February 2015 Theme: Documentation

Ah, February . . . the month of LOVE! And don’t you LOVE documentation?! If

you don’t LOVE your documentation, it may be that you’re coming at it from a

difficult angle, with a challenging system in your office, or without the proper

mechanisms to make documentation easy for you. While it might never be easy,

it can likely be easi-ER for you. When’s the last time you took a good look at

what your documentation is telling a third-party reader? If it’s been a while—or

never—consider having my team of Certified Medical Compliance Specialists

look it over. What you “don’t know” might not be so bad!

Documentation 101 We’re frequently called into chiropractic offices to perform an evaluation of their documentation. It’s essentially a friendly audit, if you will, to determine proper adherence to the generally accepted documentation principles required in patient records and insurance forms.

We wish we could say that the results were always stellar, and that medical necessity and treatment protocol were thoroughly documented, in a standardized format, across all patient forms and records in every chiropractic office we’ve ever visited. If that were true, we could close up shop, because there’d be no need for the services we perform and no reason for an article like this. Since you’re reading this, the truth is obviously otherwise: the majority of chiropractors we meet remain confused by and nervous about proper documentation—and far too many of them lie awake at night worrying about it.

And it’s not surprising. Chiropractors don’t go to school to become documentation experts. But we did. So let us help you re-set your practice with a refresher on the basics:

What Is Documentation FOR, Exactly?

The answers may seem obvious at the moment—and less so when it’s 7 p.m., you saw your last patient at 5 p.m., and you’re still in the office pushing paperwork.

Documentation is required to:

• Demonstrate medical necessity • Create a chronological record of a patient’s ongoing treatment and care• Provide a means to communicate this treatment to other healthcare providers • Record pertinent facts, findings, and observations about a patient’s health history (past and present),

including examinations, diagnostic tests, treatments, and outcomes

In this issue:

Kathy’s Message

Documentation 101

KMC University’s Q&As

The Compliance Corner

In the News

ICD-10 Countdown

Product of the Month

ChiroFunnies

Upcoming Dates for Webinars

Kathy’s

WOW!Words of Wisdom

Proper documentation of a patient’s medical record allows the chiropractor and anyone else involved with the pa-tient’s care to evaluate and plan proper treatment and to monitor the patient’s health over time. It also facilitates the communication that is sometimes necessary among all professionals involved with a patient’s care and allows for accurate and timely review and payment of claims submitted to a third-party payer.

What Are Payers Looking for in Terms of Documentation?

Unless you run a total cash practice, insurance is one of those realities you simply have to deal with in order to be reimbursed for your services. Third-party payers generally require proof that the services for which you are billing are consistent with the patient’s insurance coverage and any pre-certifications that have been authorized. They may ask that you be able to validate:

• Place of service • Medical necessity of care rendered • Nature of services provided • Accurate reporting of services provided

General Documentation Principles

General documentation principles provide stan-dard documentation guidelines for all chiropractic offices. Adherence to these principles mitigates risk in a court of law or during an audit, and ensures conformity across all types of office forms and procedures.

Here are the documentation principles that you should adhere to in your practice:

• Document a patient’s progress, response to and changes in treatment and any revision to the working diagnosis

• Identify any health risk factors • Make sure that the CPT or ICD–9 (or, as of October 15, ICD-10) CM codes you use on third-party payer claim

forms or billing statements for a patient are also documented in the patient’s medical record • Write neatly and legibly; make sure the medical record is complete • Document the reason for ordering diagnostic or other ancillary services, or make sure your rationale is easily

inferred from the record • Ensure that all past and present diagnoses are accessible to a patient’s treating and/or consulting physician

What Should a Patient’s Record Include for Each Encounter?

The documentation of each meeting with a patient in your practice should include the following:

• Reason for visit, relevant history, result of physical examination, prior diagnostic test results • Patient assessment, clinical observation/impression and/or diagnosis • Plan for care • Date and legible identity of the observer (chiropractor)

What About Medical Necessity?

Medical necessity is the vehicle that drives the payment of any claim that you submit for a patient. Without proper documentation, you don’t have a leg to stand on, so it’s extremely important to make sure that all care rendered to a patient is documented accordingly.

Necessity is defined as a condition or quality of being necessary; a pressing or urgent need; the condition of being essential. In terms of medical necessity, you must have a valid expectation, at the time care is rendered to a patient, that improvement will occur.

In order to meet medical necessity guidelines, your documentation must include:

• Patient consultation and history data • A record of physical examination findings, tests, and measurements

KMC University’s Q&As

Q: I’d like to use the code 99204 more. How can I document this to get it paid?

A: Code 99204 requires meeting all three key components of the code (comprehensive history, comprehensive exam, and medical decision-making of moderate complexity), as well as medical necessity for a service of that intensity. CPT

describes these services as typically involving problems of moderate to high severity. Keep in mind, the best

and most ethical way to choose codes is by doing what’s necessary to treat the patient, accurately documenting that treatment, and THEN choosing a code that best

reflects that treatment. You should never pick a code first then work it into your treatment.

• Subjective complaints (voiced by the patient) • Functional goals—what you hope to have this patient achieve as a result of

treatment • Diagnosis/diagnoses • Treatment plans

So . . . What Should You Do Now?

We suggest that you conduct a self-audit of your office documentation as soon as possible to ensure it meets all the guidelines presented here. If you find that you’re lacking in any area, plan whatever remedial action is necessary to ensure that your records would merit an “A” in thoroughness, compliance, and meeting the definition of medical necessity. Need help? We’re happy to give you peace of mind. Just contact us at info@kmcuniversity.com.

Compliance CornerTo Join or Not to JoinBrand new DCs as well as experienced doctors continue to kick around and go back and forth on the issue of whether to run a cash practice or to join the land of third-party reimbursement. Whichever way you go, and whether you’re looking at Medicare or commercial health insurance, the key is to be sure you clearly understand whether being in or out of network is your best choice.

New practitioners, DCs transitioning from cash practices, or even those rethinking their stance may believe it’s imperative that you scramble to join every major insurance network any potential patients could possibly belong to. We get it. It’s easy to make the incorrect assumption that patients will only come to your office if you participate with this or that network.

But there are many things to consider before joining a network. Among them are the levels of reimbursement you can expect, the restrictions placed on the practitioner’s ability to bill the patient for the balance, and the definitions they will apply to your treat-ment from their medical review policy.

It’s essential, if tedious, to read through any and all provider agreements and understand every stipulation that you are agreeing to with your signature. Far too often, doctors find out well after the fact that a procedure regularly performed in the practice is not covered or bundled per the contract. Additionally, providers may choose to add a new service or product, such as spinal pelvic stabilizers, and find that their provider agreement allows for reimbursement in the fee schedule at a level lower than the cost of the product.

If you plan to join a network, be sure that you follow every rule of the agreement that you signed.

We’ll be happy to help you sort through this decision; simply contact us at info@kmcuniversity.com.

In the NewsYour Payers May Require You to Append New Subset ModifiersMore news on the new subset of HCPCS modifiers for modifier 59 that were proposed by CMS in August, 2014! Both United Healthcare and Anthem BCBS have released new info:

• United Healthcare Network Bulletin - January 2015

UnitedHealthcare will continue to recognize modifier 59; however, current proce-

DEC’14

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ICD-10CODINGCOUNTDOWN

7 MONTHS TO GO!

EIGHT MONTHS OUT! Test drive ICD-10: take some of your

documentation and rewrite using the new

codes for practice.

dural terminology (CPT) instructions state that modifier 59 should not be used when a more descriptive modifier is available. In addition, the X {EPSU} modifiers are more selective versions of modifier 59, so it would be incorrect to include both modifiers on the same line. United Healthcare has requested providers to reference a table found on page 27 of the Network Bulletin in order to find out when the new modifiers will be implemented. The entire policy can be found here.

• Anthem Blue Cross Blue Shield December 23 Network E-Update

Important professional reimbursement information. Please see the following corrections to the December 2014 issue of Network Update. Beginning with claims for dates of service on or after January 1, 2015, Anthem (the Health Plan) will consider the new -X {EPSU} modifiers as informational only and will not be used to override an edit until further notice. Please continue your current billing practices until further notice. For further questions, please contact your local Network Relations consultant. [emphasis added]

January and February are when payers often post the new year’s Policy Updates, Reimbursement Guidelines, and Net-work Bulletins—and this year that information is changing almost weekly, if not daily. We strongly recommend check-ing your payers’ websites frequently so reimbursements won’t be delayed for your practice, and you can be assured we’ll be keeping you updated as well!

Product of the MonthMedical Necessity Documentation

This training kit will take both doctor and team members through the steps necessary to understand how to

accurately document medical necessity consistently throughout all patient documentation. Clarity is essential when

working with third-party payers, so there is a distinct difference between the care you bill to third-party payers as

medically necessary and care that is clinically appropriate, but for which the patient is financially responsible.

What’s Included:

• Training Implementation Guide

• Training Webinars, including Topical Overview Training: “Medically Necessary Care: Incident, Burst, or Full

Episode;” Quick Byte Concept: “Locating Your Carrier’s Medical Necessity Definition;” Rapid Tutorial: “Essential

Elements of Assessment;” Topical Overview Training: “Learn to ‘Tell the Story’ with Daily Visit Notes;” Rapid Tutorial:

“Better Patient Management with Discharge Summaries;” Quick Byte Concept: “Creating Subluxation Policy”

• Fact Sheets, including: Medical Necessity Tool Kit and Administrative Discharge Service

• Support Tools: When They Know Why, They’ll Comply and Assessment Reference Tool

• Sample Policies: Medical Necessity and Subluxation Documentation

Get the Product of the Month here:

http://kmcuniversity.com/shop/index.php?main_page=product_info&cPath=23&products_id=192

$100 OFF!!!NOW JUST $149!USE CODE MND215 AT CHECKOUT

Helping Chiropractors make and keep more money.

Upcoming Dates for WebinarsFebruary Live Webinar (Visit www.kmcuniversity.com/shopto order, or click the links below)

February 17th, 2014 - 1:00 PM EST :

“Documenting Active and Passive Therapies – Get Your Story Straight ”

ChiroFunniesHAPPY VALENTINE’S DAY!