Current Chiropractic News
Live and Recent Video Training
- FEE CALCULATOR
Location Based Fee Calculator
Stay Up To Date
Auditing Chiropractic Services
Published April 22, 2019
By By Evan M. Gwilliam, DC MBA BS CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow Clinical Director, PayDC Chiropractic EHR Software President, Gwilliam Consulting LLC email@example.com
Chiropractic is unique from other types of health care and auditors need to be aware of the nuances of this alternative field. While few services are performed and billed, the rules are very specific. This is due in part to the fact that chiropractic is typically delivered in an episode of care. This episode is often documented as an initial evaluation with a care plan, then a series of visits where the care plan is carried out, often over several stages of care delivered in four-week intervals. Then, ideally, the care ends when the patient reaches maximum therapeutic benefit as measured by the goals established when care began.
The most common CPT codes used (and the only ones payable by Medicare to chiropractors) are chiropractic manipulative treatment (CMT) services. There are three spinal CMT codes:
98940 spinal, 1-2 regions
98941 spinal, 3-4 regions
98942 spinal, 5 regions
Chiropractic has become the focus of more and more audits as doctors seem to struggle to create records that properly support the care provided to the patient throughout the entire episode. The Office of the Inspector General released a dozen reports focusing on chiropractic since 2005, and three of them came out just last year. Most of them indicated error rates of more than 90% and refund demands of several hundred thousand dollars.
One common issue identified was overutilization of 98942, spinal chiropractic manipulative treatment of 5 regions. 98942 has a higher reimbursement rate than the other CMT codes (the Relative Value Unit or RVU is 1.5 for 98942, 1.16 for 98941, and 0.8 for 98940), therefore the financial incentive is there to bill for the higher-level code. Based on Medicare claims submission data from 2015, 98942 was billed 7% of the time, with the remainder of the CMT codes coming from 98941 and 98940. Therefore, if a clinic appears to bill 98942 much more often than the other CMT codes, it may be a red flag.
The challenge with 98942 is that it includes five spinal regions. These regions include the cervical spine, the thoracic spine, lumbar spine, the pelvis, and the sacrum. For Medicare and most other payers, that means that each region must meet certain criteria in order to establish medical necessity. When auditing a chiropractic record and looking for documentation to support manipulative treatment, look for the following (in each region):
- Mechanism of onset
- Subjective complaint
- Objective findings
- Treatment plan
For example, for the cervical region a record showing medical necessity might include the following:
- Slip and fall while working in the yard over the weekend.
- Neck pain with radiculopathy to the right arm.
- Painful, limited cervical range of motion (passive), palpatory tenderness in suboccipital muscles, mild edema in cervical region.
- S13.4XXA - Sprain of ligaments of cervical spine, initial encounter
M99.01 - Segmental and somatic dysfunction of cervical region
- Cervical manipulation two times per week for four weeks to improve range of motion 50% and reduce pain reporting 50%.
- After four weeks range of motion is 50% improved and pain is 50% improved.
In other words, you would want to find all six of these elements in the other four spinal regions if 98942 was billed. While some of the six elements may overlap regions, such as the mechanism of onset, many of these must be uniquely noted in the record. For example, all five regions must have a complaint, objective findings, and a distinct diagnosis.
If you audit chiropractic records, learn to use the six criteria outlined here and become familiar with Medicare LCDs and private payer policies. They can help one to become proficient with chiropractic’s unique audit challenges.
Calculate fees for your area. Please enter your zip code.
About This Tool
The Basic Medicare Fee Calculator is a helpful tool which uses Resource Based Relative Value Units (RBRVS) to estimate fees. It is only for educational purposes and should not be used as your only source for fee schedule determinations. The percentages included here should only be used as a reference and should be adjusted to fit your individual needs. Please note that some states, such as Florida, mandate specific percentages of the Medicare Fee as the allowed amount for personal injury or other claims.
Enter your zip code and click on the [Create Fee Worksheet] button. Geographic adjustments will be applied to the displayed Medicare Fee. The Medicare Fee displayed is the Allowed Amount. To find the Medicare limiting charge for non-participating providers, consult your Medicare Administrative Contractor.
By providing this tool, ChiroCode does not guarantee or assure correct use and application of fees and or codes to users or any other party. Reasonable effort has been made to verify the accuracy of this tool. The regional Medicare fees used as a foundation for this tool are believed to be accurate and current. Absolute accuracy though of this tool or the use of this tool cannot be guaranteed. ChiroCode will be held harmless of any and all liability arising from fee schedule establishment or management based upon the use of this tool. This tool is not endorsed by the American Medical Association (AMA).