Medical Billing Forum

Billing => Billing => Topic started by: drpractor on February 17, 2012, 09:35:54 AM

Title: Chiropractic CMS/Medicare audits 98941
Post by: drpractor on February 17, 2012, 09:35:54 AM
Hello, I am writing from a chiropractic office in upstate Ny. The reason for my post is that we have recently received approximately 30 requests for medical records from CMS for cpt code 98941. For every request, we sent a copy of the signed S.O.A.P. note, intake forms and any other information that we felt was relavent for the information requested. On every single claim that they requested medical records for, they ended up denying payment stating that the services were not medically necessary. Upon receiving the initial denials, we tried calling Medicare to see what exactly we were lacking in either our documentation or our billing/actual claim and were given no answers or any information. We were told that they would escalate our request for information and we should be able to talk to someone within 90 (or 45 can't remember) days. Well, haven't heard anything yet.. who knows if we ever will..

I suppose my overall question is, can you help explain to us what information deems a service medically necessary? Perhaps we would be able to fax you what we submitted (of course blacking out the PHI)?? We're feeling a sense of confusion because they keep denying all claims (currently we've lost 2,000$  :-\ and being a tiny practice, that hurts!) and in the end, I think we're all striving to reach the compliance that Medicare is seeking..

Also, if this would fall under a consultation fee, or the information is in your book, let us know. We are definitely at the point of any help would be well worth the price!

thank you!!

Title: Re: Chiropractic CMS/Medicare audits 98941
Post by: DMK on February 17, 2012, 11:18:23 AM
We've been through this many times and have only NOT been paid on one claim.

#1 If your area has LCD's there is a stringent guideline for what is medically necessary.  You arrange your DX codes EXACTLY as they instruct or it will not be deemed necessary. 
      Example for our area  #1 Code is the area of MOST concern L/S 739.3
                                      #2 Code is what's affecting #1 (847.2 Sprain/strain OR 723.0 Stenosis L/S OR ...)
                                      #3 T/S 739.2
                                      #4 C/S 739.1

So you have 3 areas affected, noting the one of greatest concern with the condition.  If you don't code 3 areas, you can't get paid for 3 areas.  And if you don't code per your local LCD you won't get paid.  Be sure also to list your levels (T1, C7, L5 example) in box 19.

When they ask for records TRANSCRIBE if they are handwritten and make sure the provider SIGNS the notes.  If there is an x-ray or MRI to support the dx, send it.

Also BE SURE THE CPT INCLUDES THE RIGHT MODIFIER     "AT" for active treatment.  Supportive or maintenance care is NOT medically necessary. 

Also be sure the provider understands that ONLY spine care is covered, not cancer, not diabetes, not carpal tunnel.  Regardless of the type of chiropractor they are (straight, mixer, subluxation only, upper cervical etc) they have to bill the way Medicare wants if they want to get paid.

I hope this helps.
Title: Re: Chiropractic CMS/Medicare audits 98941
Post by: PMRNC on February 17, 2012, 01:44:35 PM
Another thing to note is never to expect ANY carrier to tell you what is or isn't in your notes/documentation keeping you from reimbursement, that's for obvious reasons. 
Title: Re: Chiropractic CMS/Medicare audits 98941
Post by: Michele on February 20, 2012, 06:42:31 AM
Last year Medicare did a "pre-edit audit" on all chiropractic claims.  In the audit, all notes were requested for any chiropractic visits, 98940, 98941, 98942.  As a result of that audit Medicare determined that the 98941 code was mis-used over 85% of the time.  So, now they are requesting medical documentation on all 98941's and some 98940's.  There are many dc's that do the entire spine every time a patient comes in.  Under Medicare guidelines, they only pay for manipulation of the spine if it is due to an acute situation.  They consider any thing else maintenance which is not covered.  Even if the dr feels that the patient needs it and it helps the pt, etc etc, it is not a covered Medicare expense.  (Please don't take my answer the wrong way, I believe that many Medicare patients are kept active and functioning due to chiropractic treatments.) 

I cannot tell you specifically what needs to be included in the patient's notes but I can say that generally they are looking in the notes to see how many regions are documented as being treated AND if that documentation shows an acute situation.  They are looking to see if the documentation indicates that it was maintenance treatment or acute flare up, etc.  And the info that DMK gave is also true, dx's must be valid and AT modifier to indicate acute.

What I have often seen is a DC using a 98941 (3-4 regions) but only indicating 1-2 regions in their dx's.  For example, 98941 w/dx's 739.3 & 722.52.  Only one region indicated in dx's but 3-4 treated?? 
Title: Re: Chiropractic CMS/Medicare audits 98941
Post by: DMK on February 21, 2012, 10:35:19 AM
Absolutely correct Michele.  There are a lot of activator method Chiropractors that will bill a 98942 because they are running the activator over many, many areas.  The dx still has to reflect what was done.  If you only have a low back diagnosis, you only get a 98940 (CMT 1-2 areas).

Chiropractors out there have to do a MUCH better job at documenting and diagnosing or eventually they will be pushed out of Medicare.  And it took so long to get included, that would be a shame. 
Title: Re: Chiropractic CMS/Medicare audits 98941
Post by: spinalhealth on March 13, 2012, 03:06:11 PM
ok....i have a question regarding this as well.....

we are receiving a TON of audit requests on a daily basis for every single patient we bill to medicare for 98940, 98941, 98942 (mainly 98941) --- our LCD for medicare only has 6 dx codes "approved" for medicare (739.0, 739.1, 739.2, 739.3, 739.4, 739.5, 739.6) -- i've checked several of the patients we've received audit requests on and one of those dx codes IS the primary dx here's my we need to NOT put any another dx codes in the 2nd, 3rd and 4th spots?  is that or could that be a reason medicare is doing this.......or is it just medicare being medicare?

any answers are greatly appreciated !!

thanks -
jen :)
Title: Re: Chiropractic CMS/Medicare audits 98941
Post by: DMK on March 14, 2012, 10:37:28 AM
The #1 thing I would look at is this:  Your 1st dx code should reflect the MAJOR complaint area of the patient.  If they say "My low back is killing me...." your 1st dx should be 739.3 or 739.4. The 2nd code should be WHY the low back hurts (ie; sprain/strain, lumbago,  disc disorder etc.) then the 3rd code would be 739.2 (if their mid back was adjusted too) etc.  If you have a study showing WHY their low back hurts (x-ray report, MRI etc.) include that with their notes (regardless of the date of study).  Don't put 739.3 then 3 dx codes for why the low back hurts then the rest of the 739.X codes.  They won't show up on the claim, and you can't get paid for a 98941 without 3-4 region diagnoses.

Don't forget the AT modifier.  It must be there or you will not get paid.  Medicare only allows ACTIVE TREATMENT not supportive care.

It's a pain, but the audits will go on in different areas around the country until they weed out the docs that won't comply.  Since the Northern California audit a few years back, I haven't had another one.  KNOCK ON WOOD!

Next, are your notes legible?  If they're handwritten, or in "Chiroglyphics", Medicare will deny.  The doctor needs to take the time or have staff TYPE the notes.  The notes should be in SOAP form or PART form.  Period. Not a travel card, not a check box system.  SOAP or PART.  The levels of the spine that were adjusted should be noted in the notes and on line 19.

I can't stress strongly enough how important it is to respond to the audits.  They will not get paid if you don't respond TIMELY.  And APPEAL if you've followed the rules and have documented and they are still denying. 

The MOST important thing is that there are diagnoses that WILL NOT GET PAID.  That's why you must read the LCD's.  They will tell you how to code to get paid. 
Title: Re: Chiropractic CMS/Medicare audits 98941
Post by: spinalhealth on March 15, 2012, 11:51:43 AM
Thank y'all so much for the info.  I had a feeling that medicare was doing audits on ALL of our 98941's we billed because it's ridiculous how many requests we're getting from Medicare on a weekly basis -- it's crazy !  We're sending everything we can, hopefully we'll start seeing payment from Medicare soon.
Title: Re: Chiropractic CMS/Medicare audits 98941
Post by: DMK on March 15, 2012, 12:41:57 PM
We had over 50% of our bills audited during the Northern California sweep.  Many Chiros in our area stopped taking Medicare, or started billing the patients if Medicare denied (I don't think they can do that if the care is denied, but it's their business, I guess.). 

I continue to work really hard to do the correct things for Medicare billing because I would truly hate to have Chiropractic carved out of Medicare.  It keeps our seniors going without pills or surgery.  And many times the Chiro finds something more serious EARLY, and it gets taken care of sooner, costing Medicare much less money in the long run. 

So keep your chin up, and understand you're not getting picked on, the whole section of care is getting looked at.

Title: Re: Chiropractic CMS/Medicare audits 98941
Post by: PMRNC on March 15, 2012, 04:56:40 PM
And that my friends is why I don't do chiropractic. I worked at a few major carriers in fraud unit and I can tell you some stories, about 75% of the private practice fraud came from chiropractors. 
Title: Re: Chiropractic CMS/Medicare audits 98941
Post by: DMK on March 16, 2012, 10:36:55 AM
Sad, but true.  And there are seminars out there every weekend teaching them how to scam the system.  Whether they think it's scamming or not.
Title: Re: Chiropractic CMS/Medicare audits 98941
Post by: PMRNC on March 16, 2012, 11:54:50 AM
Then people wonder why their insurance coverage stinks when it comes to chiropractic services.   ???