelines. By ensuring they can handle any coding challenges, you’re preventing errors and giving them the tools they need to excel in their roles.
• Coding Software: Use advanced coding software that includes the latest CPT codes and can alert you to potential errors.
• Double-Check Codes: Implement a system where multiple staff members review codes before submission to catch and correct errors.
Improper Use of Modifiers
Modifiers are two-digit codes added to CPT codes to provide additional information about the performed service. Incorrect use of modifiers can result in claim denials or inaccurate payments.
Common Issues:
• Modifier -25: Indicates a significant, separately identifiable evaluation and management service by the same provider on the same day as another procedure. Overuse or misuse can lead to scrutiny.
• Modifier -59: Indicates a distinct procedural service.
Misapplication can cause denials and audits.2
Solutions:
• Modifier Guidelines: Keep updated with the latest payer-specific modifier guidelines and ensure staff are familiar with them.
• Education: Provide regular training sessions focused on the correct use of common modifiers.
• Software Alerts: Use billing software that flags potential modifier misuse.
Inadequate Documentation
Accurate and thorough documentation is critical for justifying billed services. Inadequate documentation can lead to claim denials and repayment demands during audits.
Common Issues:
• Missing Details: Insufficient detail to support the necessity of the procedure.
• Inconsistent Records: Discrepancies between the services documented and the codes billed.
■ Lack of Patient History: Failing to document patient history and the rationale for treatments.
Solutions:
“One of the most common mistakes in chiropractic billing is not using the right codes to describe the procedures and services provided”
• Comprehensive Notes: Train providers to document thoroughly, including patient history, examination findings, and treatment rationale.
• Standardized Templates: Use standardized documentation templates to ensure consistency and completeness.
• Audit Trails: Review patient records and audit trails regularly to identify and correct documentation gaps.
Failure to Verify Insurance Coverage
Insurance coverage can vary significantly, and failing to verify coverage can result in unpaid claims and patient dissatisfaction.
Common Issues:
• Outdated Information: Using outdated insurance information leads to claim denials.
• Coverage Limitations: Not verifying the specifics of the patient’s coverage, such as limits on the number of visits or exclusions for certain services.
• Pre-authorization: Failing to obtain necessary pre-authorizations for specific procedures.
Solutions:
• Verification Systems: Implement real-time insurance verification systems to ensure accurate information.
• Pre-Authorization Procedures: Develop a standard process for obtaining pre-authorizations and tracking them.
• Staff Training: Train administrative staff to understand and navigate insurance plans and coverage nuances.
Ignoring Denials and Appeals
Ignoring denied claims or failing to appeal them can result in significant revenue loss. Understanding the reasons for denials and effectively managing appeals is crucial. Out of all the denied claims, 65% of them are never reworked — that’s huge! When this happens, your practice is losing money. It is possible to drastically decrease your denials and efficiently manage the denials that do occur if you simply make sure that the claim isn’t missing important information.3
Common Issues:
• Unaddressed Denials: Letting denied claims pile up without addressing the underlying issues.
• Improper Appeals: Filing appeals without proper documentation or not understanding the appeals process.
• Repeat Errors: Not analyzing denial trends to prevent future errors.
Solutions:
• Denial Management System: Use a robust denial management system to track and manage denied claims.
• Root Cause Analysis: Regularly analyze denials to identify common reasons and implement corrective measures.
• Efficient Appeals: Train staff on the proper appeals process and ensure they can access the necessary documentation and resources.
Incorrect Patient Information
Errors in patient information can lead to claim denials and delays in reimbursement. Accurate patient data is essential for successful billing.
Common Issues:
• Typos: Simple typographical errors in names, dates of birth, or insurance ID numbers.
• Incorrect Demographics: Errors in patient demographic information, such as address or phone number.
• Incomplete Information: Missing critical patient information required for billing.
Solutions:
• Electronic Verification: Use electronic verification tools to cross-check patient information at the time of service.
• Patient Confirmation: Have patients confirm their information during each visit.
• Accurate Data Entry: Train staff to double-check entries and use standardized forms to minimize errors.
“Out of all the denied claims, 65% of them are never reworked — that’s huge!”
Lack of Consistent Follow-Up
Consistent follow-up on claims is essential to ensure timely reimbursement and address any issues that arise.
Common Issues:
• Delayed Follow-Up: Waiting too long to follow up on unpaid claims leading to missed deadlines for appeals.
• Lack of Communication: Failing to communicate with insurance companies or patients about outstanding issues.
Unresolved Issues: Not tracking unresolved claims effectively, resulting in revenue loss.
Solutions:
• Automated Follow-Up: Use automated systems to track and follow up on outstanding claims regularly.
• Communication Protocols: Establish clear communication protocols with payers and patients regaiding claim status.
• Tracking Systems: Implement tracking systems to monitor the status of all claims and ensure timely resolution.
Overlooking Payer Policies and Updates
Insurance payer policies and coding guidelines frequently change. Staying updated is crucial to ensure compliance and proper reimbursement.
Common Issues:
• Outdated Codes: Using outdated CPT or ICD-10 codes that are no longer valid.
• Policy Changes: Ignoring updates to payer policies that affect billing practices.
• Noncompliance: Failing to comply with new regulations, resulting in denied claims or penalties.
Solutions:
• Regular Updates: Subscribe to payer newsletters and updates to stay informed about changes in policies and codes.
• Staff Training: Conduct regular training sessions to update staff on the latest payer guidelines and coding changes.
• Compliance Audits: Perform periodic internal audits to ensure compliance with current payer policies and coding standards.
Billing and coding errors can wreak havoc on chiropractic practices. By understanding the common pitfalls and implementing smart strategies, chiropractors can boost their billing efficiency, slash claim denials, and improve their financial health. The key is to stay on top of coding changes and invest in staff training that empowers practices to navigate the complexities of chiropractic billing and coding in 2024. With diligence and proactive management, chiropractic offices can optimize their revenue cycles and focus on delivering top-notch patient care.
Kristi Hudson is a certified professional compliance officer (CPCO) and vice president of business relationships at ChiroHealthUSA. Kristi serves as the vice chair of the
Chiropractic Future Strategic Plan, contributing her expertise to shape the future of the chiropractic profession. Learn more about the Chiropractic Future Strategic Plan at www.chiropracticfuture.org
References
1. O'Reilly KB. 8 medical coding mistakes that could cost you [Internet], Chicago: American Medical Association; 2023 Sept 18. Available from: https://www.ama-assn. org/practice-management/cpt/8-medical -coding-mistakes-could-cost-you
2. Medical Billers and Coders. Avoiding misuse of common modifiers [Internet], Dallas: Medical Billers and Coders; 2022 Feb 4. Available from: https://www. medicalbillersandcoders.com/blog/avoiding-misuse-of-common-modifiers/#:~:text=Modifier%2059%20is%20considered%20 the, differ ent%20 sites %20on%20the%20 body.
3. Smith K. Medical claim denials and appeals: statistics that you want to know [Internet], San Juan, PR: DrCatalyst; 2021 Feb 1. Available from: https://www.drcatalyst. com/blog/medical-claim-denials-appealsstatistics-that-you-want-to-know.
