Documentation & Coding Quick Answers

A: Using the SALT feature without making any changes to the record on each individual date can be considered fraudulent record keeping and can put a doctor at risk during an audit or record review. Cloning notes are under close scrutiny as they could be produced without a physician or patient present.

The unique information gathered on each patient visit is what determines whether that visit meets the medical necessity guidelines of a payer. If nothing is noted as being changed from one visit to the next, no progress is noted and care is not supported.

A: Both the doctor and the staff member. The staff member should document each detail of the service, sometimes including clock time in and out, exercises performed or techniques used. The doctor who is supervising the delegated service must countersign the note to indicate the treatment was performed as expected and the patient responded appropriately.

A: The Date of Onset should always be the first date you saw the patient for THIS treatment episode, except in the case of Personal Injury or Workers Compensation Injury which would use the accident date as the Date of Onset.

If the patient was discharged at the end of care the last time you treated him/her for this condition, then there is an obvious stopping point from before, and starting the new treatment episode should be distinct with the new date of onset.

A date of onset over 90 days can be a red flag to an insurance carrier that indicates possible maintenance, wellness, or supportive care. There certainly can be care episodes that last beyond 90 days, but the documentation must be present to support the need for the extended care.

A: CMS expects the documentation to be generated at the time of service or shortly thereafter.

Delayed entries within a reasonable time frame (24 to 48 hours) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service. If changes or new info comes up, you have up to 48 hours to amend the record.

A: These Functional Health Questionnaires/Functional Outcome Assessment Tools (OATs) are useful to substantiate a patient’s functional deficits and gauge the changes throughout care. These tools help to prove medical necessity and show when Maximum Medical Improvement is being reached in relationship to your goals. We highly recommend the use of these tools for every patient under active care.

The use of these Functional Outcome Assessment tools with all insurance carriers is advised as they provide the proof to satisfy the measurable and quantifiable aspects that payors are looking for when trying to determine whether the care was medically necessary as defined by their guidelines. They are a great tool in writing specific and obtainable goals and are very beneficial to the story telling of a phase of care.

You will find that some payors, when seeking authorization for visits, may ask for the scores on these questionnaires to use in their algorithms to approve visits.

A: Medicare’s utilization guidelines for chiropractic services require the following three components in order to establish medical necessity:

Presence of a subluxation that causes a significant neuromusculoskeletal condition. Medicare will not pay for treatment unless it is by manual manipulation of the spine to correct a subluxation. The subluxation must be consistent with the complaint/condition.
Documentation of the Subluxation. A subluxation may be demonstrated by one of two methods: x-ray or physical examination. If documented by physical examination, the PART system must be used.
Documentation of the Initial and Subsequent Visits. Specific documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination.

A: We and Foot Levelers have created a great guide you can download here. Basically, you need to know the medical review policy for functional orthotics of whichever carrier you're billing - usually listed on their website as "orthotics and prosthetics." Then use the verification sheet from the above-mentioned guide to make sure your team asks the right questions. Make sure you've established medical necessity according to the policy for your history, exam, diagnosis, and treatment plan. Use the billing codes listed in the guide - make sure you bill for both sides! Finally, if there's a challenge, refer to the guide for several letters of medical necessity.

A: Currently, there is only a HCPCS code for laser, which is S8948 and it is a time-based, constantly attended code. S8948 is a constant attendance code. It may not necessarily apply if you are placing the laser on a stand and only supervising the service. Sometimes you must use the unlisted modality code depending on the payer, and we suggest 97799.

Keep in mind, regardless of coding, there's no guarantee that the carrier will cover the code. Always be sure that you check each carrier’s review policy for coverage parameters and coding guidelines. Some payers require a signed agreement (could be their own) prior to transitioning financial liability for a service to the patient.

A: The correct way to bill orthotics is by using two lines on the claim form. We recommend that you use either L3020 or L3030, depending on the type you are providing. L3020 is an orthotic that is fitted to a patient mold, while L3030 is fitted directly to the patient. For example, for one set of orthotics, the claim lines would look something like this:

01/15/2015 L3020 RT 1 200.00

01/15/2015 L3020 LT 1 200.00

This would indicate a $400.00 charge for a set of orthotics. This example doesn't include all of the items on the line that need to be filled in, but you get the picture. If you had two pairs of orthotics, each line would have a 2 instead of a 1 for units.

A: Although Medicare requires that a primary subluxation be documented and coded to bill for a spinal manipulation, it may not be a requirement for other payers. It is always best to refer to the payer policies before billing any services.

A: This is where reading the descriptions of codes must be done very carefully! A 98941 is used when the provider is adjusting three or four regions of the spine. Regions are described as Cervical, Thoracic, Lumbar, Sacral, and Pelvic. Adjusting three areas in one region is still billed as a 98940.

A: Yes! Down-coding is a bad idea all around. You should always code what you do with the most appropriate CPT code that describes the care. Down-coding is just as big a red flag as many other poor coding techniques. It's more appropriate to set your fee schedule in a way that is legal and fair, code properly, and get reimbursed fairly for the work you are doing. There are ways to do this right. Maybe you need to use a Discount Medical Plan Organization (DMPO), like ChiroHealthUSA, to set an appropriate fee schedule for uninsured and under-insured patients. The best way to restructure and investigate your fees is by starting with your actual fees, getting those right, then working toward your contracted fees, your discounted fees, and then your hardship policy. You can do this legally and compliantly, and practice with ease (while coding correctly)!

A: 1. Recommended level of care (duration and frequency of visits)
2. What therapies will be performed and the expected number of sessions of each
3.Specific, functional treatment goal for each area of complaint
4. Objective measures to evaluate treatment effectiveness, such as Outcome Assessment Tools (OATS)
5. The date of the beginning of this plan(box 14) and expected end date

A: You wouldn’t use code 97110 (therapeutic exercises) when working with more than one person at a time. For these circumstances, you would bill code 97150 (group therapeutic exercises) once per person, per encounter – with only one unit, as this is not a timed code. The number of minutes you spent with the group isn't relevant for billing this code. Be careful to document the service properly in each patient’s healthcare record, as this code does not describe the services rendered to the payor.

A: These activities are performed one-on-one with the patient. This code represents a distinctly separate and unrelated procedure not considered inclusive of the CMT codes 98940-98943. If these activities are performed with multiple patients at once, the code 97150 would be used for group exercise.

A: These codes can certainly be provided to your patient, billed to an insurance carrier or the patient, without any cause for concern when performed as part of an active treatment episode and properly documented. Each payer may have specific guidelines or exclusions for these codes, but overall these services make up a vital portion of patient care in a chiropractic office, and when done appropriately, can be reimbursed without concern.

A: For paper charts, errors can be corrected by placing a single line through the error and initialing it. Never use white correction fluid/tape, erase, or completely blacken out errors. For both paper and electronic health records, addendums can be added if important information was omitted when the notes were originally written. It will need to be signed and dated indicating the time the correction was made.

A: Medicare considers CPT Code 97010 (hot/cold packs) a ‘bundled’ service. When a service is bundled, it means that the reimbursement for the code is built into or grouped with the reimbursement for another code. In this instance, it means services described by 97010 are not separately billable when rendered to a Medicare patient. It is considered a part of whatever primary service is rendered to the patient, and in the case of chiropractic that will be a CMT code (98940-98942). This is different than a ‘non-covered’ service which can be charged to the patient. A bundled service cannot be charged to the patient as it is being reimbursed within another code’s value.

A: If all of the components of an E/M services were performed the same day as a manipulation, attach the -25 modifier to the E/M CPT code. This indicates that the work value of the E/M far exceeds the basic work of an adjustment. Keep in mind, some payers have decided that they will not pay for both. We recommend that you always appeal those and ask for the written policy that indicates why you can't be paid for both when payment for both is warranted.

A: First, you will need to make sure there is medical necessity established for the region of the body you wish to bill. If that is the case, document the subjective complaint, the objective findings for that region, treatment goals for beginning treatment of that region and functional deficits associated with that region. You will need to add the diagnosis of that body region to both your billing and your SOAP note. You will then need to point the diagnosis in Box 24 to the CPT code 98943 for the body region diagnosis.
ie: Shoulder impingement and upper extremity subluxation would be pointed to the 98943