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Medicare’s CERT (Comprehensive Error Rate Testing) Program
Initiated August 1 Will Certainly Generate Medicare Audits - Are Your Records
Ready for an Audit?
As of August 1, 2010, Medicare will begin aggressively auditing offices as part
of their CERT (Comprehensive Error Rate Testing) program. It is an attempt by
the Medicare to recoup monies paid to providers when the services rendered did
not meet Medicare's guidelines. They will be auditing all types of providers
including medical doctors, chiropractors, durable medical equipment providers
and any other Medicare practitioner. For the most part, it is believed that
they will audit services rendered in 2007 and 2008. Unlike most Medicare audits
where you are given 60 to 90 days to produce the records, the records requested
under the CERT program will have to be produced in 30 days. Medicare is
pursuing an aggressive timeline for this program.
There are two important parts of the Medicare audit: 1. Proving that your
billing was completed correctly. 2. Providing documentation for the services
rendered that meets the Medicare guidelines. This article addresses the
billing aspect of the Medicare audit… making sure that you are billing correctly
for the services provided. The second article in this series will address the
very specific documentation requirements to pass a Medicare audit.
Take This Short Billing Quiz
We have prepared a short Medicare quiz. If you get all questions right, do not
bother to read this article -- you don't need it. If you miss some of the
questions, it is definitely to your benefit to wade through this article even
though some of the material is fairly dry in nature - okay, very dry. Knowing
the facts can save you a lot of money in a Medicare audit. Since many private
insurance companies use the Medicare guidelines as their standards, it would
give you a heads-up as to the expectations of any of the private insurers also.
1. The modifier AT, when added to the procedure code 98941, means Acute
Treatment.
2. A diagnosis of pain is sufficient to justify medical necessity for Medicare.
3. Subluxations can be substantiated either by x-ray or by a PART examination.
4. A neuro-musculo-skeletal diagnosis of muscle spasm substantiates a long-term
treatment plan.
5. If you are using the PART exam to substantiate subluxation, you must have a
diagnosis of pain.
6. Range of motion abnormalities can be substantiated by observation or range
of motion measurements.
7. Long-term treatment plans are usually associated with sprain/strain
injuries.
8. Medicare pays for maintenance care with the appropriate modifier.
9. Medicare requires the use of the 739.xx diagnosis codes for your primary
diagnosis; these codes describe regions of the spine, not specific vertebrae.
10. A diagnosis of postpolio syndrome would substantiate a long-term treatment
plan.
*Answers: 1. False 2. False 3. True 4. False 5. False 6. True 7. False
8. False 9. True 10. False
*A complete explanation of the test answers occurs at the end of this article.
Talk about a challenge... trying to grab your attention when talking about dull,
boring material. It is hard not to fall asleep while writing it. The reality
is this: in order to pass a Medicare audit, you have to know what they are
looking for. Because they have published guidelines, they have announced their
expectations. While some of the guidelines are up for interpretation, the
majority of the guidelines are very explicit. If you follow the guidelines, you
don't get hurt. If you do not follow the guidelines, you can end up paying
Medicare back thousands of dollars. So, back to the boring material, here are
their guidelines as published on the WPS website.
Documentation of Subluxation
A subluxation may be demonstrated by an x-ray or by physical examination, as
described below.
a. Demonstrated by X-Ray.
- Effective for claims with dates of service on or after January 1, 2000, an
x-ray is not required to demonstrate the subluxation.
- An x-ray may be used to document subluxation. The x-ray must have been taken
at a time reasonably proximate to the initiation of a course of treatment.
Unless more specific x-ray evidence is warranted, an x-ray is considered
reasonably proximate if it was taken no more than 12 months prior to or 3 months
following the initiation of a course of chiropractic treatment. In certain cases
of chronic subluxation (e.g., scoliosis), an older x-ray may be accepted
provided the beneficiary's health record indicates the condition has existed
longer than 12 months and there is a reasonable basis for concluding that the
condition is permanent. A previous CT scan or MRI is considered acceptable
evidence if a subluxation of the spine is demonstrated.
b. Demonstrated by Physical Examination Evaluation of musculoskeletal/ nervous
system to identify (PART = Pain, Asymmetry Range of motion and tissue tone
changes):
P.A.R.T. Information:
- Pain/tenderness evaluated in terms of location, quality, and intensity
Pain – Most primary neuromusculoskeletal disorders manifest primarily by a
painful response. Pain and tenderness findings may be identified through one or
more of the following: observation, percussion, palpation, provocation, etc.
Furthermore pain intensity may be assessed using one or more of the following:
visual analog scales, algometers, pain questionnaires, etc.
- Asymmetry/misalignment identified on a sectional or segmental level; P.A.R.T.
Information
Asymmetry/misalignment – Asymmetry/misalignment may be identified on a sectional
or segmental level through one or more of the following:
Observation (posture and gait analysis), static palpation for misalignment of
vertebral segments, diagnostic imaging, etc. of motion abnormality.
- Range of motion abnormality (changes in active, passive, and accessory joint
movements resulting in an increase or a decrease of sectional or segmental
mobility); and
Range of motion abnormality – Range of motion abnormalities may be identified
through one or more of the following: motion, palpation, observation, stress
diagnostic imaging, range of motion measurements, etc.
- Tissue, tone changes in the characteristics of contiguous, or associated soft
tissues, including skin, fascia, muscle, and ligament.
Tissue/Tone texture may be identified through one or more of the following
procedures: observation, palpation, use of instruments, tests for length and
strength etc.
To demonstrate a subluxation based on physical examination, two of the four
criteria mentioned under the above physical examination list are required, one
of which must be asymmetry/misalignment or range of motion abnormality.
As you skim through the fine print above, notice that Medicare has been quite
specific about the type of documentation required if you use the PART
examination to substantiate subluxation. If you are assessing pain, you can use
observation, percussion, palpation or provocation. You are also allowed to use
visual analog scales, algometers or pain questionnaires. If the patient winces
or screams during the examination, you have certainly met the criteria -- as
long as you document the response. If you have the patient fill out a pain
questionnaire or elicit that information during an interview, you have met the
criteria. For each of the four portions of the PART exam, the criterion that
meets their standards is specific.
Although it is not in bold in their guidelines, we have deliberately bolded the
final sentence. In order to qualify under the
PART guidelines, two of the four criteria are required AND one must be
asymmetry/misalignment or range of motion abnormality. Medicare requires
at least two of the four criteria and further specifies that one of them must be
misalignment or abnormal range of motion. As you document your findings, keep
in mind the four criteria of the PART exam.
Relationship of Symptoms to Level of Subluxation
These symptoms must bear a direct relationship to the level of subluxation. The
symptoms should refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo
or osteo), rib (costo or costal) and joint (arthro) and be reported as pain (algia),
inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral
pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems
as well as leg and foot pains and numbness. Rib and rib/chest pains are also
recognized symptoms, but in general other symptoms must relate to the spine as
such.
The subluxation must be causal, i.e., the symptoms must be related to the level
of the subluxation that has been cited. A statement on a claim that there is
"pain" is insufficient. The location of pain must be described and whether the
particular vertebra listed is capable of producing pain in the area determined.
In this part of the guidelines, Medicare has stated their position. For the
most part, pain in the head, neck, shoulder and hands emanate from a cervical
subluxation from Medicare's standpoint. If you can prove that a patient's arm
pain is related to a lumbar subluxation, Medicare might allow it. However, in
that situation, the burden of proof would be on your documentation and your
examination. Medicare expects that symptoms or conditions correlate rather
closely to areas of the spine.
Diagnosis, Primary and Secondary
Diagnosis: The primary diagnosis must be subluxation, including the level of
subluxation, either so stated or identified by a term descriptive of subluxation.
Such terms may refer either to the condition of the spinal joint involved or to
the direction of position assumed by the particular bone named.
When you are submitting claims, you must use the 739.x series of codes to
describe the misalignment or asymmetry. In your actual documentation, you can
be more specific and name the actual vertebra. Once you indicate the 739 code
such as 739.1 indicating a cervical misalignment, the neuromusculoskeletal
condition associated with that misalignment becomes the secondary diagnosis.
Here's the part that many doctors do not understand:
Medicare dictates the neuromusculoskeletal
(NMS) diagnosis codes that they will pay for. If the diagnosis code not
on the list, they may choose to deny it and most often will.
In addition, the NMS diagnosis code determines
the type of treatment plan that Medicare is expecting: short-term, moderate-term
or long-term.
Printed below are the acceptable codes separated into three categories of
treatment:
Short-Term Treatment (These conditions generally require short-term
treatments.)
ICD-9 CM Symptom/Condition Codes (Secondary Diagnosis)
307.81 Tension Headache
346.00 Classical migraine, without mention of intractable migraine
346.01 Classical migraine, with intractable migraine, so stated
346.10 Common migraine, without mention of intractable migraine
346.11 Common migraine, with intractable migraine, so stated
346.20 Variants of migraine, without mention of intractable migraine
346.21 Variants of migraine, with intractable migraine, so stated
346.80 Other forms of migraine, without mention of intractable migraine
346.81 Other forms of migraine, with intractable migraine, so stated
346.90 Migraine, unspecified, without mention of intractable migraine
346.91 Migraine, nspecified, with intractable migraine, so stated
355.1 Meralgia Paresthetica
721.0 Cervical Spondylosis without myelopathy
721.2 Thoracic Spondylosis without myelopathy
721.3 Lumbosacral spondylosis without myelopathy
721.90 Spondylosis of unspecified site without myelopathy
723.1 Cervicalgia
724.1 Pain in the thoracic spine
724.2 Lumbago
724.5 Backache, unspecified
728.85 Muscle spasm
784.0 Headache
Moderate-Term Treatment
353.0 Brachial plexus lesions
353.1 Lumbosacral plexus lesions
353.2 Cervical root lesions
353.3 Thoracic root lesions
353.4 Lumbosacral root lesions
353.8 Other nerve root and plexus disorders
355.0 Lesion of the sciatic nerve
355.2 Other lesions of femoral nerve
355.8 Mononeuritis of lower limb, unspecified
719.01-719.09 Effusion of joint
719.11-719.19 Hemarthrosis
719.21-719.29 Villonodular synovitis
719.31-719.39 Palindromic rheumatism
719.41-719.49 Pain in joint
719.51-719.59 Stiffness of joint, not elsewhere classified
719.61-719.69 Other symptoms referable to joint
719.7 Difficulty Walking
719.81-719.89 Other specified disorders of joint
720.1 Spinal enthesopathy
722.91 Other and unspecified disc disorder, cervical region
722.92 Other and unspecified disc disorder, thoracic region
722.93 Other and unspecified disc disorder, lumbar region
723.2 Cervicocranial syndrome
723.3 Cervicobrachial syndrome
723.4 Brachial neuritis or radiculitis
723.5 Torticollis, unspecified
724.4 Thoracic or lumbosacral neuritis or radiculitis
724.6 Disorders of sacrum, ankylosis
724.79 Coccygodynia (disorder of coccyx)
724.8 Other symptoms referable to back, facet syndrome
729.1 Myalgia and myositis, unspecified
729.4 Fascitis, unspecified
738.4 Acquired spondylolisthesis
756.11 Spondylosis, lumbosacral region
846.0 Sprains and strains of lumbosacral (joint) (ligament)
846.1 Sprains and strains of sacroiliac ligament
846.2 Sprains and strains of sacrospinatus (ligament)
846.3 Sprains and strains of sacrotuberus (ligament)
846.8 Sprains and strains of sacroiliac region, other specified sites of
sacroiliac region
847.0 Sprains and strains of neck
847.1 Sprains and strains of thoracic
847.2 Sprains and strains of lumbar
847.3 Sprains and strains of sacrum
847.4 Sprains and strains of coccyx
Long-Term Treatment
721.7 Traumatic Spondylopathy
722.0 Displaceent of cervical intervertebral disc without myelopathy
722.10 Displacement of lumbar intervertebral disc without myelopathy
722.11 Displacement of thoracic intervertebral disc without myelopathy
722.4 Degeneration of cervical intervertebral disc
722.51 Degeneration of thoracolumbar intervertebral disc
722.52 Degeneration of lumbosacral intervertebral disc
722.81 Postlaminectomy syndrome, cervical region
722.82 Postlaminectomy syndrome, thoracic region
722.83 Postlaminectomy syndrome, lumbar region
723.0 Spinal stenosis in cervical region
724.01 Spinal stenosis, thoracic region
724.02 Spinal stenosis, lumbar region
724.3 Sciatica
756.12 Spondylolisthesis
As you look through the lists above, you'll notice that the short-term treatment
plans mostly consist of headaches and pain symptoms. The moderate plans often
deal with sprains and strains. The long-term treatment is really aimed at
degenerative conditions. Remember, these codes
are the only ones that will get paid and the use of the code determines the type
of treatment plan that Medicare is expecting.
Treatment Parameters
The chiropractor should be afforded the opportunity to effect improvement or
arrest or retard deterioration of subluxation within a reasonable and generally
predictable period of time. Acute subluxation (e.g., strains or sprains)
problems may require as many as 3 months of treatment but some require very
little treatment. In the first several days treatment may be quite frequent but
decreasing in frequency with time or as improvement is obtained.
Chronic spinal joint condition (e.g., loss of joint mobility or other joint
problems) implies, of joints have already "set" and fibrotic tissue has
developed. This condition may require a longer treatment time, but not with
higher frequency. The mere statement or diagnosis of "pain" is not sufficient
to support medical necessity for the treatments. The location of pain must be
described and whether the particular vertebra listed is capable of producing
pain in the area determined.
The problem/complaint addressed and precise level of each subluxation treated
must be specified in the medical record. The need for an extensive, prolonged
course of treatment should be consistent with the reported diagnosis and must be
clearly documented in the medical record.
From their guidelines, they expect a short-term problem to be corrected within
three months or shortly thereafter. They expect a long-term problem will take
longer to correct or reach the maximum level of correction. In this case, the
length of the treatment is not explicitly stated and is more dependent upon your
documentation of progress in meeting stated treatment goals. Once a condition
has stabilized, Medicare regards continuing care as maintenance care.
Modifier Billing Guidelines
AT modifier: redefined from Acute Treatment to Active Treatment
GA modifier: If the provider uses the AT Modifier and believes a service is
likely to be denied by Medicare as not being medically necessary, the
beneficiary must sign an Advance Beneficiary Notification (ABN) and the GA
modifier must be used.
The AT modifier must not be placed on the claim when maintenance therapy has
been provided. Claims without the AT modifier will be considered as maintenance
therapy and denied.
Not only does Medicare specify the treatment parameters, they also specify the
use of modifiers. If the patient is in the active treatment phase of care, you
must use an AT modifier; if the patient is being seen for maintenance care, you
must get an ABN (Advanced Beneficiary Notice) signed and use the GA modifier.
When you use the GA modifier, you are telling Medicare that you have informed
the patent to the use of the ABN that the care will likely be rejected by
Medicare and that the patient has agreed to pay for the care.
Audit Triggers - Who Is Likely to Be
Audited Through the CERT Program?
Given their stated guidelines, what are the situations that are triggering
Medicare audits right now and what will determine the offices that the CERT
program will likely go after? Some of the audit triggers are obvious based on
the guidelines; some of these audits can be avoided. Other audit triggers are
occurring because Medicare is able to keep better statistics with advanced
technology. They are able to compare your office to other chiropractors in your
area and in the state. While computerization
has decreased your payment time, it is also increased the amount of information
and data available to the insurance carriers.
1. Treating more Medicare patients than normal within a certain timeframe
(usually six months.) This is a relatively new audit trigger that will affect
any high volume practice. For example, if Medicare statistics show that an
average chiropractor has 25 Medicare patients active at any time and your office
has 56, you are more likely to be audited. This statistic was not used until
recently as grounds for a Medicare audit. In this case, there is nothing that
you can do to avoid this audit if you are a high-volume Medicare practice.
2. Excessive use of the AT modifier. Based on the NMS diagnosis code used,
Medicare expects a certain number of visits before a patient is released to
maintenance care. If your active care phase is much longer than normal
chiropractor, this will trigger an audit. Unfortunately, many chiropractors
continue to bill using the AT modifier even when the patient has been under care
for two or three years. Here is an example: The initial treatment date was
listed as 10/1/2006. Every visit from that point until the current time has
been billed with an AT modifier. If the diagnosis has not changed and the
patient has not experienced a new condition, Medicare will consider this
excessive use of the active treatment phase.
3. A mismatch between the subluxation code and the NMS code. It is realistic
that you will sometimes make a billing error. However, if you are consistently
billing a 739.3 lumbar region subluxation with an 847.0 cervical sprain/strain,
the diagnosis mismatch will throw up red flags. Make sure that your subluxation
diagnosis codes match your NMS secondary diagnosis codes.
4. Excessive use of the 98942 procedure code. Because the 98942 requires five
regions of the spine to be diagnosed and treated, Medicare expects that this
procedure code will be used infrequently. If you use this procedure code on
more than half of your patients, this would be considered another red flag.
5. A visit frequency or visit count higher than normal. Medicare compiles
statistics and determines the average number of visits before a patient is
released from care or switched to maintenance care. They also track how many
times per week (visit frequency) is considered normal. If your individual
statistics fall higher than normal, this may trigger an audit.
6. Failure to release patients to maintenance care. Once a condition has been
corrected or a degenerative condition has stabilized, Medicare expects that the
patient is released to maintenance care. They
use the "duck" method of determining the maintenance care. If it looks like a
duck, walks like a duck and quacks like a duck, it must be a duck. If
the patient is being seen only once or twice a month, it will look like
maintenance care statistically therefore, it is maintenance care. The only way
to prove otherwise would be to document the fact that the patient is continuing
to make progress toward the treatment goals that you have specified. In the
next article, we will discuss the need for very specific treatment goals.
Understanding the Guidelines
Wading through the Medicare guidelines can be a tedious task not to be
undertaken by the fainthearted. On the other hand, once you understand their
guidelines, it is easier to extrapolate the documentation that will meet
Medicare standards should you ever get audited. Medicare guidelines are very
specific about what they require for documentation. In the next article, the
documentation requirements will be explained in depth and referenced back to the
guidelines in this article. In addition to explaining the specific
documentation required for the initial visit and for subsequent visits based on
Medicare's written material, we'll discuss the interpretations currently being
applied by WPS Medicare in recent audit situations. As a software company
providing documentation notes through electronic medical records, we have had
the opportunity to work closely with offices undergoing audits at the present
time. We have had the opportunity to observe failed audits with the use of
travel cards as well as those offices that have passed at 100% with the
appropriate documentation. Yes, it is possible to give Medicare exactly what
they want!
*Medicare
Quiz Explanations
If you missed the right answers to the Medicare quiz at the beginning of the
article, here is the explanation for each of the answers.
1. False The AT modifier has been redefined. It used to mean "Acute
Treatment." It now means "Active Treatment."
2. False Medicare is very explicit in saying the diagnosis of pain is not
sufficient documentation to substantiate care. In addition, you must have two
of the four criteria of the PART exam, not just one.
3. True This is true - refer to the documentation of subluxation.
4. False If you look through the list of NMS codes, a muscle spasm appears in
the short term treatment list.
5. False Pain can be used as one of the four criteria but it is not required.
It is required that misalignment or range of motion abnormality be one of the
four criteria.
6. True Medicare guidelines allow range of motion abnormalities to be
documented using these techniques.
7. False Long term treatment plans are usually associated with degenerative
conditions. Sprains and strains usually fall within the moderate treatment plan
range.
8. False Medicare does not pay for maintenance care under any circumstances or
with any modifiers.
9. True Unlike the 839.xx series of codes where cervical vertebrae can be
specified, the 739.x only address regions of the spine.
10. False While postpolio syndrome is usually degenerative and can cause other
spinal problems, postpolio syndrome as diagnosis itself is not listed in the
long term treatment approved codes.
Passing a Medicare Audit – There Is No
Reason to Be Scared If You Have the Documentation Required
Passing a Medicare audit is a matter of knowing the Medicare chiropractic
guidelines and following the rules about documentation. If you have the
appropriate documentation, passing the audit will be tedious but not
impossible. Let's examine the Medicare chiropractic guidelines as they have
been written.
On the initial visit, the
following information should be recorded in the patient’s record as part of the
patient history. This is subjective - as told to you by the patient.
Patient history:
1.
Symptoms causing patient to seek
treatment. There should be a portion of your case history form that asks the
patient why he/she is seeking treatment. This information should be recorded in
the patient's own words.
2.
Family history if relevant. For many chiropractic patients, the family
medical history may not be significant. In an allopathic office, family medical
history is important because certain conditions such as cancer or heart problems
have a tendency to run in families. For spinal problems, family history
information can be gathered but may not have an impact on treatment.
3.
Past health history (general health, prior illness, injuries, or
hospitalizations; medications; surgical history). There are many personal
health records that will solicit this information in a very organized fashion as
part of the patient history. ICER-2-GO offers an online personal health record
that gathers and reports all of the past history information listed above.
4.
Mechanism of trauma. Mechanism of
trauma is the area of documentation that is the most contentious at this point
in time. Prior to recent developments, chiropractors were recording
mechanism of trauma only when there was a specific accident or injury that
precipitated the care. Otherwise, if the patient woke up one day with a sore
back, there was no documentation on mechanism of trauma. Many of the current
Medicare audits have received failing marks because the mechanism of trauma was
not recorded in the documentation. It needs to be recorded for every patient.
In addition, WPS auditors were requiring that the mechanism of trauma not be
related to an activity of daily living. This would leave only a slip and fall
or an injury caused by an external force to meet the mechanism of trauma
guidelines. More recently, WPS auditors have backed off of the requirement that
the mechanism of trauma not be related to activities of daily living (ADL).
For your documentation, it is best to record a mechanism of trauma for every
new patient. If possible, ask leading questions of your patient to elicit a
specific incident that precipitated the pain that the patient is experiencing.
“Prior to experiencing your low back pain, did you slip or fall? Were you doing
any unusual activity? When did you first experience the pain? Can you recall
anything unusual that happened prior to experiencing the pain?” Record any
incident that the patient can relate that ties to the pain that brought them
into your office.
5.
Quality and character of symptoms/problem. In this scenario, you are
trying to elicit information about the type of pain that is being experienced –
dull, sharp, tingling, stabbing, ache, burning, numbness. In addition, you
might want to ask whether the pain is constant, intermittent or random.
6.
Onset, duration, intensity, frequency, location and radiation of
symptoms. If you have recorded mechanism of trauma above, it should have
included a date of onset. The intensity and frequency are also addressed in the
quality and character of the symptoms or problems. If the patient has a neck
pain radiating into the right arm, the radiation must be indicated.
7.
Aggravating or relieving factors; and prior interventions, treatments,
medications, secondary complaints. As part of your documentation of chief
complaint, there should be an indication whether certain activities exacerbate
the problem. For example, if the patient presents with neck pain, does sitting,
lying down, standing or bending over aggravate or relieve the pain? In
addition, where has the patient sought treatment… from their medical doctor?
From a physical therapist? Remember, this section of documentation is the
patient history, the subjective part of the documentation requirements.
PART exam:
After recording the patient history, the
objective portion of the examination begins. You can either use x-rays or an
orthopedic/neurological examination to justify the need for care. If the
patient is presenting with a neck problem, Medicare expects to see a physical
examination of the cervical area. If the patient presents with low back pain,
Medicare expects to see a physical examination of the lumbar area. Even though
neck pain can be related to a misalignment of the lumbar or pelvic area,
Medicare does not comprehend or substantiate a problem unless an examination of
that problem area occurs.
Thankfully, Medicare stopped short of requiring specific physical examinations
in their documentation. The examinations performed are left to the discretion
of the chiropractor. In addition to recording positive findings, be sure to
also record negative findings. Remember, there are four sections of the PART
exam: pain, asymmetry, range of motion and tissue/tone changes. To use the PART
exam to justify care, you must have positive findings in either asymmetry or
range of motion.
Treatment plan:
in addition to
mechanism to trauma documentation, the treatment plan documentation has received
the most attention from Medicare auditors. The documentation must
include the recommended level of care which is defined as duration and frequency
of visits. Again, remember that Medicare determines short, intermediate, and
long-range treatment plans based on the neuromusculoskeletal diagnosis codes so
your treatment plan should specify the primary and secondary diagnosis codes.
The most critical part of required documentation seems to be the treatment plan
- and the part that is gaining the closest scrutiny from Medicare - is specific
treatment goals. For example, if the patient's current cervical right rotation
is 50°, a specific treatment goal might be to increase the range of motion to
75°. Given that most Medicare patients are older and have some degree of spinal
degeneration, the treatment goal must be cognizant of the patient's current
condition. A 90-year-old patient will probably not be able to achieve normal
cervical right rotation unless they are in exceptional physical condition. If
you have not recorded degrees of range of motion, perhaps you have used a scale
such as zero to four to indicate restriction. If the patient is currently
experiencing a 4, severe restriction, the treatment goal might be to increase
the range of motion to a 2, mild restriction. If you are using a rating scale,
it is necessary to explain to Medicare the gradients on that scale.
For asymmetry or misalignment, it is much more difficult to establish specific
treatment goals. How do you quantify the degree of misalignment? If you have
found a good way of quantifying misalignment or subluxation, include specific
treatment goals related to correcting the misalignment or asymmetry.
If you choose to establish treatment goals related to pain, we suggest that you
use the Analog Pain Scale. Using this pain scale, the patients will rate their
pain on a scale from zero to 10 with 10 being almost intolerable. If the
patient presents with the pain scale of seven, you can establish a goal of
reducing the pain 3 or 4. In addition, you can also reference their dependence
on prescription painkillers and the possibility of eliminating drugs entirely.
With regard to tissue or tone changes, you can substantiate and quantify the
severity of muscle spasms. In most cases, doctors are using a rating scale from
zero to four.
Adjustments performed:
as the final part of your initial assessment,
Medicare requires an indication whether adjustments were performed on the
initial visit, what segments were adjusted and how.
Functional assessment:
in addition to establishing treatment goals
related to range of motion or asymmetry, you can also establish ancillary
treatment goals related to functional assessment and/or limitations. If you use
a functional assessment tool that rates the degree of difficulty in performing a
task correlated with the level of pain involved in the performance, you can
establish very specific treatment goals related to returning the individual to
as much a normal functional abilities as possible. In this case, you would have
a list of functional activities that can be graded according to difficulty and
associated with level of pain.
Subsequent visits:
once you have collected all of the data on the initial visit, Medicare looks at
your specific treatment plan and goals to see if you have achieved optimal level
of correction during subsequent visits. When it is appropriate, you should
review the history and the progress toward resolving the chief complaint. At
the time of re-examination, you should focus on all of those areas that were
positive it during your initial examination to determine whether changes have
occurred. Each treatment should indicate the treatment performed, the visit
number (as part of the visit plan), the date of the initial visit and a
treatment plan update if appropriate. Periodically throughout the treatment
plan, you should indicate your evaluation of the treatment effectiveness. When
you perform a re-examination, you should summarize the progress made toward
resolving the treatment goals.
During the course of treatment:
every chiropractor realizes that the body is not a static organism but a living,
breathing and constantly changing collection of cells. If the patient
experiences one of these three scenarios during the course of treatment, it
should be highly documented and perhaps initiate a new treatment phase:
-
New injury - a new injury especially to a
different area of the spine should be thoroughly documented. In most cases,
especially if you have a new diagnosis, you would change the “date first
consulted” or date of initial treatment since this is a new problem that has
surfaced. You would have a different treatment plan and different treatment
goals.
-
New condition - if the patient originally
presented with headaches and is now experiencing low back pain, this is
another indication for a complete examination and perhaps a new treatment
phase with new diagnosis.
-
Exacerbation/aggravation of existing condition -
suppose that you have been treating the
patient for three months and they have been making steady but slow progress.
As a result of a new daily activity, the patient experiences a return of
their symptoms. In this case, the exacerbation should be thoroughly
documented in the patient's words and through your physical exam prior to
adjustment.
Playing by Medicare's Rules:
When you accept Medicare
patients in your office, it forces you to buy into the rules and guidelines
established by Medicare. That is just a fact of life. There is no doubt
that the documentation requirements are stringent. Of course, having written
guidelines makes it easier to ”play by the rules.” There should be no
surprises. With the appropriate documentation and attention to detail, it is
possible to pass a Medicare audit at 100%. For more information or to discuss
your audit needs, the author of this article welcomes your calls.
About the Author
This article was written by Marilyn K Gard, MBA, CEO of ClinicPro chiropractic
software and ICER-2-GO LLC. Marilyn has been involved with the chiropractic
profession for 30 years, conducting chiropractic insurance seminars, writing
professional articles and running a software development company. ClinicPro
software currently offers an electronic health record program in addition to
chiropractic practice management software. As part of EMR development and
working with offices using software to meet documentation requirements, Marilyn
has studied the Medicare chiropractic guidelines intensively and talked
personally with Medicare auditors to obtain additional insight into the
interpretation of the guidelines. Marilyn can be reached at
Marilyn@clinicpro.com or 928-203-0854.
Call us for details about our
chiropractic EMR that meets all of the Medicare guidelines
PHONE: (866) 333-2776
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