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Chiropractic CMS/Medicare audits 98941

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spinalhealth:
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 code........now here's my question.....do 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 :)

DMK:
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. 

spinalhealth:
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.

DMK:
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.

PMRNC:
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. 

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