Archive for the ‘chiropractic coding’ Category

Random Thoughts Episode #136: Chiropractic Audits, Business Building & Success

by Tom Necela on July 20th, 2010 in Audits, Billing, Business, Chiropractic Audits, Coding, Collections, Documentation, Medicare, chiropractic billing, chiropractic business, chiropractic coding, chiropractic collections, chiropractic documentation, compliance

Reading time: 5 – 8 minutes

I’m on the road for the next couple weeks traveling for a number of on-site consultations with clients so this blog post will be a summary of random thoughts on the most common questions that repeatedly brought to my e-mail inbox.

1)  Chiropractic Audits: a few months ago I received a lovely piece of hate mail to accuse me of trying to disproportionately scare well intentioned, upstanding chiropractors in regards to the possibility of an audit. My latest “tweet” included a post to the most recent findings from Medicare reviews for the states of Nevada and Hawaii.  In those two states, chiropractic documentation failed to meet requirements 60 to 70% of the time.  Similar posts from other review results in the past were even higher than that and OIG reports even higher still.

I might not be the greatest mathematician, but it seems to me that the majority of chiropractors are not scared enough!  If 60%+ of chiropractic documentation is substandard, that means most of you are in trouble or headed down the wrong road. It’s not a great picture for me either.  There are roughly 50,000 chiropractors in the United States, so that it would be physically impossible for me to help roughly 30,000 of you get your documentation in order, teach you proper billing and coding, or come to your assistance in the case of an audit.  I wish that I would live long enough to be able to help, but with those numbers, some of you are just going to have to suffer the consequences.

For those of you who think slightly more highly of me or take the potential of audits more seriously, now is the time to take action. It is obvious to all that audits are a big business for not only cash-starved government entities like Medicare, but also for insurance companies looking to expand profits by taking your money back.  The audit numbers and amounts recovered in post-payment demands are so large that they are virtually beyond comprehension for the average chiropractor.

Since I don’t know most of you personally nor do I care to manipulate the facts to scare you, let me just share a few recent scenarios that came by my desk.

Chiropractic Audit case #1:  Medicare audit, six patient, 94% error rate determined; post-payment demands made for 18 months (legal limit for that state).   Total bill amounts to only a little over $2000.  Big pain in the patootie is that this doc failed a previous audit and now has to submit all claims for “pre-payment review” which means that Medicare doesn’t pay him a dime until they receive and approve all notes and every treatment.

Chiropractic Audit case #2:  Auto insurance carrier, handful of patients who were treated for the last 3 yrs on claim (bad state, no limitations statute).  Total repayment demand is approx $56,000. Legal expenses totalled $8000 so far.  Doctor may also face civil fines.

Chiropractic Audit case #3: Commercial insurance.  Re-payment demands made by insurance company after extrapolation (process of configuring an error rate to apply across the board).  Demand total was close to $95,000.  Insurance in error on reviews in some instances and doctor’s repayment will be significantly less, but she will still have to re-pay. Doctor will likely be kicked off insurance provider list as well. Legal fees approximately $17,000.

Maybe this is all chump change to you and you have a life of leisure that can afford the time and hassle it takes to wrestle with the insurance companies, hire attorneys and formulate your audit defense. The rest of you, take note.

2)  Business Building:  Don’t chase your customers or patients. Find out where they are going and get yourself or your information in front of them.  This simple advice (not mine but I can’t remember who I heard it from) is full of wisdom and potential applications.  For example, people who are sick or hurting often go to the medical doctor.  How can you get the MD to route them toward your office?  Most people work.  Which of your patients has a position in human resources or is the owner of a small business with a fair number of employees?  Rather than try to come up with some fancy high-powered presentation that you will likely work on for the next four years until you’ve whittled it to perfection, why don’t you just approach people who already know and trust you as patients and see if they can help you make inroads into their company?  People surf the Internet. First off, that means you need to have a website too.  While the chances of catching random visitors that become patients are slim, but you can stack the deck and give them a reason to come to your site by writing articles, posting videos, and providing other informative content for your community.

Obviously if you are busy enough, you may not need to employ any or even all of these strategies. But for the rest of you, instead of spending time surfing the net do something tangible to improve your web presence. Rather than whining that referrals are down, take a concrete step towards leveraging your patient relationships to increase your referrals on your patience. Instead of sitting in your office hoping patients will come to you, reach out to where they are and bring them in.

3)  Success.  Keep in mind that your business should be there to serve you and not vice versa. I’ve run into too many chiropractors whose primary purpose seems to be providing jobs for their employees. Worse, I’ve seen too more “successful” chiropractors whose drive to succeed left their spouses, children, health and sanity by the side of the road.  A few fortunate ones can come back and retrieve it. But for many once these items are lost, they are gone forever.  Take a day off and go play while the weather is nice.  Spend the afternoon with your children, the evening with your spouse.  Your bank account may not look immediately better for it, but in the long run it is cheaper to stay married, stay healthy, stay sane and not have to pay for years of therapy for your screwed up kids!

As for me, I intend to practice what I preach both working and playing.  If you have an Audit or business issue to discuss, feel free to drop me an email. That’s the beauty of the internet, it can be checked anywhere.  On the other hand, if you see a bald man not acting his age on a wakeboard at a lake near you, it just might be me :-)

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Selling Chiropractic Products and Billing Insurance

by Tom Necela on July 13th, 2010 in Billing, Coding, Collections, chiropractic billing, chiropractic coding, chiropractic collections, chiropractic practice management

Reading time: 2 – 4 minutes

Many chiropractors have realized the benefits of offering products for sale to our patients.  Whether it’s the convenience factor for the patient, our ability to control quality or brand use, or the fact that we want to be able to help our patient’s outcomes, products make sense.

Unfortunately, some chiropractors have a difficulty in making the sale of products make financial sense.

Worse, if you are the type of DC to stock your office with every “hot” new product that catches your fancy, only to quickly lose interest in it a few weeks later, product inventory and sales can become a financial drain on your profitability.

Furthermore, some chiropractors to fail to tap into the full potential of product sales, particularly those that fall into the category of Durable Medical Equipment (DME).

While most insurance companies do not provide coverage for patients to purchase nutritional supplies, analgesic gels and other OTC topicals, many insurance companies do reimburse DME.  In other words, that cervical pillow or that lumbar back brace you just sold your patient may have been covered by their insurance benefits, if you correctly billed for this supply.

If this is old news to you, that’s a good thing!  If not, you should begin checking out your patient’s DME benefits when verifying their coverage to see if their insurance covers such items.  A quick glance through ChiroCode or other coding resources will give you some common HCPCS codes used for such supplies. Note:  the bed of nails is not a recommended supply or product and does not have a HCPCS code :-)

Finally, some of you who have been doing this a while may have noticed an “extra” hoop lately that insurance companies are requiring before processing payment.  In other words, your claims may be rejected or delayed due to missing modifiers in connecting with your billed HCPCS code.

If this happens to you, the three basic modifiers most insurance companies are looking for are as follows:

  • RR Rental
  • NU Purchase of new equipment
  • UE Purchase of used equipment

In most cases, chiropractors will sell their patients a new product, in which the appropriate modifier attached to that product’s HCPCS code would be –NU.   But, if you rent or sell used equipment, you should report the –RR or –UE modifiers, respectively.

From the email inquiries I have been getting about how to get paid for DME, this should clear up the basic problems I see many chiropractors facing.  If you want the “advanced” course, you will have to check out one of my seminars this fall – the new schedule and full details are coming soon!

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The Best of…Strategic Chiropractor Blog Flashbacks

by Tom Necela on May 10th, 2010 in Audits, Billing, Business, Chiropractic Audits, Coding, Collections, Documentation, HIPAA, Medicare, Medicare ABN, OIG Report, Politics, chiropractic billing, chiropractic business, chiropractic coding, chiropractic collections, chiropractic documentation, chiropractic practice management, compliance

Reading time: 1 – 2 minutes

flashback

In business and in life, it is helpful to go back and review the basics, to take a look at where you’ve been and where you want to go.

Today’s blog post feature’s 3 links to our most popular columns of the past – in case you missed them – or in case you need “a refresher course.”  (pardon the Fletch reference)

Here they are (in no apparent order):

Enjoy!

Tom Necela, DC, CPC, CPMA

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Medicare Releases Chiropractic Medical Review Findings for the 1st Quarter

by Tom Necela on April 6th, 2010 in Audits, Chiropractic Audits, Coding, Documentation, EHR / EMR, Medicare, chiropractic EHR, chiropractic EMR, chiropractic coding, chiropractic documentation

Reading time: 4 – 6 minutes

detective

Recently, a Medicare carrier (Palmetto GBA) released their 1st Quarter results of Medical Reviews they have been conducting.  Even though Palmetto is only one of several carriers who administer claims on behalf of Medicare, their findings are relevant to chiropractors and, in my experience, reflective of trends across the chiropractic profession at large.

The goal of the medical review program is to reduce payment errors by identifying and addressing documentation and billing errors concerning coverage and coding. In their reviews, Palmetto GBA identified ten problem areas for the first quarter of 2010. These areas were as follows:

  1. Split/shared visits
  2. Signatures
  3. Labels/Diagnostic Testing
  4. Hospital & Nursing Facility Discharge Services
  5. Chiropractic Services
  6. Therapy Services
  7. Individual Psychotherapy Services
  8. Evaluation & Management Services
  9. Legibility

10.  Teaching Physician Services.

Please note this is not an all-inclusive list but does reflect the majority of documentation issues discovered during the review process.  Of this list, however, three items have direct application to chiropractic reimbursements in the Medicare program.

So let’s discuss these three “Frequently committed errors”:

  1. Signatures.  Put simply, Medicare requires an “identifier” for services provided or ordered.  That identifier is your signature – either in handwritten or electronic form.  Signature stamps in your documentation are not acceptable per Medicare Signaure Requirements (See section 3.4.1.1 B) Quite frankly, this is so basic that it is ridiculous that it even makes the top ten. Apparently, despite its simplicity, most physicians seem to overlook it.
  1. Chiropractic Services.  As a relatively small profession, we should not even make the top ten hit list.  We did, however, so now it is our responsibility to correct these problems asap as a profession.  Palmetto found chiropractic documentation to be lacking in the area of Treatment Plans.  More precisely, chiropractors were missing treatment plans with specific objective, measurable treatment goals. Follow thru with these specific objective treatment goals on subsequent visits was also often omitted.  Difficult?  Not very.  Documented?  Apparently, not very often.  Can you fix this, doctor?  Definitely!
  1. Legibility.  If this is not the biggest commercial for EMR, I don’t know what is!  Again, there is no reason any physician should be getting dinged for this one.  Alas, I have seen many of your notes and I sadly agree, that they are barely legible, sometimes only to the highly trained eye (yours and that of your longstanding staff) – and sometimes, even you cannot decipher your own notes.  Put simply, if your notes cannot unquestionably be read by a third-party without eliciting a migraine or use of some special telescopic lens, it is high time to get on EMR.  There are plenty of good systems out there.  In fact, ANY system that produces legible documentation is better than marginal handwriting – and I have yet to see an EMR system that fails to product legible documentation!

In summary, we chiropractors need to get our act together pronto – not only for Medicare, but for all third party payers.  The items above are not difficult to fix, but I realize that some of you are overwhelmed by how much work you have to do to bring your documentation, billing and coding up to acceptable standards.  Others may be so consumed with building your business that you literally don’t have time to look up and see the arrow sailing directly at the target on your chest.  And some of you are just plain tired of putting out the fires in all these areas due to a lack of solid systems that both maximize your reimbursements and minimize your audit risk.

The good news is: help is available. And while it is a physical impossibility for me to assist  all of you with these needs let alone answer the truckload of emails I receive per month on chiropractic billing, coding and documentation questions from random chiropractors at large!  But I am willing to offer a FREE, no obligation look under the hood of your practice for those of you willing to invest the time and effort into completing a Practice Analysis Questionnaire.  Download it, complete it, fax it in today and take a concrete step towards improving your practice, your business, your piece of mind and your life.

To Your Success!

Tom Necela, DC, CPC, CPMA

P.S.      Not sure what can be done with YOUR practice?  Take a look at what my clients have to say about the transformations they have achieved in their practice!

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Solutions to Your Chiropractic Billing Problems

by Tom Necela on March 23rd, 2010 in Billing, Business, Chiropractic Seminars, chiropractic billing, chiropractic business, chiropractic coding, chiropractic practice management, chiropractic webinars, seminars

Reading time: 8 – 14 minutes

blind leading blind

Solutions to Your Chiropractic Billing Problems

Warning: this post may be offensive to some (not because of language or explicit matter) but because those who it irritates are probably most in need of hearing it.

The subject matter: your billing department and its problems.

Because I don’t see your statistics here in front of me, I can’t say for sure which problems your chiropractic practice is facing due to your billing department.  But for many of you, I can venture a guess that it is either poor collections, delayed payments, denied claims, labor intensive systems or a combination thereof.

And unlike the glaring problem of not having any new patients, billing challenges tend to dwell suspiciously beneath the surface until one day you notice you are $10K , $20K, $30K or more off your collection goals.  At that point, you are painfully aware that there is a problem and you begin to scramble for a solution.

Flawed from the Start

Many of you will scratch your head and wonder how this happened.  After all, in many (if not, most) chiropractic clinics, the billing person is the most trusted employee of all.  This is because  it is typically the spouse of the doctor who does the billing.  And this person has been handpicked, trained and has a vested interest in the success of the clinic.

While this may be true, let’s analyze that a little closer.

Handpicked? Certainly, because the budget did not permit a person of adequate skill or experience to fill the position and the spouse is willing to work “for a while” until things get off the ground.

Trained?  Ah yes, the billing person is under the careful tutelage of the doctor who received…absolutely zero training on billing or coding in chiropractic college and whose continuing education credits in the matter curiously blend in with advice from would be know-it-all colleagues who are likely just as clueless in this department, however good intentioned they may be.

Truly, this is a case of the blind leading the naked (sorry for the warped 80’s reference).

Vested interest?  This certainly is accurate. The spouse is probably the most motivated employee in the clinic.  I have seen cases where I would even replace the doctor with the spouse, would it be possible.  But the Olympics provide you with an excellent example of why this is not enough.  Every Olympian is obviously motivated enough to win; they would never had made it their without superior powers of motivation.  But in the end, skill prevails.

My Billing Stinks – What Next?

For those of you who did not need the brutal awareness that you have sent your well-meaning spouse to dine with the wolves, you too may be cognizant of the fact that, well, your billing is less than stellar.

Certainly, it is still possible for your billing person to be a slacker, inept or just not quite as effective as they could be or should be – even if they are not related to you and/or may have impressive looking credentials under their belt.

The good news is that (hopefully) you don’t go to bed with this person and are not bound by marital ties.  Because of that, they are much easier to replace, if necessary.

Before You Give Them the Boot…

Regardless of who your billing person is, if you find yourself in a huge mess, or if you would rate your employee as an “F,”  let the first letter of that rating be a clue as to what you should do.

But for everyone else, there is hope.

After all, a good employee can only rise to the level of the training and the expectations they receive.

Unfortunately, doctor, this means YOU need to get to work!

How to Rescue a Poorly Performing Billing Department

The first steps to rescuing your billing department’s deplorable performance is in your hands and here is what I would recommend:

  1. 1. Monitor the Money. If you were to chart your monthly collections and the results look like a roller coaster ride, likely you have internal issues that need fixing fast.  But the only way to figure out where to apply corrective actions is to begin studying your collections, your accounts receivable and your revenue cycles.  For more assistance in this department, see How to Oversee Your Billing Staff & Service.

  1. Provide Your Biller With the Tools & Resources They Need. I haven’t tracked it precisely, but I believe there is a direct correlation between the age of your coding book and the amount of billing problems that exist in your office.  Worse, every practice that I have been that does not even own a coding book, has multiple billing issues which can potentially take months to fix.  Quit sending them to work without a tool box.  Get them the latest ChiroCode book, (see here for a link to FREE SHIPPING on the 2010 ChiroCode book and don’t say I never give anything away free).
  1. Commit to Ongoing Training for Your Billing Person. Have them attend the FREE monthly webinars that ChiroCode offers (as they are full of useful info unlike most other “free” webinars that our profession uses for an hour long sales pitch).  This week on ChiroCode webinars is yours truly.  Join your staff for seminars on billing, coding or documentation.  I have two coming up and I guarantee you will BOTH learn enough useful info that it is well worth the trip regardless of your distance.  Ignorance is costing you more than you realize.
  1. 4. Give the biller realistic job expectations. Some offices want their billing person to double as the world’s most friendly front desk person AND the most tenacious collections bulldog a delinquent patient ever had the misfortune to encounter.  Good luck with that.  Rare is the bird that can sing both of those tunes.  If you have one, hang on tightly.  If not, consider re-defining your staff job descriptions so that each team member can excel at some needed roles in the clinic, but is not required to be a superstar at everything to meet your approval.
  1. 5. Leverage Their Time. Some clinics have a broadly defined definition of billing that encompasses everything and anything to do with money. As a result, the billing person is responsible for: sending claims, posting payments, reconciling accounts receivable, sending statements, verifying insurance, handling patient finances, presenting care plans, over the counter collections, depositing funds into the business bank account and making change for the pizza guy who delivers the staff meeting lunch.  While all of these things may technically revolve around money, it may not be efficient (or cost effective!) for your billing person to handle them, particularly if they are the highest paid employee or if their desk routinely resembles Oscar Madison’s apartment (for those of you old enough to remember The Odd Couple).  Instead, delegate tasks that don’t require billing expertise (running the envelopes for the statements through the postage meter is a favorite time waster that I see too many billers involved in) and let them focus on bringing in the money and higher value activities.

Know When To Fold ‘Em

While I don’t routinely promote Kenny Rogers as a source of wisdom, sometimes you have to just take his advice and “know when to fold ‘em.”  That is, give up the goat and outsource.  Examples:

  • Recently, a doc approached me about opening a new clinic with wife as biller and mom as office manager.  Neither have worked in chiropractic before. Neither have any training.  This is a nightmare waiting to happen.  Why would you want to start your business with your most ignorant foot forward for all the world to see?  They should outsource.
  • A marginal clinic has a poorly trained CA doubling as a billing person manning the ship.  They have no money to hire a decent person, nor can they afford to send the CA for training since she wears all the hats in the clinic. Their practice is spiraling downward since the CA can’t figure out why their collections are in the toilet, mainly because she has no clue where to even start.  My two cents: outsource & pronto!

When To Get Help

There is another option available for those of you who are unwilling to throw in the towel or for those would benefit from guided expertise.  Quite simply, it may be in your best interest get some professional help.

For a free, no obligation look at how I may be able to assist you, complete the Practice Analysis Questionnaire and send it in for my review.

And while you may think that getting professional help can be cost prohibitive, consider some scenarios I encountered while working with my consulting clients who hired me for this purpose.

  • During a recent office consult, I provided a solution for one issue that the billing person (who is excellent at her job) was struggling with.  We analyzed a handful of claims that all were denied due to this problem and unsurfaced approximately $8000 worth of reimbursable services that she will correct and get paid for.  The savings will be further capitalized multiple times over when she applies this same correction to the dozens of other claims with the same situation.
  • Another client (again, with an excellent biller) had repeatedly made one innocent coding mistake to the tune of $60,000 per year in botched income and services.
  • A struggling office was able to increase its billable services from an average of $39 per patient to $64 per patient within 2 months of my consulting, which will yield a $90,000 increase this year – even if they do nothing else!

Bottom line:  billing IS a major factor in your bottom line.  It is too big to ignore and too critical to be left in the hands of an unskilled employee.  Get a handle on your billing and you will be able to steer your practice in the right direction.  Let it go adrift and you will likely sail into dangerous waters.
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How Medicare’s New Consult Code Policy Affects Chiropractors

by Tom Necela on January 20th, 2010 in Medicare, chiropractic billing, chiropractic coding

Reading time: 3 – 5 minutes

pickpocket-intro

For those of you chiropractors who have been following Medicare’s new consult policy that recently went into affect, you may feel like we are yet again victims of another Medicare scheme to pick our pockets of the few reimbursements we do receive.

Recently Medicare removed reimbursement for Consultation Codes (99241-99245) and the impact is being felt across many health disciplines, including chiropractic.  If you are unfamiliar with using Consult Codes, you have likely been missing out on significant income opportunities by documenting your services accurately.

Chiropractors, for the most part, view the consult as the time when we meet with a New Patient, answer a few of their questions and discuss the benefits of chiropractic care prior to actually performing an examination on the patient.  This does NOT in any way meet the CPT definition of a consult code (99241-99245) and should never be billed as such.

On the other hand, a true consult occurs when a patient arrives in your office at the request of another physician.  In other words, the other doctor (an MD, for example, is common) tells the patient to seek your professional opinion or expertise as a chiropractor.  In this type of situation, with proper documentation and conditions met, you can bill a consult code (99241-99245) in place of your normal E/M code and (here’s the reason for their popularity), these codes will pay significantly better than standard E/M codes.

So, if your office receives MD referrals regularly, you have been missing out on a great opportunity to increase your income that, unfortunately, may now be drying up.  For example, a typical billing of 99203 may be $100, whereas the consult equivalent of 99243 may be $150. I know several clinics who have increased reimbursement by thousands of dollars per year over standard E/M fees because of consult codes.

As of January 1, 2010, Medicare has indicated that it will no longer reimburse consult codes.  For DC’s, we may view this is as no big deal since Medicare does not reimburse us for exams anyway.  Unfortunately, since most third party payers and commercial insurance companies (such as BCBS, Aetna, Cigna, etc) use Medicare as a basis for payment decisions, many other insurance companies have stopped paying for consults as well!  And that can be a big deal for us!

Based on this, I would recommend two action steps for you to take:

  1. Contact your large payers to determine if they are still paying consult codes.  If so, keep (or start) using them until further notice.
  2. Eliminate billing consult codes to payers who have indicated that they are denying the code.
  3. Document the consult for either #1 or #2 as it is still important for the legal record, to indicate that the patient was a consult and that you have performed this services upon request from another provider.  You may not be paid but you are still obligated to report the service as rendered.

While many would agree that Medicare’s policies frequently appear to torture chiropractors, this one has far reaching impact that crosses the line towards other payers as well.  But, as mentioned previously, all payers have not yet adopted this new policy so be sure to utilize these codes while you can.

In the meantime,  if new developments about this occur or if similar, new opportunities comes our way, I will be sure to let you know! And for those of you who are wondering if you are missing out on any other items related to billing, coding or documentation that would help you improve your reimburesements, the answer is likely “YES!”  Take some time to fill out a FREE Practice Analysis Questionnaire and I will be glad to discuss how I may be able to specifically assist your clinic in this area, while also protecting you from unecessary audits due to your billing, coding or documentation mistakes!

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