"Medicare Learning Network" (72.9% Chiropractic Medicare Fail Rate)

Newsletter

April 30, 2013

Chiropractic Medicare

"Medicare Learning Network"

(72.9% Chiropractic Medicare Fail Rate)

Well....we Chiropractors made the Medicare Quarterly Provider Compliance Newsletter again! (Volume 3, Issue 3 – April 2013). The very first report is Comprehensive Error Rate Testing (CERT) Special Study: Provider Types Affected: Physicians and Chiropractors.

Problem description:

The majority of chiropractic services claims errors in this review were the result of insufficient documentation. Note that the Medicare Fee-for-Service 2011 Improper Payment Rate Report’s finding that insufficient medical record documentation was the most common reason (72.9%) for improper chiropractic payment. (See "The Supplementary Appendices for the Medicare Fee-for-Service 2011 Improper Payment Rate Report," released on November 2, 2012 at http://www.cms.gov/research-Statistics-Data-and-Systems/Monitoring-Programs/CERT-Reports-Items/Nov2011Appendix.html on the CMS website.)

This type of error occurs when the medical records do not contain enough information for the reviewer to make a decision about medical necessity for the item or service furnished. Some common reasons for insufficient documentation errors were:

• The documentation submitted did not adequately describe the service defined by the billed CPT code, Healthcare Common Procedure Coding System (HCPCS) code, or HCPCS modifier;
• The documentation did not include the Date of Service (DOS) or the beneficiary’s name;
• The was no treatment plan documented to support a plan of care;
• The signature was illegible.

Other errors in this special study were categorized as medical necessity errors. These errors occur when the medical records contain sufficient documentation for the reviewer to determine that the services billed were not medically necessary based upon Medicare coverage policies.

A common reason for medical necessity errors was that the submitted medical records did not support the need for the service based on the Medicare National Coverage Determination (NCDs) and Local Coverage Determinations (LCDs). The rest of the medical necessity errors were due to claims in which the beneficiary symptoms were not related to the spinal regions manipulated.

Example: Mr. Jones’ medical record shows that he had an injury that led to a subluxation of the spine with acute back pain. However, as required by the chiropractic services LCD, the precise level of the subluxation was not specified by the Chiropractor. This claim was scored as an improper payment due to an insufficient documentation error.

Let’s Get Back to the Basics! The statistics indicate 72 out of every 100 claims filed were paid improperly. If you are going to stay in practice and do Medicare and Obama Care, you simply have to do it correctly!!

Recommendation – Have questions in regards to doing Chiropractic Medicare correctly, or becoming Medicare Compliant? Give me a call at (618) 395-3800. Learn the correct way to "Document The Chiropractic Necessity of Care"!