www.njchiropractors.com I 13 Most Chiropractors agree that rules, regulations and laws surrounding coding, documentation and reim- bursement are confusing and difficult to understand. Coupled with the fact that record requests and audits are significantly on the rise, many DCs are left frustrated and concerned about how they can keep up and stay compliant. Being able to recognize some of the frequent issues associated with coding and billing can be very helpful in avoiding an audit and limiting potential denials and recoupment. Below are a four of the most common mistakes I see chiropractors make in regards to coding and billing: 1. Incorrect use of Modifiers: Since chiropractic procedures and services are often complex, sometimes we need to supply additional informa- tion when we’re coding. CPT Modifiers provide additional information about the procedure(s) we are performing. Without a proper understanding of this “additional information,” adding a modifier can have very negative consequences if not properly used. For example, adding the -59 modifier to all modalities and therapies, regardless of whether they apply to the codes used, can “flag” an office. This in turn can increase the provider’s profile and potentially turn into an audit request. Even if adding the modifier has no financial impact on the claims (meaning it wasn’t necessary to use), it can still result in audit. In other words, when you use modifiers incorrectly you are essentially alerting the payer that you don’t know proper coding rules and run the risk of inadvertently inviting them to have a look around. The key to remember is that documen- tation determines the use of a modifier, not reimbursement. When using modi- fiers, I always suggest that providers look to Medicare guidelines – even if they are not sending claims to Medicare. Medicare is the “gold standard,” and most payers mimic their guidelines. When it comes to proper use of modifiers, the National Correct Coding Initiative (NCCI) is the best resource a provider can use. NCCI lists which codes bundle and which codes don’t. NCCI is free and if followed, can significantly reduce audits. http://www.cms.gov/ Medicare/Coding/NationalCorrectCodI- nitEd/index.html 2. Frequency of Services: Providers often ask, “How often and when can I perform these services on my patient? How do I justify my care?” My answer once again is Medicare. Even if you don’t get paid by Medicare for a particular service, Medicare provides valuable coverage guidance for almost every service provided in a chiropractic office. As an example, the Novitas Local Coverage Determination (LCD) L35036 regarding therapy and rehabilitation services. This guide identifies how frequently certain modalities and therapeutic procedures should be performed and for how long. It also often includes what conditions warrant a particular service and what diagnosis are acceptable. Additionally, the Novitas LCD L35424 on chiropractic services has created a hierarchy for diagnoses and provides specific guidelines as to how many visits would be acceptable for a given diagnosis. Providers should use these LCDs as a guide for all payers, not just Medicare. These guidelines can provide a glimpse into what many insurance companies adopt as acceptable treatment param- eters. To look up the current LCDs for any code check out the following link: Medicare Coverage Database Look Up 3.  The Level of Evaluation and Management (E/M) Services The code sets used to bill for office visits (otherwise known as Evaluation and Management services, aka E/M) are organized into various categories and levels. In general, the more complex the visit, the higher the level of code the doctor would use. In order to bill any code, the services furnished must meet the definition of the code. It is the provider’s responsibility to ensure that the codes selected reflect the services furnished. There are three key components when selecting the appropriate level of E/M service provided: history, examination, and medical decision-making. Chiroprac- tors should rarely, if ever, bill high level codes such as 99204 and 99215. This is primarily because chiropractors typically don’t see patients that require a review of as many systems as required for these codes nor is there a high enough type of medical decision-making based on the risk of morbidity and/or mortality. Most chiropractic patients rarely have presenting problems to justify high level E/M encounters. Conversely, chiropractors should rarely bill CPT 99211. This is because “usually, the presenting problem(s) are minimal” and will often self-resolve. Notably, this code may not even require the presence of the provider to bill, and the work is often included in other codes e.g. blood pressure, heart rate, etc. Oftentimes providers will use this code so they can “fly under the radar” and avoid audit. However, by using such a low-level code, providers can actually send conflicting information to a payer – the code tells a payer the patient has a very minimal problem, yet the provider needs to see the patient multiple visits and perform multiple services. [ CONTINUED ON NEXT PAGE ] By David Klein ANJC Coding and Compliance Consultant The Top Four Coding and Billing Mistakes Made by Chiropractors