Where Did I Go Wrong?   Reprint of featured article on Chiropractic documentation. 

Where Did I Go Wrong?

By R.L. Ramsdell, Ph.D., DABFE, LFMAAMA

As compliance auditors, we review hundreds of cases from our Chiropractic clients where their services were denied based on “medical necessity”.  The question is always “why?”.  

If you ask your billing person, they will normally tell you that the patient probably “maxed their limits”.  Actually, it is because you failed to properly document the case.  

All carriers that do not set “specific coverage language in their policies” use various guidelines to set “frequency parameters” These “condition based” frequency parameters are often used as a plateau that flags the case for medical review to insure the necessity of continued treatment.   

Carriers recognize a “new injury” that happens during the current course of treatment however most Chiropractors do not document it properly with a “new” initial evaluation or add it to the billing diagnoses and change the injury date on the claim.  The “claim” appears the same each time and becomes a “computer edit” to request notes when the parameters are exceeded and “maintenance therapy” is suspected. 

The Medicare “AT” modifier, for instance, is not new.  It has been a part of the HCPCS modifier system for many years.  It’s mandatory use was implemented based on the 2003 “Improper Medicare Fee For Service Payments” report that indicated chiropractors filed claims incorrectly almost 1/3 of the time; the highest provider error rate in Medicare.  

The use of the AT modifier is still left to the practitioner’s judgment and whether you believe that the care you have rendered is active treatment or maintenance therapy.  The final determination however is going to be based on how well your “documentation” convinces the third party reviewer that it is “corrective” since your “personal input” will not be solicited after the “documented facts” are reviewed.  Auditors do not want to debate the “what ifs” of a case.  The fact that you believe that we are dealing with a silver-crested, winged aviate waterfowl, will not normally change our determination that it is, in fact, a “Duck”.   

The longer the patient is under care, the more important your formal progress evaluations become. These need to be much more detailed than your daily notes and should be used “specifically” to clearly document the patient’s current status, improvement and expected progress and benefit from continued care.  Treatment plans should always be revised to meet the remaining challenges and goals to avoid the “appearance” of maintenance.

 

“Maintenance therapy:  When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.”

For Medicare, you better know the difference. Adding the AT modifier to claims where you “know” or “should know” that your therapy is not active/corrective WILL put you at risk.

 THROW AWAY YOUR TRAVEL CARDS AND ROUTING  SLIPS. They are not proper documentation especially for Medicare.

Most primary neuro-musculoskeletal disorders manifest primarily by a painful response, which results in a “physical complaint” from the patient that must be documented as the reason the patient is seeking treatment on this visit !  The simple auditing guideline is: No complaint, No necessity for treatment.

 Pain and tenderness findings must be identified through one or more of the following:

• observation,

•  percussion,

• palpation,

• provocation, etc.

 You will win or loose medical necessity based on your documentation of the initial visit.  In many cases we review, the problem or condition is reported as being symptomatic for a considerable period of time.  No acute aggravation is noted nor is an increase in pain score.  Why are we now starting treatment?  Did the patient get a “free consultation” where they were informed that their insurance would cover “the entire expense”?

 At the absolute minimum, your documentation must cover:  

• Symptoms causing patient to seek care; “why are they here and what is bothering them”
• Quality and character of symptoms/problem; “describe the pain”
• Onset, duration, intensity, frequency, location and radiation of symptoms; “When did it start, how long have you been suffering, how bad is it now and where does it hurt and why do we need to treat it now when you could “live with it” before?
  • The symptoms should refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo or osteo), rib (costo or costal) and joint (arthro) and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must be related to the spine by notation. The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited.
• Mechanism of trauma; 
• Family history if relevant;
• Past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history);
• Aggravating or relieving factors; and
• Prior interventions, treatments, medications, secondary complaints.
• Evaluation of musculoskeletal/nervous system through physical examination.
• Diagnosis: The primary diagnosis should be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named.
• Treatment Plan: If you don’t have a long term one, do a short term one!

After you have reviewed the patient’s history intake form, a dictation of the visit may follow this format:

Patient: John Smith

For Service Date: January 10, 2005

Attending: B.K. Cracker, D.C.

 Mr. Smith presents to the office with complaint of low back pain that began approximately three to four weeks ago without identification of a direct cause.  The patient tried conservative self care at home with over the counter remedies however he states his symptoms have progressively worsened to a point where he is unable to perform normal activities at work and personal daily living.  He rates his current average, constant pain at a 6/10 with fluctuation increase to a 7-8/10 with physical activity and reduction to a 5/10 level with rest and application of a heating pad.  He describes his pain as a constant deep, dull aching sensation, with intermittent daily episodes of sharp, stabbing pain in the low back that refers down the upper thigh.  Upon additional questioning, the patient reports description of worse in the left and right sacroiliac joints and the adjacent para-vertebral muscles.  The patient relates that this is his first episode and has not sought care elsewhere. 

Examination: Mr. Smith is a 34-year-old Caucasian male, 5’ 10” in height of 200 pounds, married with 2 young children.  He appears physically fit and is alert and orientated x3. Mr. Smith presents in apparent physical discomfort exhibiting difficulty in rising from the sitting position and an encumbered gait.

 Family History: Noncontributory

Past Medical History: Noncontributory 

Social History: Mr. Smith is employed full time in mid-management that requires prolonged sitting at a desk.  He denies use of tobacco or drugs, affirms an inconsistent exercise program and social use of alcohol and consumption of 3 to 4 cups of coffee per day. 

 Palpatory Findings:  Exquisite taut and tender fibers into the L4-L5 with right and left sacroiliac joint pain.  Muscle spasms evident over the involved areas in the para-vertebral muscles.

 Orthopedic Examination: Positive Yeoman for sacroiliac dysfunction and lumbar instability. Heel walk and toe walk negative. 

Neurological Evaluation:  Deep tendon reflexes are +2 and symmetrical.  Cranial nerves II thought X grossly intact and functional.  L4-S1 nerve root levels within normal limits when tested with a pinwheel.

 Radiographic Finding Summary: AP and lateral lumbar views were obtained.  Lateral views reveals right spinous rotation with a moderate amount of pelvic un-leveling at the iliac crest and at the hip socket with the left being substantially higher (approximately 17 mm higher) and formaminal encroachment at the L5-S1 nerve root level.  No gross soft tissue or osseous pathologies were noted.  Films are consistent with moderate to severe muscle spasms. 

 Assessment:

1. Lumbar region segmental dysfunction
2. Sciatica
3. Myofasciitis
4. Paravertebral myospasms

 

Treatment:   Chiropractic Manipulation was performed to L4, L5 S/I bilaterally (you can add in the method if you wish) \ e-stim for muscle spasm control was applied to the lumbar paravertebral muscles for a period of 15 minutes,  Ultrasound was applied to the same area for circulatory influence and relaxation of musculature.

 Plan:  The patient will undergo a course of chiropractic manipulation therapy three times a week for 2 to 4 weeks based on contemporaneous evaluations and progress.  Modalities for pain control, spinal stabilization and muscle strengthening will be integrated as needed on a per-visit needs determination basis and a limited home exercise program instituted and adjusted as the patient’s condition improves.  Patient should return as scheduled with formal re-evaluation of testing and progress in 2 weeks.  Continuation and/or modification of plan will be determined at that time.   (This is an example of a “short term” plan)

 We suggest you avoid references to golfing, gardening and the like on any presentation.  Without a “good” history of the chief complaint, we are left with the assumption that the patient “over did” on a specific day and the complaints are attributable to “minor, over exertion, muscle pain” that would spontaneously resolve with a little rest and some Ben-Gay.  

Audit guidelines specify that the “daily notes” also need to be encounter specific for each day of service. It should be clear from the documentation why the service was necessary that day.   

You must set the stage for the necessity of treatment “each visit” and if you routinely adjust multiple regions, you must justify the need for each with not only your physical findings but also a patient complaint that the area is bothering them.  Most carriers will deny or down-code based on the lack of a “presenting complaint” not only on treatment but also diagnostics.

Quick fill in forms are ok provided they contain the needed information and are “interpretable” by an auditor or third party reviewer.  If you are the only one who can interpret them, they are no use to anyone but you and are therefore not compliant with documentation rules.

Your simple, yet critical rule for documentation is that the record must be created and maintained in a manner that will survive its’ creator and should clearly state not only what you did and what you want to do but also “why”. 

 About the Author: 

Ronald L. Ramsdell, Ph.D. is the President of MedCorp Compliance Network, a firm that specializes in coding and documentation compliance.  Dr. Ramsdell is a Board Certified Diplomate of the American Board of Forensic Examiners, Executive Director and a Life Fellow of the M.A.A.M.A,; a life member of Who’s Who and a long time member of the American Academy of Pain Management. He has served as a compliance and documentation consultant to hundreds of practices of all healthcare disciplines and is frequently engaged by health care law attorneys for independent assessment of their clients Medicare/ Medicaid and overall compliance though comprehensive audit.  Dr. Ramsdell can be reached through his Las Vegas, Nevada office at (702) 838-0054 or by e-mail to DrR@MAAMA.ORG.