DHHS OIG Targeting Tactics for Chiropractic Audits

While you were making last minute preparations for ICD-10, the Department of Health & Human Services Office of the Inspector General published a new report on 9/29/2015. The report makes specific recommendations to CMS with regard to curbing “questionable and inappropriate payments for chiropractic services.”

Why should you care? Well, if you know what OIG considers questionable and inappropriate, you can make adjustments (no pun intended) to your documentation, use of CPT codes & modifiers, and visit frequency to avoid trouble — the kind of trouble that may eventually land you in a position of oversight (including pre-authorizations for services), not to mention fines and return of funds previously paid.

You undoubtedly have a computer in your office & can generate all sorts of reports that provide information about patients. DHHS has computers too. OIG did a great deal of data analysis on chiropractic services performed in 2013. And their data mining techniques helped them pinpoint those of you who don’t seem to follow the rules — and outliers. So… what are they looking for and what can you do to stay off their radar?

  • First, don’t forget to use the AT modifier for chiropractic services. It’s required. CMS realizes that its use doesn’t guarantee the service was actually reasonable & necessary, but the modifier is required. In 2013, 96% of all claims included this modifier.
  • Think twice before using CMT code 98942 for the majority of your Medicare patients. 10% of paid services in 2013 included this code and OIG believes that almost half of these were upcoded. Why? OIG computes your RVU’s (Relative Value Units). They identified 1450 chiropractors who were being reimbursed at higher levels than their colleagues. (Outliers.)
  • High average numbers of claims per beneficiary by your practice indicates to OIG that you’re providing maintenance therapy. OIG believes that 16% of chiropractors received questionable payments and that almost half of these were probably for maintenance therapy. To be specific, 96% of chiropractors averaged 8 services per beneficiary. In contrast, the remaining chiropractors averaged 25 services per beneficiary. This is where your documentation becomes critically important.
    1. If you use an electronic kiosk system where patients enter their own subjective data and have the ability to indicate: “No change. Same as last time” regarding subjective symptoms, and use this option regularly, you will have a problem when your documentation is reviewed.
    2. With CMT codes, make sure you separately document each region you treated.
    3. Active/corrective manipulative treatment is expected to be an improvement in, or arrest of progression, of the patient’s condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. Your documentation must chronologically reflect the active nature of the care you are providing. If you’re unable to document changes in a patient’s subjective complaints & objective findings over time, a CERT audit won’t help you.
    4. Document exact bones (e.g. C5, C6) and/or area (e.g. lumbo-sacral). Documentation must support the symptoms and have a direct relationship to the subluxation. You must have a treatment plan that includes: recommended level of care (duration and frequency of visits), specific treatment goals, and objective measures to evaluate treatment effectiveness.
    5. Be familiar with your Medicare carrier’s LCD (Local Coverage Determination) and use the tables.
    6. You can attest to signatures & plan of care when you get audited, but ideally your documentation should be electronically signed / locked, and your care plans should be reflected in your locked notes.
  • Getting back to those RVU’s, OIG also looked at chiropractors whose paid services indicated the possibility that they were working 16 hour days, which OIG labeled an “unlikely # of services per day.” As you apply CPT codes, you must consider them within the context of other codes you used that day. Make sure you have a sign-in sheet that can back up the fact that those patients were in your office.

Finally, let’s distinguish behavior characteristics considered questionable vs. average by OIG in 2013:

  • Average amount paid per chiropractor: $45,313 vs. $10,303.
  • Average # of paid claims per chiropractor: 1,604 vs. 407.
  • Average # of beneficiaries per chiropractor with paid services: 101 vs.47.

Where do you fit in?

Fortunately, if you’re using the ECLIPSE Encounter to document your Medicare visits, you have everything you need to help you establish each patient’s progression of care.

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