#chiropractic documentation

New Post has been published on http://www.strategicdc.com/medicare-auditors-reveal-2-biggest-ehr-weaknesses-that-may-lead-to-fraud/

Medicare Auditor’s Reveal 2 Biggest EHR Weaknesses That May Lead to “Fraud”

Buried amidst a flurry of OIG recommendations, targets and auditing hoopla are two gems that can help us as chiropractors reduce the possibility of EHR-induced documentation problems.

 The news is riddled with stories about the cost of health care “fraud” (current guestimates put this between $75 billion and $250 billion) and are starting to spook even the most jaded of practitioners. Unfortunately, while the widespread growth of EHRs has helped on one hand by enabling chiropractors to efficiently create much better documentation, there is a downside as well. EHR may also enable more widespread problems when used improperly.  To this extent, Medicare recently identified the two biggest EHR taboos that could lead to “fraudulent” billing practices.

 CLONING

A common EHR documentation practice is known as “copy-pasting” or “cloning”. Regardless of you’re your particular chiropractic EHR system calls it, cloning allows you to select information from one visit or section in an EHR and replicate it in another section or visit date.

Make no mistake: this is an incredibly useful and time saving tool. Copying repetitive information that has not changed can be much more efficient than having to re-type all the information (or worse yet, accelerate your arthritis by hand-writing it).

However, cloning is easily susceptible to misuse. When chiropractors clone information but do not update it or ensure its accuracy, erroneous data may enter the patient’s medical record. In turn, inappropriate charges may be billed to patients or third-party health care payors. Likewise, improper cloning can facilitate attempts to upcode claims and duplicate or create fraudulent claims.

Here’s a few quick ways to avoid cloning errors:

 Never copy the subjective portion of your daily SOAP note.  It’s pretty hard to argue that your notes aren’t cloned when then the last 17 visits state: “Neck pain is improving, Low back pain remains unchanged since the last visit.”  Even IF the findings truly had not changed, you’ve got a medical necessity issue on your hands due to the fact that you’ve had 17 visits in a row with virtually no change.

Avoid copying entire sections from your initial exam note.  Face it, you most DC’s don’t perform tests over and over again every visit. While it’s great you took the patient’s blood pressure, temperature or pulse on their initial visit, its likely that they do not have the same exact vitals each  and every subsequent visit.  And you haven’t re-taken those vitals either.  So to act like you did and simply copy every single test you’ve ever done into your daily SOAP note is unnecessary at the least and at the worst, can be potentially fraudulent as you are misrepresenting yourself.

Never copy “extraneous statements.”  On the positive side, recording comments that your patient makes, noting when you refer them to another doctor or reviewing diagnostic testing results are all great ways to improve your documentation.  However, when you copy those notes visit to visit, an auditor can smell a cloned note from a mile away.  Imagine the ease at which “reviewed MRI results with the patient which revealed L4-5 disc herniation” begins to stand out when seen on your documentation M, W and Friday.  Did you really review those MRI films three days in a row? Of course not, you copied the note and forgot to delete that info.  Busted. 

  OVER DOCUMENTATION

Another EHR documentation practice that is troublesome is “overdocumentation.” Under this scheme, a chiropractor inserts false or irrelevant documentation into the EHR, creating the appearance of medically necessary information that supports billing at a higher level of service.

Overdocumentation typically occurs in EHR systems that auto-populate fields when using templates built into the system. It may also be seen in EHR programs that generate extensive documentation from the single click of a checkbox. If  the chiropractor does not properly edit the documentation and/or gets “click happy” the information may be wildly inaccurate and may lead to inappropriate billing.

Though most DC’s don’t seem to fall into this trap, a growing minority are using EHR to “beef up” their documentation dangerously. 

Here are some tips to avoid the bad practice of over-documentation:

Don’t equate length with quality.  For some, a longer note means a better note.  Get that thought out of your head because it’s not true at all. I’ve been personally tortured with excessively long notes that say a whole lot of nothing and still missed the mark.

Test Don’t Teach: there’s no need for you to describe HOW to perform a particular orthopedic test or chiropractic procedure, just do it and record the results.  Describing how to perform Kemp’s Test and what will produce a positive finding certainly creates a lengthy and perhaps impressive looking note – until it is read.  You are not Charles Dickens getting paid by the word.  Keep it simple and give what’s needed. No more, no less.

  Final Thoughts & Recommendations

Notice I have intentionally used the word “fraud” in quotes several times in this article.  In my experience, few if any of these errors would be prosecuted as fraud.  However, the lesser but still unpleasant cousin of fraud is known as “Abuse.”   These errors would likely be classified as Abuse which carries penalties of its own: namely, postpayment demands, disciplinary sanctions, providership removal and a whole lot of stress of its own.

Good documentation is a factor of good compliance that most chiropractors know they need, but don’t care to address.  Unfortunately, with the onset of more auditing, the impending arrival of ICD-10 and the increasing emphasis on improving the quality of your notes, now is the time to eat that frog and get moving on getting more compliant, creating better notes and protecting your business.

New Post has been published on http://www.strategicdc.com/chiropractic-targeted-in-oigs-2014-audit-plan/

Chiropractic Targeted in OIG’s 2014 Audit Plan

Each year, the Office of Inspector General (OIG) publishes their yearly “work plan” which summarizes new and ongoing reviews and activities that OIG plans to pursue with respect to HHS programs and operations during the current fiscal year (FY) and beyond.

 In plain English, the OIG Work Plan shows the latest targets that auditors will focus on with respect to Medicare programs and unfortunately, chiropractic services have made the list (again).  In 2014, the OIG has identified three separate audit activities they will be aiming at chiropractors throughout the United States.  Here they are:

Chiropractic services—Portfolio report on Medicare Part B payments (new)

The OIG will compile the results of prior OIG audits, evaluations, and investigations

of chiropractic services paid by Medicare to identify trends in payment, compliance, and fraud vulnerabilities and offer recommendations to improve detected vulnerabilities. Prior OIG work identified inappropriate payments for chiropractic services that were medically unnecessary, were not documented in accordance with Medicare requirements, or were fraudulent.  This planned portfolio document will offer new recommendations to improve Medicare chiropractic vulnerabilities detected in prior OIG work.

Chiropractic services—Questionable billing and maintenance therapy (new)

The OIG will determine the extent of questionable billing for chiropractic services.

We will also identify trends suggestive of maintenance therapy billing. Previous OIG work has demonstrated a history of vulnerabilities relative to inappropriate payments for chiropractic services, including recent work that identified a chiropractor with a 93-percent claim error rate and inappropriate Medicare payments of about $700,000.

Chiropractic services—Part B payments for noncovered services

The OIG will continue to review Medicare Part B payments for chiropractic services to determine whether such payments were claimed in accordance with Medicare requirements.

What This Means To You, the Doctor of Chiropractic

 Personally, I don’t see the OIG report as all bad news but it’s certainly not all good either.  Here’s a breakdown of what I can glean from this report:

 The Bad News

The poor chiropractic track record is causing the Feds will be increasing the number of audits to chiropractors.  Expect that they are coming to a town near you.

Inappropriate billing and documentation are apparently still rampant.  Expect this to get worse if chiropractors don’t master ICD-10 quickly.

The Good News

The OIG aims to identify trends suggestive of maintenance billing.  Further clarification in this area can help chiropractors see what factors Medicare feels are indicative of maintenance care.  This should help chiropractors better differentiate this apparently grey area.

What You Can Do About It

1.  Resolve to change!  Many DC’s know that their notes are inadequate, but they fail to do anything about it.  Documentation gets pushed to the back burner, again and again.

2.  Fix it before ICD-10.  As you may have guessed, ICD-10 is going to be changing enough of your practice.  Might as well address the documentation issues while you still have time.

3.  Get Help!!  Many DC’s at my seminars tell me that they don’t even know where to start to improve their documentation, billing or coding.  They know that they are “missing the boat” and floating through treacherous waters with subpar documentation.  Equally frustrating is the feeling that they are leaving money on the table by not knowing how to properly bill or code for all the services they are doing.  If this is you, here are three options to consider for help:

a.  Seminars:  Learn ICD-10 for chiropractors along with how to properly bill, code and document your services.

b. Compliance Training:  Our Audit Armor program is an interactive compliance training program (completely online) that helps you and your staff become more compliant in the area of billing, coding, documentation, HIPAA and even ICD-10!  Best of all, you can do it from the comfort of your home or office.

New Post has been published on http://www.strategicdc.com/what-chiropractic-ehr-system-do-i-recommend-and-why/

What Chiropractic EHR System Do I Recommend and Why?

One of the most common questions that I get in my billing, coding & documentation seminars, via my blog, and from my consulting clients is this: what EHR do you recommend?

While many of you have seen me dance around the EHR issue over the years, in my opinion, a clear leader has emerged from the pack of options available to chiropractors. And although I don’t believe EHR’s will fix all your practice problems (or cure your baldness), I  highly recommend ACOM Health’s Certified Complete EHR RAPID software solution.

Here are a few reasons why:

Proven – They have over 550 Chiropractors completing attestation with their system

Guaranteed – It is the Only system in the Market with a Money Back Guarantee

Affordable – They have a guaranteed Financing Program starting at $200/Month

Intelligent – Automating your practice helps minimize your risk, maximize your revenue and helps you work smarter

Timely – Chiropractors who participate in the Government EHR Incentive Program may qualify for up to $39,000 over the next 4 years, per eligible Chiropractor

Stable – The ACOM Health company has been around for nearly three decades, has served multiple health professions (including chiropractors) and thousands of clients worldwide.

Simple — Most other systems use proprietary programming (bad news if you ever want to switch and your data doesn’t go with you) to do even the most basic tasks such as write a report, ACOM’s reports are viewable in formats even non-technies understand (like MS-Word).  All EHR’s have a learning curve, but it’s nice when you are on some familiar ground.

Why am I recommending this transition from paper records to automating your practice now?

EHR is the way of the future and you will have to do it sooner or later

If you miss it this year (2013), the total maximum incentive payout drops by $15,000

An investment that positively affects your bottom line and decreases your risk is worth every penny

ACOM Health’s pricing is reasonable, transparent and inclusive – no hidden fees or surprises

Here’s the best news: it comes with our profession’s only “Federal Stimulus Guarantee” - follow ACOM Health’s meaningful use guidance and training with your new certified software and ACOM Health guarantees in writing that you’ll receive stimulus dollars or your money back.

Because of all the above, I would encourage you to call ACOM Health today at 866-286-5315 and give them 30 minutes out of your entire week to demonstrate their software – it is well worth your investment.

Special Bonus!

And as a special bonus, let them know Dr. Necela from The Strategic Chiropractor told you to call and they’ll take $500 immediately off the software price just for 30 minutes of your time. Or if you prefer, just use the link below and an ACOM Health practice consultant will get back to you directly.

Get More Info + Schedule Your ACOM Health RAPID EHR Demonstration

                                    (click link for more info)

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New Post has been published on http://www.strategicdc.com/eliminating-the-auditors-ace-in-the-hole-improving-chiropractic-compliance/

Eliminating the Auditor's "Ace in the Hole" & Improving Chiropractic Compliance

Truthfully, most chiropractic billing experts would agree it’s a bit sneaky.

But it is technically “by the books” so you can’t fault payers like Medicare or other commercial payers for going to their auditing “ace in the hole” when necessary.

When I first read of payers using this audit trap, I admit that I thought that it was a blatant scare tactic to make providers unduly nervous or perhaps somehow reinforce the push to electronic health records.

Unfortunately, a little more than one year after Medicare released yet another warning in August 2012, the reality has come true. And other payers are using the same strategy to ensure that you are hard pressed to defend the right to each and every penny they demand back in a post-payment audit.

In fact, I’ve seen this tactic used by four different payers just in the last month of attempting to defend some chiropractors who have been hit with an audit.

The Achille’s Heel of Your Audit

Let’s face it: the prospect of an audit doesn’t hit anyone gently.  But if you have billed things properly, used correct chiropractic CPT codes and documented your services accurately, you should stand a good chance that you don’t have to mortgage your house or sell your first born to pay the payer the gargantuan sum that they have slapped you with.

That is, unless they aim the audit squarely at what appears to be the “achille’s heel” of chiropractic documentation.

What’s our weak link?  The miniscule missing item that drags us down amidst much kicking and screaming?

It’s your signature.

Yes, that’s right.

Despite all your sweaty fears, your documentation actually passed the test.  Your billing- spot on.  Coding was correct.

I’s dotted and t’s crossed and just when you think you’ve cheated death and avoided the sting of the auditors accusations, the payer comes back and lays down his “ace in the hole” with a deafening, definitive thud.

Signature Requirements

Chiropractic Signature Requirements for Medicare

“Medicare requires that services provided/ordered be authenticated by the author. The signature for each entry must be legible and should include the practitioner’s first and last name.”

Before you get too optimistic and think that this is just Medicare’s oddball rule that can be randomly enforced, check out the remarkably similar signature requirements for other payers:

BCBS of Kansas Chiropractic Signature Requirements

All notes should be signed and dated by the clinician performing the services. A legible first initial and last name is minimally required. If not present, reimbursement will be denied. A stamped signature is not acceptable. (see Blue Shield Report, S-1-09, Jan. 15, 2009)

BCBS of Massachusetts Chiropractic Documentation Guidelines

The record shall be kept in chronological order and record entries shall be made contemporaneously. Each such entry shall be signed by, or shall otherwise adequately identify, the registered chiropractor who is treating the patient to whom the record pertains.

A quick review of your local commercial carrier’s documentation requirements will likely reveal similar language.  The bottom line? Sign your note or else!

Alternative Signature Solutions 

If this article has you antsy, there are a few solutions you can employ to legitimately provide a signature.  Unfortunately, the “alternative” options are not quite fool proof, nor are they the preferred method because they have to be utilized in a compliant manner and cannot simply replace your forgetfulness.

Option 1 – Sign Your Note

The simple and obvious solution: get with the program and sign your note.  Read Medicare’s Signature Guidelines to see acceptable versions of your signature.

Option 2 – The Signature Log

If you’re still a paper pusher and still holding out on moving towards EMR (another issue for another day), the idea of signing your note may be a bit tough to swallow, creating a signature log may work

A signature log essentially allows you to sign your note, but then have a separate form that identifies your signature throughout the records.  This is good for those who know their handwriting is going to produce illegible chicken scratch and therefore run the risk of going through the trouble of signing the note, but not having their signature count because no one can read it.  The good news is you can create a signature log at any time.  The bad news is that your signature still has to be present in the record in order to create the log.

See Medicare Signature Guidelines for more info

Option 3 – The Attestation Statement

If a payer creates an issue with your signature (illegible, can’t verify whose initials are whose, etc) then you can complete an attestation statement to verify that those signatures are in fact your 100% original work of art.

See Medicare Signature Guidelines for more info

What Won’t Work

As demonstrated above, what won’t cut it with payers is a lack of any signature in your daily notes.

And most payers make it abundantly clear that if you alter your record after the fact (i.e. add a signature when none was originally signed), it is not acceptable.  In fact, it may be even considered fraud.

Unfortunately, this is exactly what many chiropractors have, which can certainly be bad news if an auditor or payer makes a post-payment demand.

What to Do NOW!

Take this to heart – sign your notes.

This is the quickest and simplest route to improving your chiropractic compliance.

Will that fix everything and make you compliant?  Probably not.  As we’ve mentioned previously, chiropractors are subject to HIPAA deadlines, fee compliance, billing, coding and documentation compliance – all of which obviously include much more than signing your note.

If today’s article caused your inner auditing alarm to wake you up in a panic, perhaps you should check out our Chiropractic Audit Armor interactive compliance training and mystery caller program.  It will help guide you towards creating a compliant office so you can sleep at night.

And if the signature is all you have to fix, then congratulations — but fix it fast!

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New Post has been published on http://www.strategicdc.com/chiropractic-documentation-what-exactly-are-objective-measures/

Chiropractic Documentation: What Exactly are Objective Measures?

The denial is in plain black and white, but you still don’t understand it.  The payer states that the service is denied (or that you must pay it back) because your documentation lacks “objectively measurable” goals.

You are befuddled.  To you, the patient’s progress can easily be seen. And you documented that. So what exactly are these “objective measures” you should be including to show the payer what is obvious to you?!

Objective measures can be a number of things:

Standardized patient assessment instruments OR

Outcome measurements tools OR

Measurable assessments of functional outcome.

Your use of these objective measures at the beginning of treatment, during and/or after treatment helps quantify patient progress, prove medical necessity and justify continued treatment. Some chiropractor may use forms (Oswestry, Roland Morris, etc.) to measure treatment effectiveness.  (Note from Railroad Medicare: If this is the case, then a patient would need to complete the form on every visit.)

Additionally, some forms may not contain answers that are objective; in other words they do not include actual measures or values. The Chiropractor or patient may need to add additional information. For example, the form may use the term ‘severe’ for the evaluation of pain. ‘Severe’ is not an objective measure. The pain would need an actual value –i.e. quantify it or give it a number.

In a recent article, Railroad Medicare also gave a clear example of objective measures to evaluate goals.  See below:

Examples of objective measures to evaluate goals include:

Pain

Baseline: 9 on a scale of 1-10

Goal: Decrease pain to 1

Standing:

Baseline: Only able to stand for 20 minutes

Goal: Able to stand for more than 1 hour

Range of Motion (ROM):

Baseline: Lumbar spine flexion of 53 degrees and extension 11 degrees

Goal: Increase lumbar flexion to 80 and extension to 25

Hope this helps clarify some of the mud surrounding your chiropractic documentation of objective measures!

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