Are Medicare Audits Triggered?

As long as we file a "clean" claim, most all Medicare carriers simply pay. However, there are a few things that "pop" out in a claim and lines us up for audits.

1. Item #14, Date of Current:
If date of current does not change in 60 days and the claim is with an "AT" modifier, an audit is probable. Date of Current #14 should change for any accidents, exacerbations, exams, x-rays, evaluations, etc.

2. Diagnosis must support care rendered:
The diagnosis for a patient with an exacerbation may be something like...Subluxation of L5, degenerative joint disease (if you have an x-ray less than one year) and sprain/strain, all in the same spinal region.

3. Patient Notes Review:
When asked to send one or two patient visit notes to your Medicare carrier and your patient notes only include S.O.A.P. notes and NO other "documentation" for the necessity of Chiropractic care, there is a problem. Now the Medicare carrier knows you do not know how to "document" and will do a full audit for money recovery.

Those are the three most prevalent reasons for an audit. Audits can be rough, however, if you know the correct way to do Chiropractic Medicare, after winning that first audit they will leave you alone.