August 20, 2012
"The Medicare Claim Tells the Story"
Most of my fellow Chiropractors, when they call about an audit or pre-pay request for records, ask why they received the record request. Most of the time they have a request for records because the items on the claim do not match.
Date of Current on an active patient should NEVER be over 60 days if your are expecting Medicare reimbursement.
Or...the diagnosis only consists of a subluxation with maybe arthritis. The carrier knows this patient can be adjusted twice a day for 6 months and an x-ray indicated a subluxation and arthritis. No improvement and no reimbursement. The diagnosis should have three parts to it. An example: subluxation, arthritis and sprain/strain if there has been an exacerbation.
If item #19 does not have both date of x-ray(less than one year) or P.A.R.T., the claim may not be payable. The carrier may ask for patient records to verify if the doctor proved a subluxation by either an x-ray less than one year or a P.A.R.T. form for each visit. X-rays are mandated each year, if the doctor proves subluxation by way of x-ray. A P.A.R.T. form is mandated each visit if the doctor does not use x-rays to prove the subluxation.
Some carriers ask for office patient records periodically to verify if the doctor has a treatment plan with the three key components. The "documentation" provided by our program consists of both "Federal Documentation" and also a treatment plan meeting all three components.
Many times the carrier will ask for patient S.O.A.P. notes to verify the doctor did in fact adjust vertebrae is specific regions in which they billed Medicare. If you adjust 4 regions on your patient for example, your billing will match the S.O.A.P. notes as to the number of regions you adjusted and billed to Medicare.
Generally the information on each claim should all match.....diagnosis supports the care rendered, Item #14, date of current, is less than 60 days old, Item #19 contains date of x-ray or P.A.R.T., and specific terminology indicating any exacerbation and the "documentation" has been produced.
Once the correct way to do Medicare is understood, you are half the way.