What Compliance Means for the Chiropractic Practice

by | Last updated Jun 26, 2023 | Published on Feb 11, 2019 | Specialty Billing

Chiropractic Practice
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Compliance became a buzzword among chiropractors when the Office of Inspector General (OIG) formulated and published compliance program regulations for individual and small-group physician practices in October 2000. Voluntary compliance programs offer a way to prevent and reduce improper billing and coding conduct and protect the integrity of Medicare and other federal healthcare programs. In fact, chiropractic billing companies help providers ensure that the claims submitted to federal healthcare programs are true and accurate. However, for the chiropractors, sound compliance also includes maintaining proper documentation, performing a security risk analysis of their EHR, adhering to HIPAA rules and establishing medical necessity on claims. Let’s look at the implications of compliance for the chiropractic practice.

  • Proper coding: The chiropractic codes selected must correctly reflect the chiropractic care provided to the patient. Providers need to be up-to-date on ICD-10 and CPT coding to report services accurately. The newest ICD-10 code set for chiropractic which came into effect on October 1, 2018 includes updates for myalgia and muscular dystrophy. It is crucial to be as specific as possible when choosing the diagnosis code. CPT codes frequently used in chiropractic practices are include: manipulation: 98940-98943; Evaluation and Management, Initial Visit: 99202-99204; Evaluation and Management, Established Patient: 99212-99214; Therapeutic Exercises: 97110; Neuromuscular Re-education: 97112; Manual Therapy: 97140, and Physical Performance Examination: 97750. Chiropractors need to know the rules to bill these procedures. For instance, AAPC points out that chiropractors should not bill high-level codes such as 99204 and 99215 because the patients they see rarely have presenting problems to justify high level E/M encounters.
  • Proper documentation: The American Chiropractic Association (ACA) stresses the importance of completely documenting each patient encounter. While documentation may not be required for initial billing of services, it substantiates that the service was actually performed, which is important to prevent auditors from deducing that care was not provided appropriately.
  • MACRA: A 2016 article in Chiropractic Economics notes that MACRA (Medicare Access and CHIP Reauthorization Act of 2015) matters for compliance. Once registered as a Medicare provider, doctors of chiropractic cannot opt out like other physicians. To succeed with the new payment model, providers need to have the ability to report and stay complaint with the new system.
  • Compliance with HIPAA and other standards: The Health Insurance Portability and Accountability Act (HIPAA) is here to stay. Every practice should have clearly written standards and procedures for access of the patient records, (by patient, by other providers and by a third-party payer such as a chiropractic medical billing company) and authorizations required for access-HIPAA compliance. Similarly, there should be well-established procedures for documentation of informed consent, creation and preservation of treatment records, content of treatment records, and time frames for entry of data. All policies and procedures should be implemented on regular basis to ensure that patient encounters are properly documented, claims are billed properly to third-party payers, and all patient information is confidential and secure. Staff training is an important part of EHR security and protection against virus attacks. In addition, chiropractic practices must adhere to the standards of Occupational Safety and Health Administration (OSHA) to ensure a safe and healthful working environment for staff by setting and enforcing standards and to provide training, outreach, education, and assistance. Staff training is crucial to prevent injury and illness.
  • Medicare documentation: Both the OIG and the Centers for Medicare and Medicaid (CMS) insist on more stringent documentation standards for chiropractic physicians in an effort to ensure medically necessary treatment for Medicare beneficiaries. Chiropractors’ billing claims should clearly establish that the care they are providing is medically necessary. Medicare is a significant source of revenue for many providers. Generally, maintenance care is scrutinized more closely and will be denied outright by Medicare and some other payers if medical necessity is not established. So, doctors of chiropractic need to manage their Medicare documentation to promote legal and compliance protection and get appropriate financial compensation for their services.

The ACA recommends that chiropractors perform self-audits to avoid regulatory and commercial payer audits and recoupments. With self-audits, practices can confirm that services are properly documented and billed. A self-audit can be performed on a daily basis before services are billed, or on a monthly, quarterly, semi-annual, or annual basis. Audits can be performed on each chart for a particular date of service or occasionally for proper coding, documentation and compliance with insurer contracts. Medical billing outsourcing companies that specialize in chiropractic billing have stringent QA measures in place to ensure error-free claim submission.

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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