Archive for the ‘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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What Exactly is “Defensible” Chiropractic Billing, Coding & Documentation?

by Tom Necela on January 5th, 2010 in Audits, Billing, Coding, Documentation, compliance

Reading time: 5 – 8 minutes

steal-this-bike

There has been a lot of talk and a lot of panic surrounding the ideas of “compliant” billing, coding or documentation in the chiropractic practice.

Most of you who have read my blog or attended my seminars are well aware of our poor performance as a profession in this arena and the backlash that has ensued in terms of post payment audits, claim denials or payment delays.

Following a recent column of mine in Dynamic Chiropractic (Insider Secrets About Postpayment or Recovery Audits), I received a wave of requests for templates that create “bullet proof” documentation every time.  Similarly, I get more questions than I can physically answer from random chiropractors wanting to know if certain procedures they utilize fit the definition of a specific CPT code.  Finally, either before (or in some cases, after) an audit, many DC’s (and even professional billers) have emailed me asking if a certain methods of billing are legit.

Most of these questions come from hard working, well meaning and nice chiropractors who are probably a lot like you in the most basic sense. Some are from worried DC’s who are on the verge of audits.  Many are from individuals irritated or angry with the system that we play within which changes rules and requirements arbitrarily and seemingly without much notice.

In a number of different ways, all of these questions revolve around the same issue: how can I create a “defensible” system for what I do on a daily basis?

While this is an excellent question, there is no simple answer. First, let me dispel a few myths, then allow me to explain my lack of cookie cutter response.

Audits Don’t Presume Guilt Nor Innocence

Let’s be clear on one thing: Just because someone requests your notes does not automatically mean you have done something wrong.  It may be a sign of some questionable practices on your part, or it may just be your random luck of the draw.  Don’t take it personally, unless there is a pattern that emerges that you need to fix.

Even if a payer suggests that your practice patterns are outside industry norms, regional averages or plan parameters, it STILL does not mean you are a bad egg.  However, it generally will mean that you have to justify why you act, look or treat differently than others.

Finally, while the above scenarios are certainly true, do not for one moment believe that you operate “above the law.”  Statistically speaking, as a chiropractor, you create a mess that stinks just like many of our colleagues.  And if third party payers persistently or frequently request your notes, delay your billings or force you to argue over the care you rendered, there is a good chance your mess needs some cleaning up before the stink sabotages your clinic or before you no longer have a business that you refer to as your practice.  License plate manufacturing does not look good on a chiropractor’s resume.

Why Some DC’s SHOULD Be Scared

While this may sound like unnecessary scare tactics to some of you, let me remind you that I have seen enough chiropractic documentation to know that there is a significant portion of you who SHOULD be very scared!   Here’s why:

1) There are few of you who have taken adequate steps to protect yourselves from audits.  I have met no chiropractic equivalents of the above bicycle owner, who is obviously well-protected, if a bit paranoid.

2)  If you repeatedly asked me to give you $50,000 per year and I was generous (or dumb enough) to give it to you with hardly any questions as to what, where, or why you needed the money…how long do you think this scenario would go on before I started asking some questions about the perennial need for this funding?

While this may sound like a strange question, how is it much different than many insurance scenarios?

Sure we provide a service to our patients.  But if we don’t adequately communicate what we did in that service to deserve payment (via our billing, coding or documentation) why would or should the insurance company keep paying us?

Furthermore, why wouldn’t the insurance company want to take some of that money back if we didn’t provide them with an adequate “receipt” (again, in the form of our billing, coding and documentation) for our services?

When you put things in this perspective, it is not too surprising that third party payers are auditing doctors of all types.  Sure they already are making tons of money and probably don’t need the extra dough they are squeezing out of the hard working docs but…they can, so they will.

Creating a Defensible Plan

Our job, then, is to reduce the impact of insurance profiteering on our practices.  We do this by adhering to proper standards of billing, coding or documentation.  By creating a record of what we did and why we did it.  And by learning and staying up-to-date with the rules so that we can keep our noses clean.

This is how you create defensible documentation, coding or billing.  Those interested in learning, I look forward to bringing you more of this information via my blog, webinars and seminars in 2010.  Those who are well aware that they need this information customized to their specific practice needs and requirements , you would do well to have me take a look “under the hood of your practice.”  The first step is to complete a FREE, no obligation Practice Analysis Questionnaire.

Best wishes for a successful 2010!

Tom

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Chiropractic Billing Ignorance or Fraud? Inconceivable!

by Tom Necela on December 29th, 2009 in Audits, Billing, Business, Coding, Documentation, Politics, compliance

Reading time: 5 – 8 minutes

inconceivable

“You keep using that word,” Inigo Montoya says to Vizzini in the cult-classic comedy The Princess Bride. “I do not think it means what you think it means.” The word that Vizzini so frequently misuses in the film is inconceivable. Unfortunately, it’s a term that seems to be floating around in the heads of too many chiropractors as well.   As we near 2010, many chiropractors are now painfully aware that their coding and billing activities are being scrutinized more closely than ever before.

(Inconceivable? Read on…)

If you have been following recent legislative developments, you will have noted increasing overpayment recovery efforts by Medicare and its contractors. The current administration has declared that health care fraud enforcement will be a top white-collar crime priority for the Department of Justice (DOJ) and the various investigative agencies. Moreover, additional funding to fight health care fraud has recently been proposed in the Senate. Senator Ted Kaufman (D-DE) has sponsored the Health Care Fraud Enforcement Act of 2009, which, in addition to increasing the criminal penalties for health care fraud, allocates an additional $20 Million per year for health care fraud detection and investigation.

($20 Million extra for fraud detection?  Inconceivable!)

While universal health care coverage may remain controversial, there is widespread support for additional legislation aimed at reducing health care fraud. This is not an attack on chiropractic per se (that would be inconceivable!) — these guys are going after every health profession at large!

Though I hesitate to get involved in all manners of political wrangling, there are some major issues creeping our way which can vastly affect our profession of chiropractic.  We need to be aware of these not only on a profession-wide political level, but also in terms of how they affect our everyday practice.

If you haven’t already heard, here’s what’s coming unless someone puts a stop to it:

  • Requiring that the U.S. Sentencing Commission amend the Federal Sentencing Guidelines to redefine the term “health care fraud offense” to include all health care crimes, regardless of where they are codified. Notably, it would also increase the offense score associated with health care fraud offenses, considerably increasing the length of any sentence handed down by the Court;
  • Making it clear that all payments made in connection with illegal kickbacks constitute “false claims” under the False Claims Act; and
  • Clarifying that it is not necessary that a defendant be aware that their conduct violates a specific provision of criminal law in order for them to be held accountable for their actions. Instead, a person would be guilty of a health care fraud offence if he (or she) knowingly does what the law forbids.  (Inconceivable!)

That last proposed provision in Senator Kaufman’s bill should scare the bejeebees out of all small physician practices, including (and perhaps) especially chiropractors. Here’s why:

Unlike the big entity hospitals who have a fleet of attorneys to defend their every move, this provision puts the small timer at a big mechanical disadvantage.

To make matters worse, we have another problem related to the meaning of the word fraud.  For many physicians, Inigo Montoya’s clarification is again applicable:  “I do not think that it [ in this case, the word fraud] means what you think it means.”

For many of us, we have heard lawyers argue that the fine line between what constitutes fraud and good old fashioned red blooded ignorance (oops I made a mistake) is intent.

This definition makes sense to me, as a non-lawyer type.  If I repeatedly conduct my business or an aspect of it (say documentation, billing or coding) in a way that is deemed illegal, substandard or just plain wrong and despite my knowing better, I continue to do so for financial gain, this seems like a reasonable definition of fraud.  On the other hand, if I don’t really know what I am doing, I may be wrong but it is out of ignorance not bad intentions.  Consequently, the ignorant (but well meaning) doctor who is reprimanded, fined or otherwise correct then proves that his intent was always good by doing one thing:  he corrects his actions.

Again, I am not an attorney, but if this provision passes through, I believe it sounds like the word fraud may not mean what we think it means.  Or at the least, the lines of intent will be sufficiently blurred to be inconsequential. It won’t matter whether you acted honestly but erroneously; you will still be guilty of health care fraud.

The Bottom line: I see a few action steps here:

1. Now, more than ever, is the time to support your local (state) AND national association to help fight these battles on our behalf!  No excuses.  Most state or national memberships will cost you the equivalent of one adjustment per month to join.  Membership in both will run you two whole adjustments per month.  The safety of your livelihood is certainly worth that much regardless of your political persuasions, philosophical differences or nitpicking with their ability to fulfill your agenda.  Get over it and support these associations now!

2. Training in compliant billing, coding, documentation should be a priority for both doctor and staff. The only way you can adequately defend yourself, prevent fraud and screen for errors is to know what you are looking for.  Unfortunately, chiropractors are either woefully inadequate at detecting their own problems or unwilling to address the issues.  Both can have devastating effects on your practice and the profession.

3. Encourage each other to rise to a higher level. Many states are requiring billing, coding or documentation education as a part of their CE requirements. State Boards need to be proactive in teaching doctors on how to comply with the requirements of their state before the docs get in trouble. Unfortunately, I have seen many docs disciplined for things that are “grey areas” such as exam documentation, SOAP note requirements, cash or TOS discounts, etc.  If we fail to meet local standards, it’s practically a sure bet that we will fail nationally as well. So we need to go to our state Boards and associations with our challenges and work to find solutions so they don’t become national problems on public display.

Certainly, I am not proclaiming that better billing, coding and documentation will solve all our chiropractic problems (that would be inconceivable!) but a lack of proper systems in these areas will definitely put us at risk for failure in a variety of different forms.

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Changing with the Times in Chiropractic

by Tom Necela on December 22nd, 2009 in Billing, Business, Coding, Collections, chiropractic practice management

Reading time: 7 – 12 minutes

Changes_next_exit

Although some pundits have declared that the worst of the recession is over, I know that some offices are seeing the pinch of the slow economy and/or the holiday season on their patient’s finances.  And while it may be true that you cannot get “blood from a stone,” don’t take comfort in all the talk of economic doom and gloom by leading yourself to believe that everyone’s practice is down right now.  Those lies are told by those who want others to join them in their own shortcomings.  Plus, it most certainly is not true.

However, this is not to say that chiropractic offices that are thriving in this marketplace by doing the same old thing. For example, my client who called to tell me he was still alive (hadn’t heard from him in a while, so I sent him a search & rescue email!) has been busy adapting new strategies for his office, adding staff and been busy, busy, busy to the tune of a $60,000+ increase in the last three months since he hired me.  His excellent stats are not the result of pure luck, being in the right place at the right time or multiple mantras chanted towards attracting infinite abundance.  Sorry to all you fans of “The Secret” or other similar think and grow rich spinoffs – this fella did the work, made some proactive changes and is reaping the rewards of his smarter strategies.

Let me make one thing clear: I am not telling you to start to do your own billing, over the counter collections or put a register in your treatment rooms to collect co-pays!  However, I do think that, as the CEO of your business, you need to spend time in consideration of the way your office currently handles finances.

Unless you have been wearing blinders for several years now, $5 co-pays and $250 deductibles are becoming as rare as a monogamous celebrity.  In many cases, the insurance step children have taken their place in the form of $50 co-pays and $5000 deductibles.  Obviously, the clinic who approaches patient finances like it were 1985, 1995 or even 2005 has strategies that either won’t quite fit in today’s environment or ones that don’t even border on reality.

Instead, savvy practices that are succeeding today are coming up with an assortment of ways to make sure that the patients still get the care they need AND to ensure they are paid to deliver it.  Here are a few ideas and tips to think about in this regard:

1. Your Credit Card machine is mandatory. The first line of defense for a patient who doesn’t have cash on hand – be it for a co-pay, deductible or to purchase the bulk of needed care –  is to have a credit card machine.  You are a dinosaur if you don’t.  Those of you who would laugh at the notion at someone practicing without a credit card machine need to meet some of the characters who send me snail mail because they “don’t do internet.”  I bet they “don’t do credit card machines.”  And it is likely, they “won’t do practice” for long either.  Get the machine.  And for those of you who have one, shop yearly for transaction rates, fees and other little ways the companies will suck more of your money than need be.

2. Consider Auto-Debit. Some people don’t like the idea of paying 22.5% interest on their credit card which seems to be the direction many companies are headed.  As an alternative, allow them to make payments.  But whatever you do, refuse to accept payments the old-fashioned way!  In other words, someone owes you $500 and your well-meaning staff member agrees to accept $50/month payments only to find out that 10 months turned into 17, included 19 reminders sent by your staff to get the $500 and in total, you actually lost money by spending more in staff time than you received.  Instead, use auto-debit through your bank or a processing company such as FirstACH.com or PaySimple.com.  Patients are used to having their bills paid this way, and with a simple form, they can pay you the money over time without having it be a headache and a financial nightmare on the back end.

3. Make Sure Your Hardship Agreements are in Writing. Some of you are too easy on what constitutes a hardship in your clinic and you waive co-pays at the drop of the hat.  Not only is this potentially dangerous for legal and/or contractual reasons, it may make little business sense.  Certainly, if someone is in need, you want to get them the care because you have a good heart.  But be sensible about this.  DEFINE what a hardship is and stick to it.  I get way too many emails from staff that complain about their doctors being all over the map in this regard.  Get the poverty levels for your area and see what your state says about who doesn’t have any money and who should qualify for your generosity.  That way, when someone approaches you with what seems like a legitimate financial challenge, you have some concrete criteria to see if they meet the definition legitimately.  One final note: your hardship agreements should be in writing and be temporary (put an end date in which the hardship ends or must be re-qualified).

4. Beef Up Insurance Savvy, Cash Friendly Services. Even though much of the coding, billing and documentation advice I give slightly favors third party payment systems, it is a wise move to have services that are both reimbursable through insurance and for which patients readily pay cash.  My favorite choice in this category is massage therapy because it costs little to start up, has excellent profit margins, generates quick cash flow, is frequently reimbursed by insurance companies and routinely paid for in cash as well.  My How to Build a $300,000 Massage Practice in Your Chiropractic Clinic program is one of our top sellers for this reason – and it continues to get rave reviews because the program is a simple step-by-step model for how to create a successful massage department.  Certainly, massage is not alone in the insurance savvy, cash friendly category; but I do believe it outweighs the other choices by a large margin.

5. Clean Up Your Messes. Many of us are willing to point the finger at the patients or the economy for our financial struggles when the real answer is the mess that is in our own backyard. To put it bluntly, you will never achieve high levels of financial success if your Accounts Receivables are too high or inappropriately pushing beyond the 90 day mark.  If your billing person (or system or company) is a mess and can’t get you paid, there is no amount of compensating you can do on the other side to squeeze more profits out of your patients that will ever balance the scale.  Finally, if your documentation and your coding systems stink or were passed down to you by Uncle Louie, DC who was a big roller in the 70’s,   you are in for financial trouble at the least.  In today’s marketplace of heavily scrutinized claims, post payment demands and recovery audits, it makes little sense to bill for anything and everything with little attention paid to proper billing, coding or documentation standards because you will only to pay it back later.  Instead, spend some time cleaning up your own messes.   If you have even an average practice in terms of volume and visits, I can virtually guarantee you are leaving hard-earned money on the table because of your lack of expertise in these areas.  I say this, not to brag, but because this is what I do every day of my consulting business and there is literally that much to improve in most of our practices.

So, which of these steps are you missing in your practice?

Is it all of them?  Can you survive doing business the same way you are doing it now or is it high time to “kick it up a notch” and change with the times.  You may not be able to do much individually about the state of the economy, but you can do a whole lot about how your private practice handles finances.  So, get to work.  And if you don’t know where to start, consider completing my Practice Analysis Questionnaire so I can give you some guidance in this regard.  There’s no charge nor any obligation to utilize my services, but I am willing to give you some candid opinions/recommendations (like ‘em or not!) for those who take the time to fill out the questionnaire.

Happy Holidays!

Tom Necela, DC, CPC, CPMA

P.S.  For those of you who would like more in-depth strategies, check out my Chiropractic Collections & Financing Secrets program which has dozens of different tips and techniques to improve collections.

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Your Toughest Chiropractic Billing, Coding, Documentation Questions Answered – FREE!

by Tom Necela on December 15th, 2009 in Audits, Billing, Business, Chiropractic Seminars, Coding, Collections, Documentation, EHR / EMR, HIPAA, Medicare, Medicare ABN, OIG Report, chiropractic EMR, chiropractic documentation, chiropractic practice management, chiropractic webinars, compliance, seminars

Reading time: 3 – 4 minutes

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You are invited as a guest to Join Tom Necela, DC, CPC, CPMA — Certified Professional Coder, Certified Professional Medical Auditor, former Insurance Claims Analyst, and current President of The Strategic Chiropractor — for a special FREE 60 minute Webinar!

FREE WEBINAR!


Thursday December 17, 2009

– 9 am PST/10 am MST/11 am CST/Noon EST

So…

Bring your TOUGHEST questions on Chiropractic:

  • Billing
  • Coding
  • Documentation
  • Collections
  • Getting Paid for the Work You Do!

And receive the ANSWERS you need that will help you:

  • Maximize your reimbursements
  • Decrease denials
  • Shorten Payment delays
  • Lower Accounts Receivable
  • Reduce your risk of audits

We are hosting this seminar as a special “thank you” to all of our blog readers, clients and customers who have made The Strategic Chiropractor the #1 source for teaching chiropractors how to “Work SMARTER, not harder” for increased profits.

As a sign of our appreciation we’d like to offer you a FREE seat for this webinar and the chance to have your question answered “live” during the event.

(If you cannot attend or would like a CD copy of the webinar, see below for details.)

Historically, this is our most popular event webinar of the year, so you need to act quickly! Previous editions of this webinar resulted in hundreds more questions than we could physically answer in a limited time format.

Space is limited and ADVANCED REGISTRATION is MANDATORY to submit questions (the earlier you submit them, the better chance they have for being included in the presentation material).  So register below, submit your questions and get your front row seat for the ultimate biggest bargain on the subject of chiropractic, billing, coding and documentation!


CLICK HERE TO REGISTER!


Hope to see you there!

Tom Necela, DC, CPC, CPMA
The Strategic Chiropractor

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Are You Coding Your Chiropractic Adjustments Incorrectly? New Coding Clarification!

by Tom Necela on December 1st, 2009 in Audits, Billing, Business, Coding, Documentation, chiropractic documentation

Reading time: 6 – 9 minutes

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The October 2009 edition of the CPT Assistant featured some clarification on chiropractic coding issues specific to coding for Chiropractic Manipulative Treatment, both Spinal (98940-98942) and Extraspinal (98943).  In addition to spelling out what constitutes each of the five spinal regions, the CPT Assistant provided some additional clarification on the Extraspinal Regions that was previously left unclear in previous editions of the CPT code book.  Specifically, I would call your attention to the definitions of Lower Extremities and Upper Extremities, which are now well defined.

To give you a little background, the CPT (Current Procedural Terminology) coding book is published each year by the American Medical Association and is the “official” coding standard rules and guidelines for proper coding procedures throughout all health professions.  As the full volume of the publication is quite large, various spin-offs of the CPT book exist (such as ChiroCode) in specialty professions to help practitioners in specific disciplines access the portion(s) of the CPT that are relevant to their profession.  Similarly, the CPT Assistant is published each year for coding professionals (from all disciplines) and it clarifies updates, problems, commonly misunderstood items, deletions and additions to the  CPT codes.

For most issues of this pricey publication, the CPT Assistant has little relevance to anything we do as chiropractors mainly because we represent only a tiny fraction of health professions at large.  To be honest, each year, I wrestle with the idea of canceling my subscription but the occasional nugget of useful information I can pass on to you and/or my clients keeps me going.  The most recent issue of the CPT Assistant has by far the most relevant hairsplitting that has been published on chiropractic in a looooong time.  The issue featured definitions of chiropractic manipulative therapy codes (most of which you already know) but there were a few tidbits that were included that could potentially have a major impact on your ability to bill, code and document your services correctly.  Done right, they can help you INCREASE income.  If done incorrectly, you could be LOSING money.  Here they are:

Extremity Coding Clarifications
For Lower Extremities, perhaps the most critical definition for chiropractors is the inclusion of the “Hip” in this category.  As you know, a patient presenting with a hip problem could really have a chief complaint of SI joint pain, pelvic pain or problems in many other anatomical structures located in the surrounding regions of the lumbar spine, hip, pelvis or sacrum.

Similarly, many chiropractors have expressed confusion over what structures constitute the Upper Extremities.  The present edition of CPT Assistant also clarifies this issue: the upper extremities include the shoulder, arm, elbow, wrist, and hand.  Therefore adjustments that you perform in the Thoracic region of the spine would not include the shoulder, even though some of the surrounding structures are adjacent anatomically.  The CPT Assistant makes it clear: Shoulder Manipulations are Extra-spinal (98943).

From a coding, documentation or billing perspective, it is essential to be specific in your reporting of pain in these areas, as it may have significant impact on your selection of the appropriate CPT code to bill for your services and in turn, the revenues generated from that service.  For example, since the SI joint is classified under Pelvis for coding purposes, adjustments to this region would count towards the number of spinal areas for which you are billing.  On the other hand, if you perform an adjustment to the hip, your service should be coded as an Extraspinal Adjustment (98943) and would not count towards the number of regions you would choose for spinal area adjustments (98940-98942).

Potential Risks and Benefits of This Coding Clarification Obviously, if you incorrectly document, bill or code for any of these regions incorrectly, you run the risk of either upcoding your services (because you have billed for more regions than you truly adjusted) or downcoding your services (because you failed to bill for all the areas you adjusted).  Neither is correct and both have financial implications.

One final note: the CPT definitions of anatomical regions are not consistent with the diagnosis code selections included in the ICD-9 code set.  This discrepancy was pointed out in the 2009 edition of the ChiroCode Deskbook, but its application becomes particularly relevant when dealing with coding issues in reference to the regions mentioned above.  Because it may not be possible to correlate all anatomical regions with specific ICD-9 codes, use extra caution to make sure that your documentation fully supports both your choice of CPT codes and ICD-9 codes.  Failure to do so may result in your claim being denied or delayed.

Now that you have been informed,  the next step is to go back and correct your procedures if you have been doing it wrong.  For those of you who suddenly found out that you are leaving lots of money on the table by the current way you are billing, coding or documenting your services, let me suggest a three step plan:

  1. Fix It! The insight is not the solution — your improvement requires action! So get to it before you expose yourself to potential audit trouble and/or keep losing hard earned money.
  2. Admit That You Don’t Know Everything. This is sort of a “healthy” view of ignorance.  Some call it the beginning of wisdom.  It is the realization that you cannot possibly know everything there is about all aspect of your business.  Certainly there are other similar items that you don’t know that are also costing you money (or will cost you money if you are audited).  Once you can own up to that, perhaps it’s time to fill out my Practice Analysis Questionnaire and see how I may be able to assist you.  My review of your Questionnaire is free and there is no obligation to utilize my services, so the only thing you have to lose is your stubbornness to admitting you know everything.  By the way, just in case you think I may be a little hypocritical here, I don’t claim to know everything either.  It’s highly likely I know more than you about billing, coding, documentation as this is what I specialize in, but you won’t find me telling you how to adjust your patients or what to do with your 401K plan.  For some things, it is helpful to have access to someone with specialized knowledge around. If you can accept that line of thinking, fill out my Practice Analysis Questionnaire and we’ll talk.
  3. Give Something Back.  There is potential for some of you to make big bucks off this blog post due to the fact that you have been doing it wrong for who knows how long.  Take an average of only 20 adjustments per week @ $50 per adjustment for 50 weeks of the year.  That’s a $50,000 impact on your practice for one item!  At the very least, you may owe me a nice dinner (just kidding), should hire me (kidding – sort of — it will cost you less than $50K and make you more) or give something back to the profession (not kidding at all — choose your state and/or national association and send a check – they need the money!).
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How Can I Increase My Chiropractic Income?

by Tom Necela on November 10th, 2009 in Billing, Business, Coding, Collections

Reading time: 5 – 8 minutes

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At one point in time, virtually every business owner – chiropractors included – has asked the question “How can I improve my income?”  Today’s post will discuss this mega-dilemma of nearly all entrepreneurs.

But before we discuss potential SOLUTIONS, let’s take a critical and closer look at the question, knowing that the only way to arrive at better answers is to ask better questions.Truly, do you really want to just increase your income?  Most would shout: “YES!”  But looking at things from a broader perspective, the astute entrepreneur would probably also want to know the costs involved with increasing income.

Let’s take a look at two common ways to increase income.  First, you could raise your fees.  This almost immediately produces an income boost. The cost to do so is nothing.  Sounds perfect?  And while increasing fees is one thing I believe is critical to your financial success, it does have limits.  After all, in theory you could double your fees and double your profits.  You also may multiply the number of patients who head for the door.  So, although raising fees may be smart, it is a limited strategy by nature.

Now let’s look at the example of new patients.  Most chiropractors would agree that having more new patients is key to increasing income.  Certainly that is often true. But don’t be too hasty in proclaiming new patients as the premier method of increasing income.  Why?  Two words: acquisition costs. If your new patients come from referrals, the cost to acquire them is nearly zero so this can be a profitable venture.  On the other hand, if the new patient walks in as a result of an ad you placed, you need to now calculate the costs of the ad and the potential income the patient will generate for your practice.  In this way, some new patient acquisition methods can certainly be profitable while others less so or not at all.

So, perhaps a better question to ask is:

What’s the most cost-effective improvement I can make to increase income?

In the October 9, 2009 edition of Medical Economics, healthcare consultant Keith Borglum gives the answer, plain and simple: “The most cost effective improvement is usually in improving your coding.”

Of course, as a Certified Professional Coder myself and one who routinely utilizes proper billing and coding to help improve revenues for my consulting clients, I certainly would agree. Sure I am a bit biased, but here’s the reasoning behind Mr. Borglum’s proclamation:

“An extraordinary number of physicians fail to stay current in their knowledge of coding, resulting in reduced reimbursement or delayed and denied claims.  Many physicians purposefully undercode out of fear of penalties for overcoding or unbundling. Others leave their coding to support staff – an inappropriate approach virtually guaranteed to result in errors …”

Although this consultant is speaking in reference to Medical Doctors, in my experience, we chiropractors are really no different.  In chiropractic school, we were taught examination procedures based on creating a working diagnosis so we could accurately assess the patient’s condition and create an appropriate plan of care.  In other respects, our exams were also about protecting ourselves from malpractice resulting from potential hazards that could be mis-diagnosed. But I have yet to meet a chiropractic graduate from any school who was taught how to properly document an exam for purposes of correct coding and billing.

As a result, most fall into one of two camps mentioned above.  Conservative chiropractors tend to undercode or underbill, thus denying themselves reimbursement for procedures they actually performed.  More aggressive chiropractors tend to bill for procedures out of some sense of justification for the time they spend performing a service that may not necessarily match up with coding or documentation requirements.  As a result, they overbill or upcode.

Many clients come to me seeking ways to improve income, but most also have some predetermined methods that they believe they need to use to achieve this and hope that I can somehow teach them a new “trick” or “secret method.”  On the contrary, most clinics I see would benefit not from something new, but by returning to the old.

In other words, they can reliably improve income by making sure they are being paid for what they are already doing. They can increase revenues by maximizing reimbursements and minimizing errors that cause them to leave money on the table.  Proper billing, coding and documentation can help you achieve this – without the added expense of new equipment, extra staff or additional funds in the marketing department.

On top of that, if you consider correct coding from an expense point of view, proper coding not only has the potential to increase your income, but also prevent you from losing income –few strategies can ever achieve both.

If you want to get down to pure return on investment, taking a coding class for $100 could easily find you at least one item that you could improve.  Even if that resulted in a $25 increase for a service or procedure you performed just a few times a week that could result in a $5000 increase over the course of a year or a 50:1 ROI!  Personally, I have had seminar attendees tell me that one of my strategies was worth $25,000 to their bottom line!  Take that one step further and spend a few hours consulting with a coding expert and you could easily turn your investment into a 6 digit return.  I do this routinely for my clients.

So, the next time you are seeking ways to increase income in your practice, remember the following:

  1. All income increases are not equivalent – consider return on investment
  2. Correct coding can help you prevent income loss AND increase income

One of the most basic steps towards improving your coding should include the purchase of the ChiroCode deskbook.  Quite frankly, no office should be without it.  Every office I have seen without one of these books that is making major coding errors that are costing them money and exposing themselves to audits.  Unfortunately, I can think of no exception to this rule.

While we are on the topic, for a more interactive instruction on proper coding, billing, documentation and business development, I have two “live in person” seminars left for the year – one in Portland and one in Seattle on November 12 and 14th respectively. More info can be found at www.strategicdc.com/seminars.html For those of you for whom travel to the Northwest is inconvenient or impossible, I also have two upcoming webinars on the same topics scheduled  (stay tuned for more details in a future email).

Now is the time to start planning and investing in next year’s success!

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