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Chiropractic CMS/Medicare audits 98941

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drpractor:
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!!

-Megan

DMK:
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.

PMRNC:
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. 

Michele:
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?? 

DMK:
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. 

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