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Navigating the world of billing and coding can be overwhelming for chiropractors. Compliance with Medicare and private insurer requirements is crucial and providers must carefully manage coding, coverage, and documentation of services to ensure timely payment. However, mistakes can occur and can lead to denied claims, lost revenue, and even compliance issues. While outsourced chiropractic billing services can ensure faster claim processing and improved cash flow for the practice, chiropractors need to be aware about the common chiropractic billing errors and how to avoid them.

Here are 5 common mistakes that can occur in chiropractic billing:

  • Coding errors: Accurate coding is crucial for proper chiropractic billing. The precise level of subluxation must be specified on the claim and must be listed as the primary diagnosis. The neuromusculoskeletal condition necessitating the treatment must be listed as the secondary diagnosis. All claims for chiropractic services must include the following information:
    • Date of the initiation of the course of treatment.
    • Symptom/condition/Secondary diagnosis code(s)
    • Subluxation(s)/Primary diagnosis code(s)
    • Date of Service
    • Place of Service
    • Procedure Code

Failure to report these items will result in claim denial or delay.

Mistakes in selecting the appropriate diagnosis and procedure codes can result in claim denials or underpayment. Coding errors include upcoding and undercoding. Here are two examples of upcoding –

  • Reporting CPT codes in claims for services or treatments that were not actually provided, inflating the billed amount and potentially leading to higher reimbursement.
  • Coding an established patient office visit as a new patient visit to obtain increased reimbursement.

Undercoding, on the other hand, occurs when a practitioner bills for a lower level of service than what was provided. Both upcoding and undercoding can result in denied claims, lost revenue, and even legal issues. Overcoding can be seen as fraudulent billing, while undercoding can be seen as a failure to provide proper care.

Here are some specific chiropractic coding issues as listed in a Chiropractic Economics article (published September 10, 2021):

  • General coding errors – Billing incorrect unit numbers for time-based codes; time missing in the documentation for modalities and procedures; service provided by unqualified team members.
  • 97014/G0283, Electrical Stimulation – Billing more than once per patient encounter, regardless of areas treated; billing using 97014 when the payer requires the alternative HCPCS code G0283.
  • 97110, Therapeutic Exercises – Documentation missing specific exercise, location, time, reps, or muscle groups.
  • 97124/97140, Massage and Manual Therapy – Service performed by someone other than the DC when the payer indicates it must be performed by the DC.

To prevent such errors, it is crucial to stay abreast of the latest coding guidelines and accurately assign billing codes that precisely represent the services rendered. CMS requires that diagnosis codes are coded to the highest level of specificity. Chiropractors should carefully review their documentation and ensure its alignment with the appropriate codes. If uncertainty arises regarding the correct code to use, they can consider consulting a medical coding service or utilizing trustworthy resources like the CMS website.

    • Lack of documentation: Proper documentation is essential for billing and reimbursement. Inadequate or incomplete documentation can result in claim denials or audits. Chiropractors should ensure that their documentation includes the patient’s chief complaint, examination findings, treatment plan, progress notes, and any other relevant information.Coding from documentation is critical to the compliance process.

Documentation should meet state guidelines, AMA guidance, CMS guidelines for evaluation and management (E/M) services, malpractice documentation guidelines for policyholders, including their recommendations for obtaining informed consent, and third-party payer guidelines.

The medical review policy for chiropractic care frequently incorporates the essential criteria for documenting the medical requirement of the treatment, along with the necessary elements to be included in the patient’s health record.

Medicare’s documentation standards are considered an excellent guideline for all the practice’s documentation. CMS requires documentation that supports the medical necessity. Claims submitted without diagnosis codes will be denied as being not medically necessary. While documentation in the form of progress notes need not be submitted with each claim, it should be available upon request. CMS requires that claims submitted for Chiropractic Manipulative Treatment (CMT) CPT codes 98940, 98941, or 98942, must contain an AT modifier or they will be considered not medically necessary (https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=56273).

CMS documentation guidelines for evaluation and management (E/M) services usually apply to commercial payers. Moreover, each Medicare administrative contract (MAC) publishes guidelines on local coverage determinations (LCD) and coding and billing for initial and routine visits for Medicare patients.

    • Incorrect or incomplete patient information: One of the most common billing mistakes is entering incorrect or incomplete patient information, such as misspelled names, incorrect insurance policy numbers, or outdated contact information. This can lead to claim denials or delays in payment.

To avoid this mistake, practices should obtain the patient’s insurance information at the time of scheduling and verify coverage before the appointment. This is important to ensure that the patient’s insurance will cover the cost. Insurance eligibility verification experts call the insurance company or utilize online resources to confirm the patient’s coverage. . Failure to verify coverage can result in denied claims and lost revenue.

    • Billing for non-covered services: Another common mistake in chiropractic billing is billing for non-covered services. Chiropractic services are covered by most insurance plans, but there are certain services that may not be covered. For example, maintenance care is not covered by Medicare. Claims for non-covered services will be denied. Verifying insurance coverage before providing services is the best way to prevent this mistake.

Chiropractic offices may want to submit charges to Medicare to obtain a denial necessary for submitting to a secondary insurance carrier (CMS). Examples of services that, when performed by a chiropractor, are excluded from Medicare coverage include: Laboratory tests, X-rays, Office Visits (history and physical), Physiotherapy, Traction, Supplies, Injections, Drugs, Diagnostic studies including EKGs, Orthopedic devices, andNutritional supplements and counseling

  • Failure to follow insurance guidelines: Each insurance company may have its own specific guidelines and requirements for chiropractic billing. For example, different payers assess coding in different ways. Certain payers enforce stricter criteria to determine medical necessity, while others may classify similar services as experimental, investigational, or unproven. Failure to follow these guidelines can result in claim denials or underpayment. It’s crucial to familiarize yourself with the insurance policies and requirements of the different insurance companies you work with.
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Billing mistakes can also occur due to inadequate training of staff members responsible for billing and coding. It’s important to provide ongoing training and education to ensure that your billing staff is up to date with the latest coding and billing guidelines. Partnering with a chiropractic billing company is a practical way to streamline the billing and coding process. Experts stay updated with the latest industry changes and insurance requirements, and can ensure accurate billing to maximize reimbursements.

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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