Proper Documentation Crucial for Chiropractic Insurance Billing Success

by | Last updated Feb 28, 2023 | Published on Feb 8, 2017 | Specialty Billing

Chiropractic Insurance Billing
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Recent reports indicate just how crucial proper documentation is for the success of chiropractic medical billing. In October 2016, Medscape reported that the Department of Health and Human Services (HHS) had found that most Medicare claims from chiropractors were improper and failed to meet documentation requirements. Many practices are turning to experienced chiropractic insurance billing service companies to ensure that claims are properly filed and supported by necessary documentation. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation requires flawless chiropractic documentation. Chiropractors with a documentation/billing/coding error rate of 85% or more will face Medicare pre-payment auditing.

The following example illustrates good chiropractic documentation:

Spinal manipulation services are covered under the following CPT codes:

  • 98940 (manipulation to one to two regions of the spine)
  • 98941 (manipulation to three to four regions of the spine)
  • 98942 (manipulation to five regions of the spine). The treatment must be documented and the medical necessity must be demonstrated.

Here are some pointers on preparing the chiropractic documentation:

  • Medical necessity must be demonstrated.
  • The documentation must support the need for treatment to the regions of the spine that are treated.
  • Identifying pain (P), asymmetries (A), range-of-motion abnormalities (R), and tissue tone (T) (P.A.R.T.) changes are a required component of Medicare documentation.
  • To meet P.A.R.T., at least two of the following must be documented: pain or tenderness, misalignment or asymmetry, range of motion abnormality and tissue tone changes. One of these has to either be misalignment/asymmetry or abnormality of range of motion.
  • P.A.R.T. should be segment specific and not only by the region of the spine.
  • In conjunction with other documented pertinent clinical findings, P.A.R.T. can establish medical necessity for manipulative care that is both reimbursable and defensible.

Medicare’s Quality Payment Program planned for 2019 fees is meant to encourage healthcare providers including chiropractors to give importance to the outcomes of care over the number of services rendered. The Quality Payment Program includes two payment options – the Merit-based Incentive Payment Systems (MIPS) and an Alternative Payment Model (APM) system. Under MACRA’s MIPS, which came into effect in January 2017, CMS will determine Medicare payment adjustments based on a MIPS composite score comprising four components: quality, resource use (cost), clinical practice improvement activities, and advancing care information. Getting chiropractic documentation right is critical for proper reimbursement and to avoid pre-payment Medicare audits.

With changing healthcare regulations such as MACRA and increased scrutiny of chiropractic documentation, efficient chiropractic billing services can prove very useful to help providers submit accurate claims, adapt to the new payment environment, and increase compliance with Medicare’s policies.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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