Mastering Chiropractic Medical Necessity in 2015 (Part 2)


In Part One of this article, we looked at a few medical necessity “traps” that are plaguing chiropractors.  In other words, things NOT to do when attempting to document or meet criteria for medically necessary care.

We also discussed that one of the challenges with mastering the maze of medical necessity is that the definitions may vary from payer to payer.  However, don’t lose hope.  There are a few common elements that contribute to most insurance payer requirements.

Here are ones that are most often missed — but frequently needed — in establishing your care as medically necessary:

Matching Your Chiropractic Billing-Coding-Documentation. Perhaps one of the most overlooked, yet simple tests for medical necessity is the Billing-Coding-Documentation Matchup.  Essentially, all this means is that you have billed a 98941 then your diagnosis coding must communicate that you have a three to four region adjustment and your documentation must correlate as well.  An auditor who reviews a 98941 claim and detects that only two spinal areas have been diagnosed need go no further: the claim does not meet medical necessity. Similarly, if the billing and the coding match, but the documentation only supports a two level adjustment, medical necessity is also not met.  To prevent this from happening, “set the stage” correctly from the start. It’s likely that if you’ve diagnosed all the problems from the onset, you will always have the diagnosis in place to support your adjustments. Then it’s just a matter of making sure your documentation matches up.

Response to Care.  Here is another area easily overlooked that can be fatal towards your attempts at proving medical necessity.  Basically, you need to indicate the patient’s response to your care in your documentation.  In doing so, the essential point you want to communicate is this: can an outsider view your treatment notes and get the impression that the patient is progressing, staying the same or getting worse with care.  While it may sound horrifying to report that a patient is worse, reviewers understand that you are not obligated to be a miracle worker. However, a consistent downward spiral would probably indicate your care is not needed, because it is not working.  On the other hand, an auditor does not always assume your care is getting the patient better because they do not have the benefit of being a first hand observer to the patient’s progress, as you are.  Therefore, the best remedy is to always indicate a response to care so that you can clearly depict the results your treatment is getting.

Be Fixable.  A final stumbling block I have observed in medical necessity documentation is the concept of treating a “fixable” condition.  The buzz word “functional improvement” goes a long way in describing how we should approach our treatment and its medical necessity.  Sometimes, this is quite simple.  A patient with mid back pain has restricted motion of the thoracic spine.  The chiropractor’s adjustment restores motion and alleviates the back pain. Certainly this would meet medical necessity in the basic sense.  Now, complicate that scenario by stating that the patient also had severe, longstanding degeneration in the mid back.  Here, the chiropractor may not actually be able to reverse the degenerative process with the adjustment, but the end result is the same: the adjustment improves motion and pain is relieved.  If the chiropractor is able to document the functional losses from the condition at hand and the resulting functional improvements due to chiropractic care, most would agree this meets medical necessity.

In this category, many chiropractors get flustered with chronic conditions. While these may not be “curable” (due to the degenerative process, a permanent problem, etc) the painful situation the patient is experiencing is “fixable” and can meet medical necessity if documented accurately.  Particularly, if you have labeled this a “chronic” problem for which you document temporary relief and objective gains.

What to Do Next

For many there is a great mystery surrounding the idea of medical necessity. But most of the time, there are missing elements, bad habits or lack of understanding at the heart of most medical necessity denials.

The good news is that although these too may be “chronic” problems, they are also fixable.  Here’s a start:

1.  Address the items above. If one of these elements (or those discussed in Part 1) are missing, you are going to have problems

2. Develop consistent systems to ensure that you bill, code and document correctly.  Knowing how is only one part of the battle.  The bigger issue is DOING it.

3.  Get help when needed.  If you’ve been wrestling with your notes, denials, underpayments or the dreaded sense that you are leaving money on the table due to errors, lack of information or other preventable mistakes, it’s time to get help to move forward (or prevent the pain of denials, audits and under-performance).

Want to Work Smarter in 2015?

You still have time to conquer medical necessity, decrease audit risk and increase profits to make 2015 the year your Chiropractic Business Works SMARTER! In our Work Smarter 2015 Online Workshop, you will discover  the 4 most important elements in your chiropractic business and how to tweak them dramatically to increase your profits & your freedom while decreasing your risk. Click the link above for more info and register today!

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