Posted by Team KMCU on Oct 9, 2023
Know Potential Red Flags to Help Avoid Future Audits
All providers look for and identify clinical findings that are red flags and raise suspicion of more serious underlying medical conditions. However, most providers are unaware of and never look for the red flags in their documentation and coding which could trigger an audit. Sure, some audits are completely random and unavoidable but many times an audit is triggered by a pattern of coding and claim form errors that lead to a records request. Unfortunately, doctors may know what these red flags are, but they never look for them until they are in the middle of an audit. An audit can be an extremely difficult issue to resolve, and it can result in recoupments and penalties, not to mention the high levels of stress on the provider, staff, and practice. The best approach is to be aware of, look for, and avoid making these mistakes in the first place.
The Audit Process
Today, claims are mostly sent electronically. Even claims that are mailed are entered into a computer at some point. Everything about your patients’ conditions and treatment is summed up in a few codes. Your computer talks to the insurance payer’s computer. Offices must know that a processed and paid claim does not mean that you are in the clear. Many payers track patterns in submitted claims. When you are an outlier in the way you bill or code, that is when you will receive an audit letter requesting records. Audits tend to start out small with only a handful of patients or dates of service being requested. You must act quickly because you don’t get much much time to respond. Find out exactly which records are requested and get them sent in. Then prepare to wait. Because the insurance company has a financial incentive to find errors, it will take its time to scrutinize every detail. Sometimes the documentation helps tie up the loose ends that were not apparent from the claim form and the insurance company will pay the claim. On the other hand, if they find errors in a few claims, odds are there are errors in other patients’ files as well. The payer may just keep expanding the audit until they have recouped all of the payments they can. They may also create a formula that is applied to all the claims you have submitted to the insurance company or Medicare over the last couple of years to determine what you owe. An audit is not something to take lightly and ignoring it can be even worse since you are automatically telling them you don’t have the documentation to support your claims.
Common Audit Red Flags and Triggers
Here are a few items to scrutinize in your billing and documentation to ensure you aren’t directing any negative attention to your practice:
- One Size Fits All Care: A chiropractic office is not meant to look like a factory assembly line. Treatment plans should be individualized for patients based on a number of factors including their presenting symptoms, health history, and their response to treatment. If the patient’s treatment looks the same on Day 1 as it does on Day 100, or if most of your patients get the same adjustments and exercises regardless if they are coming in for a neck or low back complaint, chances are you will be asked by the payer to defend your treatment protocols.
- New Date, Same Old Complaint: Box 14 of the 1500 claim form is the date that treatment started. While it looks bad if the date in Box 14 is a few years old, it is just as bad to keep changing the date when it is not actually a new condition. Consider whether or not the patient might actually be in the maintenance phase of their care and if billing is still appropriate.
- Upcoding or Down Coding: It is important to learn what the medical necessity definition is for the various payers you work with. Not every full spine adjustment is worthy of billing a 98942. This would mean that the patient came in with a complaint in all five spinal regions! If 98942 is being billed out more than 5-10% of the time, consider if it is being overutilized. Likewise, it would be unusual to see an office that exclusively bills 98940. This might appear that the office is purposely down coding services to avoid charging the patient for the full service that was provided.
- Incorrect Use of Muscle Therapy Codes: Manual Therapy and Massage are not always medically necessary, and they may not be reimbursed according to the payer policies. Many payers state that massage must be performed by a chiropractor to be considered for payment and will not cover it if done by a licensed massage therapist. Improperly billing these services under the doctor’s license is insurance fraud. Massage (97124) is not interchangeable with manual therapy (97140) either. Massage therapy includes techniques such as effleurage, petrissage and/or tapotement. Manual therapy, on the other hand, involves manual mobilization, trigger point therapy, or myofascial release. Be aware of payer policies that do not permit muscle therapy to be performed in the same region as a manipulation. Report the muscle therapy code with a -59 or -XS modifier to indicate that the service was done in a different region of the body than what was adjusted.
The Best Defense is to Look Yourself!
Avoiding red flags in your claims and documentation can keep you off the insurance company’s radar. Doctors and staff in every practice must train in proper billing and coding procedures. Regular internal documentation, coding, and billing audits help catch errors and allow for correction and focused training. Make sure your documentation supports the services that you are billing so the patients’ charts tell their whole story. Keeping your office compliant will give you peace of mind knowing that you are doing everything you can to keep your chances of being audited to a minimum.
Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and enjoyed practicing for over 20 years. Her interest in Medical Compliance began when she earned the 100-hour Insurance Consultant/Peer Review certification from Logan University in 2015. She has been a certified Medical Compliance Specialist-Physician since 2016 and a Certified Professional Medical Auditor since 2022. Dr. Auchenbach joined the excellent team at KMC University as a Specialist in 2020, and as a part of this dedicated team is determined to bring you accurate, current, and reliable information. You may reach her by email through info@kmcuniversity or by calling (855) 832-6562.