(from page 210 in chapter 3.5 of the 2017 DeskBook) One of the biggest problems providers face when audited is that many services are deemed not medically necessary and are routinely denied. Much of the proof falls back on the medical record.

Here are some specific situations as they may relate to audits. 

  • Irrelevant physical examinations The exam must pertain to the patient’s presenting problems or complaints and their history. It may be appropriate to manipulate/adjust a segment(s) that may not be symptomatic and/or located in the same spinal region as the area of chief complaint, but is contributing to the patient’s overall condition. The need for treatment to these segments should be established through clinical measures and have a direct therapeutic effect and be well documented. Objective findings could necessitate a more comprehensive exam. It is essential that such findings are clearly indicated in the documentation to support the clinical need for this extended examination. (See the segment “Nature of the Presenting Problem” in Chapter 5.3 — Evaluation and Management for help with establishing medical necessity for exams.) 

  • Unnecessary Durable Medical Equipment ( DME) There must be clinical rationale for the DME and proof that it supports the healing process. 

  • Unnecessary diagnostic testingThe need for any diagnostic testing must be substantiated in the documentation. The rationale for ordering the test should be based on the provider’s inability to establish a diagnosis to a reasonable degree of clinical certainty without the test results and/or to rule out pathologies, etc. 

  • Unnecessary services It is inappropriate to bill for procedures for parts of the body that are not associated with the patient complaint, presenting problem or those found through objective measures. Be aware of individual payer policies of what they consider necessary.

  • Unjustified frequency of re-examinations and re-x-rays This is an issue when there is little or no documented clinical assessment of the patient’s progress that would require the billing for such services. Essential and required information should be in the daily notes. If progress has not been noticed, there should be a referral for further testing and evaluation.

  • Experimental/unproven services Performing and billing for services deemed “experimental or unproven” by payers is potentially problematic. For this reason, many payer policies include lists of services that are specifically excluded from coverage. 

  • Routine Services. Another issue is billing for services which are performed on a routine basis as opposed to clearly establishing and supporting medical necessity per third-party billing requirements. When these types of services do not meet coverage guidelines, they are easily identified when evaluating provider claims.

Two of the most common services performed on a routine basis, without medical necessity, include 97010 (hot or cold packs) and 97012 (mechanical traction). For more help on audit issues and how to avoid them, see chapter 3.5 of your 2017 DeskBook.