Archive for the ‘EHR / EMR’ Category

The Final Word on Chiropractic EHR Stimulus Dollars (For Now)

by Tom Necela on July 27th, 2010 in Business, Documentation, EHR / EMR, chiropractic EHR, chiropractic EMR, chiropractic documentation, compliance

Reading time: 3 – 4 minutes

The recent release (July 16, 2010) of the “Final Rule” regarding Meaningful Use criteria and EHR (Electronic Health Records) Financial Incentives has certainly prompted lots of questions from many chiropractors about how to obtain stimulus dollars for their EHR / EMR systems and what they need to do to qualify.

Below is a summary of some key points regarding EHR eligibility for those of you who don’t care to read the original documents or fact sheets on Meaningful Use and EHR Financial Incentives in their entirety:

Meaningful Use Criteria which establish eligibility for financial incentives are for EHR Certified programs only. Translation: if your EHR is not certified, you may not receive any financial stimulus. Many EHR companies are advertising that they are “eligible” for certification, although this is not the same as being certified. Buyer beware!

You know only need to complete 20 of the 25 Meaningful Use Objectives/Measures as defined in the Final Rule issued by CMS. Even though you may “defer” 5 of these requirements, this is still an ambitious list for most practitioners in order to qualify for the funds. (See my previous blog post “The 25 Meaningful Use Criteria for Chiropractic EMR Systems” for a full list of criteria)

The completion of these Objectives/Measures fulfills Stage 1 requirements only (which make you eligible for the financial incentive portion). Stage 2 and Stage 3 objectives exist, but the exact requirements and penalties are not as well defined.

Chiropractors are Eligible Professionals that may qualify for the EHR financial incentives

Chiropractors may be eligible for EHR financial incentive payments as early as 2011; payments can proceed for up to 5 years.

The total financial payments that chiropractors are eligible to receive is a maximum of $44,000 over a 5 year period or equal to 75% of Medicare allowable charges for covered professional services furnished by the chiropractor in an eligible year. This is perhaps the biggest criteria EHR companies fail to mention. In other words, in one given year, you can receive up to $18,000 IF (and only if) you provide at least $24,000 worth of covered services (based on allowable charges) to Medicare patients. On the other hand, if you have a small Medicare practice, your eligible financial incentives will be reduced accordingly and capped at 75% of the allowable charges for your covered services (which, in chiropractic, is CMT only). Do the math to see if your practice qualifies for anywhere near the $44K amount.

The Bottom Line

My final opinion is not changed by the “final rule” criteria. I would highly recommend that most offices switch to some form of electronic health records. However, this advice is NOT based on the presumption that you are doing so to capture any potential financial stimulus incentives. Rather, migrate to EHR because of its potential to improve your documentation, level of care and overall recordkeeping.

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 1^st 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:

Split/shared visits
Signatures
Labels/Diagnostic Testing
Hospital & Nursing Facility Discharge Services
Chiropractic Services
Therapy Services
Individual Psychotherapy Services
Evaluation & Management Services
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”:

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.

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!

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!

Correcting Chiropractic Billing Snafus, Altering Records & Advice from Bob

by Tom Necela on February 22nd, 2010 in Audits, Billing, Documentation, EHR / EMR, chiropractic documentation, compliance

Reading time: 8 – 12 minutes

altering records

In the wake of insurance denials, some chiropractors pose an interesting question in their attempt to get paid for what they do. It is some variation of this:

“If I billed something incorrectly…or the insurance company denied a particular service…or procedure A was bundled with procedure B…can I change my records/billing/coding so I can get paid for this?”

Certainly, my loyal blog readers know that one of the two primary purposes of my writing this column is (1) to help you maximize reimbursements by getting you paid for ALL the work you do. But this purpose is also coupled with keeping you compliant in your billing, coding and documentation while attempting to achieve my other goal for you, which is (2) to minimize your audit risk.

In other words, I would love to see every chiropractor paid well for all of the work they do (not more than they deserve, but not less) and, of equal importance, possess the proper documentation necessary to KEEP the money they earned.

Answering the question(s) posed then is not a simple “yes” or “no” but an “it depends.” Let’s explore this a little further.

Amendment of Records Can Be a Good Thing

Amendment of a medical record can be a good thing. Reviewing your records to check for accuracy and completeness and taking the time to amend them is common and commendable. We all know that the daily duties and pace of practice often cause us to spend less time taking notes that we may want to or that good documentation may warrant. Therefore, a practice of reviewing notes before the day’s end, for example, can be a good way to catch any missed items needing documentation as well as prevent incorrectly billed or coded services.

Obviously, the best practice is to complete your records correctly the first time. But if you didn’t, you can make an addition or correction later. You must do so in a legitimate and above-board fashion—timely and not apparently an “alteration.” Different payers may have varying definitions of what constitutes “timely” documentation, but most appear to indicate that the note should be completed during the actual encounter of shortly thereafter. Most payer descriptions I have seen of this seem to indicate “shortly thereafter” means within 24hours after treatment.

Avoid Alteration of Records

Let’s differentiate between the terms: “Amendment” or “Alteration.” For our discussion, Amendment refers to the process of reviewing and/or correcting mistakes within a short period of time (as above) for the purposes of correction. Alteration, on the other hand, does not quite convey the same corrective intent.

For example, if you alter your records once a lawsuit has been filed or an attorney has requested your records, it’s too late and this would not be considered a legitimate “correction” or amendment of the patient’s file.

Unfortunately, this is a common scenario: you receive a request for records, review your documentation, and see that some fact is omitted or some entry is inaccurate. You quite innocently think that you can “improve” the record.

Let me stop you there. Don’t do it.

Every state chiropractic board in the country has heard numerous cases of records alteration and, I am sure, cringes every time they have to review one.

In reality, the insurance company, plaintiff’s attorney, claim review company and who knows who else has likely already obtained a copy of your records in their original form. As the jury is shown both the original record and your “revised” record, you will see your credibility disappear before their eyes – even if the alteration of the record was innocent, helpful or minor.

At the least, any alterations you make in the records significantly after the treatment date can be viewed as self-serving. Taken to the extremes, it can also be regarded as a cover-up or potential fraud. (See picture at start of blog for what technology can do to squash your attempts to alter records anyway!)

Adding To or Correcting Records

What should you do if you discover an omission? Suppose you review your earlier progress note and discover that you forgot to state that you made an appointment for a patient x-ray? Or what if you reviewed the x-rays and in the process of documenting your findings, inadvertently left a key finding out of your report?

Sometimes, omissions may not have clinical relevance but are needed for accuracy. For example what do you do when you discover that a simple typing error has made your 26 year old patient 62 years old?

In cases like these, adding a note can illustrate the fact that you are a conscientious chiropractor by demonstrating that you are careful enough to review your notes and concerned enough to add the missing information.

To properly amend records, you need to:

Put a notation in the margin next to the original entry: “see my note below.”
Enter another note at the time you discover the error. Write in the added information. Initial and date it.
Draw a single line through the incorrect entry. Make sure that the original entry is still legible.
Explain the correction. If possible, explain why the earlier note was incorrect, the reason for the error, and the reason the error was noticed.

On the other hand, erasing, using correction tape or fluid, or obliterating any documentation in the record is unacceptable and would be a big no-no that can land your tail in hot water.

Billing Snafus

Many chiropractors contact me – after the fact – about their claim denials, payment disputes or billing problems which may have occurred as a result of errors or ignorance. Some of these problems are correctable.

If you legitimately performed a procedure, documented it correctly and simply forgot to bill for the procedure alongside the other services that were rendered during that visit, you may wish to submit a corrected claim and get reimbursed for this. Provided you do this in a timely manner, the insurance should reprocess the claim and pay for your for the service.

Similarly, if an insurance company has denied your service based on a claim submitted with the wrong code on it (due to a human error, mistake, number dyslexia, etc), re-submit your claim for payment consideration. In these instances, I find a short letter submitted with the corrected claim to be helpful. (i.e. Dear Sirs, I inadvertently billed for 58940 instead of a 98940. There was no Oopherectomy performed, in part or total, during the course of the patient’s chiropractic visit nor was it my intention to attempt to get paid for one. The service performed was…)

Some billing problems, however, should not be corrected.

For example, adjusting 3-4 areas of the spine (98941) and performing manual therapy (97140) in one of those same areas won’t fly with payers and will result in a denial. If you have billed this out and find a rejection letter staring you in the face, you should not downcode your service to a 98940, re-bill it and hope to be paid for your “corrected claim.”

Presuming you did adjust three or four areas in the first place, it would be fraudulent to downcode because you are essentially lying to get paid. Again, take your lumps and correct the issue.

Likewise, if you bill for a service only to find it denied, you should not re-submit the claim using a different code in an attempt to get paid. Look in any coding book, page 1 or thereabouts and you will see instructions that read something like “Select the name of the procedure of service that most accurately identifies the service performed.”

Spaghetti billing methods (throw it to the wall, see what gets paid/sticks) are not advisable, inefficient and potentially fraudulent.

Parting Words of Wisdom…From Bob

So what do you do if you have a billing problem that causes you to lose money, but which you cannot correct if you wish to keep your nose clean?

Identify and research the issue so that you can understand the problem.
Seek experienced help. Billing and coding errors rarely occur in isolation. Typically, I find multiple errors that are costing my clients thousands of dollars in unrealized income or potential losses.
For future purposes, and on the lighter side, see Bob Newhart’s classic advice on the matter below. A little on the rough side, but technically accurate! J

To Your Success!

Tom Necela, DC, CPC, CPMA

The 25 Meaningful Use Criteria for Chiropractic EMR Systems

by Tom Necela on February 15th, 2010 in Business, Documentation, EHR / EMR, chiropractic EHR, chiropractic EMR, chiropractic business, chiropractic documentation

Reading time: 8 – 14 minutes

chasing-money

Adopting an electronic medical records (EMR) system can net you up to $44,000 in government incentive money. Or can it?

Some of the most frequently asked questions I received in 2009 (which still continues through 2010) is in regards to how to select an EMR system and the stimulus funds that potentially go with EMR implementation.

The problem?

All stimulus incentives hinged on practices adopting “meaningful use” of the EMR systems in question. The problem? Up until December 2009, “meaningful use” was left undefined!

In other words, you could not get the money unless you were using EMR according to certain set criteria but no one went on record to establish exactly what those criteria were!

Unfortunately, the cloud was not exactly lifted this past December because the proposed rules for “Meaningful Use” are 556 pages long! Worse yet, industry experts don’t expect the final rule to be much different so knowing the proposed rule is essential to meeting meaningful use and getting paid.

So, then, how does one crack the mystery code and define meaningful use? Lost in those 556 pages are a total of 25 requirements your practice must meet to achieve meaningful use. Don’t worry, I will spare you the trouble of reading the electronic equivalent of War and Peace (which is far more difficult to understand and much less entertaining) and summarize the 25 points below.

But let me cut to the chase. For those of you who have recently purchased an EMR system or who are considering a purchase, don’t bank on getting those stimulus dollars just yet.

For those of you who are still considering getting an EMR system, let me go on record and state that I think that is a great idea for most practices. However…don’t purchase one just because you feel the stimulus dollars are going to be rolling in afterward.

Purchase one with the intent of having a system improve your clinical documentation, practice management and overall efficiency. Most will do that, provided you choose the right system to suit your needs.

Can’t decide which system to choose?

Given that you should take stimulus dollars out of the equation, there are certainly other factors to consider in choosing the right system for you. Before you make a $10,000 mistake, perhaps you should consider investing less than 1% of that figure into my “How to Choose a Chiropractic EMR System audio program.”

This 1.5 hour program (on 3 Audio CD’s) walks you through the thought process of how to make an intelligent decision on purchasing the right system for your practice. I won’t come out and tell you to buy X, Y or Z but teach you how to shop and the tough questions you should be asking to make sure that you are getting the right system.

Frustrated with Your Own System?

It’s not too late to start over and think strategically about what will be a better fit for you and your practice. I see far too many chiropractors who have expensive EMR systems collecting dust because they abandoned ship out of frustration and went back to paper.

There was a reason you chose to get EMR, you should find a system that you can actually use – they ARE out there! Again, before you run out and buy another program, consider a small investment in strategy, some collective wisdom and a system to make a good purchase – my “How to Choose a Chiropractic EMR System” audio program accomplishes all of these.

And now, as promised, here are the 25 “Meaningful Use” Criteria for eligible providers. (These criteria were taken from the proposed rule: Medicare and Medicaid Programs; Electronic Health Record Incentive Program.)

The List: 25 Meaningful Use Criteria

1- Objective: Use computer physician order entry (CPOE)
Measure: CPOE is used for at least 80 percent of all orders

2 -Objective: Implement drug-drug, drug-allergy, drug- formulary checks
Measure: The EP has enabled this functionality

3 – Objective: Maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT®
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry or an indication of none recorded as structured data

4 – Objective: Generate and transmit permissible prescriptions electronically (eRx)
Measure: At least 75 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology

5- Objective: Maintain active medication list
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient is not currently prescribed any medication) recorded as structured data

6- Objective: Maintain active medication allergy list
Measure: At least 80 percent of all unique patients seen by the EP have at least one entry (or an indication of “none” if the patient has no medication allergies) recorded as structured data

7 – Objective: Record demographics.
Measure: At least 80 percent of all unique patients seen by the EP or admitted to the eligible hospital have demographics recorded as structured data

8 – Objective: Record and chart changes in vital signs
Measure: For at least 80 percent of all unique patients age 2 and over seen by the EP, record blood pressure and BMI; additionally, plot growth chart for children age 2 to 20

9 – Objective: Record smoking status for patients 13-years-old or older
Measure: At least 80 percent of all unique patients 13-years-old or older seen by the EP “smoking status” recorded

10 – Objective: Incorporate clinical lab-test results into EHR as structured data
Measure: At least 50 percent of all clinical lab tests results ordered by the EP or by an authorized provider of the eligible hospital during the EHR reporting period whose results are in either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data

11 – Objective: Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, and outreach
Measure: Generate at least one report listing patients of the EP with a specific condition

12 – Objective: Report ambulatory quality measures to CMS or the States.
Measure: For 2011, an EP would provide the aggregate numerator and denominator through attestation as discussed in section II.A.3 of this proposed rule. For 2012, an EP would electronically submit the measures are discussed in section II.A.3. of this proposed rule.

13 – Objective: Send reminders to patients per patient preference for preventive/ follow-up care
Measure: Reminder sent to at least 50 percent of all unique patients seen by the EP that are 50 and over

14 – Objective: Implement five clinical decision support rules relevant to specialty or high clinical priority, including for diagnostic test ordering, along with the ability to track compliance with those rules
Measure: Implement five clinical decision support rules relevant to the clinical quality metrics the EP is responsible for as described further in section II.A.3

15 – Objective: Check insurance eligibility electronically from public and private payers
Measure: Insurance eligibility checked electronically for at least 80 percent of all unique patients seen by the EP

16 – Objective: Submit claims electronically to public and private payers.
Measure: At least 80 percent of all claims filed electronically by the EP

17 – Objective: Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and allergies) upon request
Measure: At least 80 percent of all patients who request an electronic copy of their health information are provided it within 48 hours

18 – Objective: Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, allergies)
Measure: At least 10 percent of all unique patients seen by the EP are provided timely electronic access to their health information

19 – Objective: Provide clinical summaries to patients for each office visit
Measure: Clinical summaries provided to patients for at least 80 percent of all office visits

20 – Objective: Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically
Measure: Performed at least one test of certified EHR technology’s capacity to electronically exchange key clinical information

21 – Objective: Perform medication reconciliation at relevant encounters and each transition of care
Measure: Perform medication reconciliation for at least 80 percent of relevant encounters and transitions of care

22 – Objective: Provide summary care record for each transition of care and referral
Measure: Provide summary of care record for at least 80 percent of transitions of care and referrals

23 – Objective: Capability to submit electronic data to immunization registries and actual submission where required and accepted
Measure: Performed at least one test of certified EHR technology’s capacity to submit electronic data to immunization registries

24 – Objective: Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice
Measure: Performed at least one test of certified EHR technology’s capacity to provide electronic syndromic surveillance data to public health agencies (unless none of the public health agencies to which an EP or eligible hospital submits such information have the capacity to receive the information electronically)

25 – Objective: Protect electronic health information maintained using certified EHR technology through the implementation of appropriate technical capabilities
Measure: Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308 (a)(1) and implement security updates as necessary

The Sum Total

Again, not all these criteria seem terribly relevant to chiropractic and quite frankly, I would love to see how some EMR providers can define these in such a way that they can guarantee stimulus dollars.

My recommendations:

If you already are using EMR, approach your provider with this list and see how their system can complete the measures to obtain each objective so that you at least have a chance at getting some stimulus funding.
If you do not yet have an EMR system, use these criteria as part of your questions to each system that you are considering for purchase, particularly if they are claiming to get you some stimulus funding. Also, consider purchasing “How to Choose a Chiropractic EMR System” Audio series to further assist you in making a wise choice of systems that will fit your needs.
If you are unsatisfied with your current system, consider shopping for another and following the instructions in #2 – but do not purchase your new system just because you think you are going to get the HITECH dollars!

Best wishes for continued success!

Tom Necela, DC

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

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

Answers to Common Chiropractic Medicare Problems

by Tom Necela on November 3rd, 2009 in Audits, Billing, Business, Coding, Documentation, EHR / EMR, Medicare, Medicare ABN, OIG Report, compliance

Reading time: 6 – 10 minutes

questions2

In my last article on The Perennial Problem of Medicare for Chiropractors, I offered to respond to some common questions and dilemmas that you have been experiencing in regards to Medicare and your chiropractic practice. Since the blog was posted last week, we received a total of 326 responses with questions, comments, angry remarks about CMS and a few demonstrations of our collective chiropractic misunderstandings about all things Medicare.

In other words, the rumors are still out there, docs are still frustrated and problems still abound. To be fair, I did receive ONE response from a DC who was a bit perplexed about all the fanfare and indicated that Medicare was the easiest payer to deal with. Certainly, his response was the exception, not the norm. The one caution I would raise for docs who similarly feel that they are sailing along without any trouble: the RAC audits have started and they may change your opinion of the matter.

Now, let’s get to the questions! Obviously, I cannot address all 326 responses, so I have summarized the concerns into a few basic categories as follows:

Payment Denials or Downcoding. Several readers were upset that Medicare had denied or downcoded the level of service and paid them less (or not at all) as a result. More were confused about what this means. Since your adjustments are the only service Medicare pays chiropractors for, the “level” of service refers to the number of areas that you adjust and bill for – i.e. 98940, 98941 or 98942. When I perform Documentation Reviews for clients, the most common mistake I see here is that your objective findings don’t match the level of service billed. In other words, you billed a 98941 (3-4 region adjustment) but only had objective findings for perhaps 1 or 2 areas (or less). Therefore, Medicare concludes that either you didn’t meet medical necessity for the service you performed at all or that you only met medical necessity for a service that was lower (fewer areas) than the one you billed. The result: your claim will be downcoded (i.e. a 98941 will be paid at 98940 rates) or denied ( you didn’t meet medical necessity at all).

Fixing Problem Claims. This question of what to do with incorrect, incomplete, or problematic claims came in a variety of formats. Per Medicare Transmittal 1588, you can submit a corrected claim if your original claim was filed in a timely fashion and was incomplete. By incomplete, Medicare means items are missing such as NPI #, patient demographic info or other such requirements on your claim form. Incomplete does not mean that you get to re-submit your corrected claim because your original clinical documentation was substandard or missing items you should have included in the first place.

Error Rate and the Aftermath. Error rates probably mean bad news for most DC’s! Error rates are the % of claims submitted in error to Medicare that are determined to be such after a review. Error rates can result in overpayment demands (Medicare paid you, but since 20% of your claims were in error, they want a refund) or can lead to future audits (your error rate is too high, therefore Medicare will audit you again in the future to monitor your progress) or can even cause “Pre-Payment Reviews” (Medicare determines that your error rate is repeatedly too high and they will have to review your documentation prior to approving any future payments). As I said at the start, none of this is good news, although if you are receiving notices of PrePayment reviews, you definitely need help in the area of proper billing, coding and documentation.

Avoiding Medicare Patients. Some of you indicated that the only sure-fire way to avert Medicare disaster was to avoid treating Medicare patients. Certainly, you have the right to refuse to treat Medicare patients so long as you do so within the confines of your state laws. Whether this is a good tactical move may be questionable, as the Baby Boomers represent the single largest segment of the population who will be driving lots of healthcare dollars in the name of Medicare. To exclude them may represent a significant portion of your practice base. Also, be careful when you state that you do not treat any Medicare patients. By the questions some of you posed (whether hypothetical or not), you ARE treating Medicare patients but you are simply not billing Medicare for the service. If you are not doing this correctly, you could be accidentally committing fraud by doing so.

Medicare, EMR and Stimulus Funds. Several questions came in regarding integration of EMR and Medicare. According to the program, physicians (including chiropractors) will be eligible to receive stimulus funding as soon as 2011 for EMR that meets certain “meaningful use” criteria. At this point, the specific details of these requirements are still to be determined. While I am a big proponent of moving to EMR, in this respect, I agree with the ACA’s advice on the matter: “do so with the fundamental focus of improving patient care.” In other words, get the EMR because you want it to help your documentation, your clinical practices and business management – not because you may get some money from the government.

CERT Request and Audits. Apparently, there are many of you who wonder if CERT requests are an audit. CERT stands for Comprehensive Error Rate Testing and it’s likely many of you have received such a notice from Medicare. It is their way of randomly testing the accuracy of payments made. So the key word is random and is in no way an indication that you are doing things wrong (or right for that matter). Comply with the request and do not ignore it. For more detailed information on the Audit process (for both Medicare and other third party payers), types of audits and what to do I suggest you get a copy of How to Prepare Your Chiropractic Practice for Recovery Audits so you can understand what auditors are looking for and how to respond.

ABN Mysteries. ABN questions dominated my inbox in varying forms and it’s obvious there’s still a lot of confusion over ABN’s. First, by definition the ABN is an advanced notice (meaning, you have to give it to the patient beforehand not to cover your tracks afterward) that Medicare may not pay for the service you are about to render. Secondly, to simply have your patients sign an ABN each and every visit is incorrect. It presupposes that none of your chiropractic adjustments are necessary. This is not something you want to communicate to Medicare or your patient! Finally, for more detailed discussion of ABNs, let me refer you back to an older post entitled: ABN Abuse: A Common Chiropractic Practice.

FREE or Discounted Medicare Services. The “Can I include Medicare patients in my Free or Discounted…” question was posed in several ways, but the same theme is underlying. What can I give away or discount to my Medicare patients? Here is your answer. According to OIG interpretation of Section 1128a(5) of the Social Security Act, exam specials, coupons, or similar discounts should not exceed $10 individually or $50 annually per patient. So, your FREE exam or adjustment may be problematic in that it either exceeds the $10 value or that you don’t charge enough for your services. One way, you’re in trouble with Medicare; the other, your business is not likely to generate a profit if you are charging less than $10 for exams, x-rays, adjustments, etc.

Chiropractic Billing, Coding, Documentation Seminars come to Seattle, Portland, Boise

by Tom Necela on October 2nd, 2009 in Audits, Billing, Business, Coding, Collections, Documentation, EHR / EMR, HIPAA, Medicare, compliance, seminars

Reading time: 2 – 3 minutes

seattle idaho-boise portland

Many of you have been emailing me regarding upcoming seminars for Fall 2009.

Here are a list of dates for Seattle, Portland and Boise:

SEATTLE, WA

Thursday, October 22, 2009
Saturday, November 14, 2009

River’s Edge Best Western
15901 West Valley Highway
Tukwila, WA 98188
425-226-1812
http://www.bestwesternwashington.com/hotels/best-western-rivers-edge/

PORTLAND, OR

Saturday, October 24, 2009
Thursday, November 12, 2009

Avalon Hotel
455 SW Hamilton Ct
503.802.5800
http://www.avalonhotelandspa.com/

BOISE, ID

Saturday, October 31st

Cambria Suites Boise Airport

2970 West Elder Street
(208) 344-7444

Discover the latest strategies to maximize reimbursements AND reduce audit risk from Tom Necela, DC and The Strategic Chiropractor!

New Red Flag/ Identity Theft Plan Needed by 11/2009 – get one FREE at the seminar!
Medicare Recovery Audits started in August – are you ready?
What you need to know about the HITECH Act of 2009, EHR stimulus hype & your compliance
Learn Surefire Methods for Defensible Documentation
Avoid the 4 Deadly Mistakes of EHR or computerized SOAP notes that trigger audits
Learn ’09 Premera Blue Cross, Aetna & Cigna policy changes that affect your practice!

Also — save $$$ on taxes and get your corporation in gear with Jim Bowen’s fast paced, business & tax info that you just can’t get anywhere else!

Registration for all seminars is available online at my co-presenter Jim Bowen’s website at www.bowen.us/seminars

Hope to see you there!

Upcoming Chiropractic Seminars: Learn the Latest Billing, Coding & Documentation Strategies

by Tom Necela on September 17th, 2009 in Audits, Billing, Business, Coding, Collections, Documentation, EHR / EMR, Medicare, seminars

Reading time: 10 – 16 minutes

seminar4

Discover the latest strategies to maximize reimbursements AND reduce audit risk from Tom Necela, DC and The Strategic Chiropractor!

New Red Flag/ Identity Theft Plan Needed by 11/2009 – get one FREE at the seminar!
Medicare Recovery Audits started in August – are you ready?
What you need to know about the HITECH Act of 2009, EHR stimulus hype & your compliance
Learn Surefire Methods for Defensible Documentation
Avoid the 4 Deadly Mistakes of EHR or computerized SOAP notes that trigger audits
Learn ’09 Premera Blue Cross, Aetna & Cigna policy changes that affect your practice!

seattle3

SEATTLE, WA

Thursday, October 22, 2009
Saturday, November 14, 2009

River’s Edge Best Western
15901 West Valley Highway
Tukwila, WA 98188
425-226-1812
http://www.bestwesternwashington.com/hotels/best-western-rivers-edge/

portland1

PORTLAND, OR

Saturday, October 24, 2009
Thursday, November 12, 2009

Avalon Hotel
455 SW Hamilton Ct
503.802.5800
http://www.avalonhotelandspa.com/

boise1

BOISE, ID

Saturday, October 31st

Cambria Suites Boise Airport

2970 West Elder Street
(208) 344-7444
http://www.cambriasuites.com/hotel-boise-idaho-ID042?promo=gglocal

Handling Your Insurance Conflicts with Success

by Tom Necela on September 1st, 2009 in Audits, Billing, Business, Coding, Collections, Documentation, EHR / EMR, Medicare

Reading time: 6 – 10 minutes

david-and-goliath-sumos2

It’s a dilemma all too many offices face.

You submit your claims to the insurance company, Medicare or other third party payer and…you expect to be paid.

You check your mail, your clearinghouse submission file and perhaps even make a call to inquire about the status of your claim because the check simply has not arrived.

And here is where things get complicated and emotional.

In your eyes, the claim was sent and payment should be received. Period. End of story. In the eyes of the payer, the claim may have been received or it may qualify for reimbursement, but first, a few things need to be checked.

Meanwhile, you are still waiting for paycheck. Yes, I used the term “paycheck” because that is exactly what each and every reimbursement represents: a portion of your paycheck and, for that matter, a portion of your staff’s paycheck as well.

And so, the battle is set in motion. As you see it, your job is to submit a correct claim, in a timely manner and receive payment as quickly as possible. From the payer’s perspective, they need to verify the accuracy of benefit information, determine if the claim is free or errors and perhaps even request documentation – before they even consider paying your claim.

Time adds an interesting variable to the equation. From your side of things, you have a time limit in which to file the claim and the payer has a time limit in which they must pay. On the payer side, they are aware of the same two requirements, but they also factor in profitability which dictates that they cannot pay all claims at once, nor should they, because some claims are simply not-reimburseable.

Therefore, the payer has the added burden of factoring in legalized payment delays in the form of documentation requests and claims scrubbing that looks for basic errors in submission. If the payer can catch either mistake on your part, they have a legitimate excuse not to pay. Some payers also use questionable tactics to delay payments which range anywhere from stating that claims were lost in transit to downcoding (paying a lesser code than the one you submit).

For the naïve or newly initiated, this whole process can be extremely confusing, frustrating or downright pointless. Even the most experienced billing staff or service has days when they question the logic of the entire system. Alas, it is what it is.

While you probably cannot do much about the way that payers conduct their business, you certainly CAN try to control your side of the equation and tip the scales as much as possible in your favor. Whining and complaining about the unfairness of the system rarely produces any tangible improvements, although my email inbox is frequently filled with frustrated rants and raves about the inherent evils of the insurance game.

To this, I have two responses. The first is my favorite line from motivational speaker, Les Brown, who states: “Whoever told you life was fair? You were misinformed!” My second response is to advise all DC’s to not go into battle empty handed. Here are a few “weapons” I would recommend using:

1) Prompt Pay Statutes. There are prompt payment laws in virtually every state. If the insurance fails to pay in a timely manner, hold them to the fire. They will do the same for you, if you fail to file your claim on time. One note: most of these laws will support you, provided you have submitted a “clean” claim. If your claim has errors and the payer delays or fails to pay, it’s your fault and the rules don’t apply. In fact, in June 2009 Medicare released an update that states that claims which do not meet basic legibility, format, or completion requirements are not considered as received for processing and may be rejected from the system.

2) Electronic Format. If you are still submitting all claims on paper, you are worse than a plaid suit. Certainly wearing such a monster dates you as completely old school (as in old fart, not as in old skool retro cool). At least has the plaid suit has a chance to come back in style someday. Your paper claims are just a testament to your inner dinosaur and about as efficient as the pony express. Electronic is faster on both ends – payment and submission – cheaper, and it allows to catch errors more quickly so you can turn them around for resubmission.

3) Legibility. Don’t bother submitting documentation that is illegible unless you don’t mind working for free. Virtually any EMR is superior to handwritten notes, if they are even borderline illegible. Who defines legibility? Unfortunately, it’s the guy on the other side of the fence who also determines whether you should be paid. See above, for Medicare (and many other payers have similar policy language) if they can’t read it, you didn’t submit it.

4) Appeals. Less than half of all claims are ever appealed. Yet, most payers routinely reject 15-35% of all claims submitted. Some payers even randomly reject claims that may be perfectly payable, but you won’t get them to admit it. Why would they do such a thing? It’s good business (sort of). The payers know that a percentage of your submissions will be eventually denied for errors and that you will never fix them or appeal. If they deny them right off the bat, they have saved time and staff effort in actually performing a claims review. And they know you won’t fight back.

5) Get Trained or Get Out of the Way. Far too many offices leave billing in the hands of amateurs. For some, that may mean the doctor does the billing and we all know how well we were trained in chiropractic school for that purpose. Other offices randomly hand over billing to the front desk person who may be qualified to answer the phone and greet patients, but is in no way ready to handle billing duties. There’s a lot more to getting paid than collecting co-pays and verifying insurance (and unfortunately, not all offices are even doing that correctly). In this arena, your best “weapon” may be brutal self-awareness. Are you truly fit to train your staff? Is your billing department well equipped to handle the duties? Are you willing to invest time and money into getting your staff trained and provided with proper resources to do their jobs? If not, you should admit that you are in over your head and get help. It was not the sling and the stone that led David to victory over Goliath, but divine intervention. While I am not undermining the power of prayer, if your chief strategy when battling the insurance companies is to hope for a miracle, then perhaps it’s time you step aside, get out of the way, and outsource and/or get some experienced assistance for the ensuing conflict.

While I certainly don’t propose to have all the answers, I do have a few resources available for those who recognize the need for assistance:

Products. For those inexperienced in the art of appeals, it is an art form in that you need to know what to appeal and how. Most DC offices leave big bucks on the table, because they never bother to appeal anything. Check out my “done for you” Chiropractic Appeals Toolkit for easy assistance in this matter.

Training. Per your request, this fall I am offering more webinars devoted to timely topics in the area of training you and your staff to get paid and keep out of trouble. If this particular article hit home, you should check out the upcoming webinar “How to Oversee Your Chiropractic Billing Staff or Service” for more helpful hints of this nature. The webinar takes place on Thursday September 3, 2009 and will also be available on CD for those who can’t attend. Check your email for more details.

Personalized Consulting. I can work one-on-one with your office (in a variety of formats) to help you improve your billing, coding, collections, documentation and ultimately help your office maximize reimbursements and minimize audit risk. Feel free to email me for more info.

“Meaningful Use” of EHR for Defined- Finally!

by Tom Necela on June 23rd, 2009 in Billing, Documentation, EHR / EMR, Uncategorized

Reading time: 3 – 4 minutes

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For all of you who have been doing your homework in regards to purchasing an EHR program, we have some concrete news — finally! Until now, the path to see if you can qualify for President Obama’s stimulus incentives has been pretty murky and no one was exactly clear on the definition of “meaningful use” of EHR technology that qualifies you to receive federal funding.

While many EHR companies have stepped up their advertising trying to entice you to get on board with their company pronto, the reality of the situation is that they did not know if their product actually would meet the criteria to get you some of Uncle Sam’s money. This was mainly due to the fact that no one knew the criteria! Unfortunately that didn’t stop many EHR companies from attempting to lure you towards their product, but that’s another story for another day.

The BIG NEWS is this: The Office of the National Coordinator for Health Information Technology (ONC) has finally released its preliminary definition of “meaningful use” June 16, 2009.

Here it is in a nutshell.

Beginning in 2011, Medicare physicians who implement and report meaningful use of electronic health records will be eligible for an initial incentive payment of up to $18,000, and early adopters could receive a five-year bonus of up to $44,000.

The definition for achieving meaningful use of health data includes three parts:

Data capture and sharing by 2011.
Advanced clinical processes by 2013.
Improved outcomes by 2015.

You can also go to the ONC website to read the definition in its full glory.

But…

Before you get too excited or we spend hours discussing the ramifications of “meaningful use” in the chiropractic setting, there’s a chance for bad news as well.

Oh come on, you didn’t expect that? This is the government we’re dealing with!

Here’s the bad news: there is still a chance to submit opinions on the preliminary definition for meaningful use until 6/26/09 so… the definition may change.

Although the definition may be still a bit in the dark, one thing will probably emerge clear: we will see a new wave of advertisements from EHR companies pretty soon. And don’t be surprised if the ads feature buzzwords like “data capture,” “advanced clinical processes” and “improved outcomes” in them. While that may propel some of your colleagues to feel a sense of urgency to purchase a system to capture stimulus dollars – YOU my friends, will know the difference: no one truly knows if their system will qualify for federal $$$.

So, if you’re purchasing an EHR because it’s the best thing to do for your practice (and it very well may be!), go right ahead. Just don’t buy one because some salesman is telling you that you will definitely get a nice fat check back from the feds. The salesman will certainly get a check based on your purchase; you, on the other hand…well…let’s wait and see.

The Strategic Chiropractor Blog

Billing Coding & Compliance Quiz

Archive for the ‘EHR / EMR’ Category

The Final Word on Chiropractic EHR Stimulus Dollars (For Now)

Medicare Releases Chiropractic Medical Review Findings for the 1st Quarter

Correcting Chiropractic Billing Snafus, Altering Records & Advice from Bob

The 25 Meaningful Use Criteria for Chiropractic EMR Systems

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

FREE WEBINAR!

Thursday December 17, 2009

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

CLICK HERE TO REGISTER!

Answers to Common Chiropractic Medicare Problems

Chiropractic Billing, Coding, Documentation Seminars come to Seattle, Portland, Boise

Upcoming Chiropractic Seminars: Learn the Latest Billing, Coding & Documentation Strategies

Handling Your Insurance Conflicts with Success

“Meaningful Use” of EHR for Defined- Finally!

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