According to the May 2008 CERT report, the highest paid claims error rate by specialty for South Carolina is Chiropractic at 24.2 percent. The paid claims error rate measures the extent to which the Medicare program is paying claims correctly. To bring this error rate down, here is a tip sheet of the problems we are seeing and what you can do to file accurately. Also, we have included a Billing and Documentation checklist that you might use to review your claims. (Click on the attachment below.)
Medically Unnecessary Services
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What we are seeing…
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What you can do…
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Non-acute conditions that do not meet medical necessity
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Submit a claim only for acute conditions or certain allowed chronic conditions. Note: The AT HCPCS modifier does not automatically justify medical necessity.
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Chronic conditions that do not show reasonable expectation of recovery or improvement of function
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For chronic conditions, submit a claim only for services with reasonable expectation of recovery or improvement of function (not maintenance therapy).
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Services Incorrectly Coded
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What we are seeing…
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What you can do…
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Upcoding: submitting for preventive or maintenance care on areas in excess of the acute-condition regions under active treatment
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Submit only for the regions under active treatment. Preventive or maintenance care for other areas will not be paid. Note: Use the Advance Beneficiary Notice (ABN) for services that Medicare will not reimburse.
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Omission of the GY HCPCS modifier
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If you know that a service will not be reimbursed (statutorily excluded), but the beneficiary insists that you file a claim so that a secondary insurer can authorize payment, you can use the GY HCPCS modifier to trigger an intentional denial.
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Appeals
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What we are seeing…
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What you can do…
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Notes for just the appealed date are insufficient to get the total picture
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Send in enough information to show the: patient's condition, effectiveness of treatment, and medical necessity of continued chiropractic visits (as well as frequency), records for other dates of service, and treatment plan. If these are in the notes for the initial visit, send those in at the same time – total picture!
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Hand-written notes that are not legible
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Strive for documentation legibility.
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Insufficient documentation
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What we are seeing…
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What you can do…
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Patient’s name not found on each page of the documentation
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Be sure to include the patient’s name on each page of documentation, as some documentation can be many pages long.
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Physician signature missing or illegible for each date of service and/or the service
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Strive for legible signatures and include a signature (whether hand-written or electronic) for each patient encounter.
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Actual treatments not documented
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Document the actual treatments performed, e.g., which regions were manipulated.
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Missing medical necessity for the treatment of an acute condition
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Document medical necessity for the treatment of an acute condition, e.g., the mechanism of trauma (car accident or a fall).
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Lacking measurable goals and time period for improvement during initial visit
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Define measurable goals and the time period for improvement during the initial visit.
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Subsequent visits lacking key items of the: history, physical exam, and documentation of treatment
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For history, include: a review of the chief complaint, changes since the last visit, and a system review (if relevant). For the physical exam, include: an exam of the area of the spine involved in the diagnosis, assessment of change in patient condition since last visit, and evaluation of treatment effectiveness. Lastly, include documentation of treatment.
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Lacking progress toward goals in subsequent visits
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Document progress toward goals in the subsequent visit(s).
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