9 Chiropractic Coding and Billing Red Flags

Highlights

• Insurance billing codes for chiropractic treatment require specialized knowledge and training in CPT codes to prevent issues during payer payments.
• The CMS has introduced more stringent regulations for chiropractic billing and coding, which could result in chiropractors having to repay CMS in instances of overpayment.
• Common causes of overpayment include failure to demonstrate medical necessity, incorrect use of billing codes, a lack of documentation, and improper upcoding or downcoding.
• A centralized view of customer data, insurance, and provider notes and documentation can reduce the potential for chiropractic billing errors.

Are your chiropractic billing processes as reliable and accurate as you think? It’s crucial to be certain.

The Centers for Medicare and Medicaid Services (CMS) has implemented more stringent regulations to ensure healthcare providers are reimbursed fairly. As a result, CMS may identify cases of “potential overpayment” based on claims data.

Chiropractors must be aware of red flags in coding and billing to avoid being audited and having to pay back improperly billed services.

Here are the nine chiropractic coding and billing red flags to look for in your office’s processes.

1. Failure to Demonstrate Medical Necessity

Medical necessity is one of the most important elements of any insurance claim. Chiropractors must prove that their treatments were medically necessary for the patient to receive reimbursement.

One way to do this is to support all procedures with clearly written SOAP notes. Also, Medicare expects providers to bill multiple CPT codes for chiropractic care encompassing multiple procedures.

‍Don’t file everything under one code.

Be as specific as possible when using codes so payers understand exactly which services were rendered and how they were relevant to the patient’s condition.

2. Using an Incorrect CPT Code

Chiropractic billing and coding is its own language. Codes are constantly being updated, too.

Keep your billing staff ahead of the curve by investing in ongoing education about code updates.

Use chiropractic billing software that automatically updates with code changes and integrates charting and billing for automated data flow and to avoid billing errors.

3. Lack of Independent Documentation

Independent documentation refers to any documentation (such as SOAP notes) that isn’t required as part of a claim but could help support its validity. It’s the what and the why behind the treatment’s medical necessity.

Being unable to support your reason for providing a service to a patient could be a red flag to payers.

4. Bundled Services With Independent Documented Services

Bundled services combine several services as part of a single treatment. They complement each other and need to be performed together on the same visit. As a result, these services are billed together (in a bundle) instead of being billed and reimbursed separately.

In many cases, chiropractic billing codes for services are separated, though the services were bundled during the visit. Adding a modifier to chiropractic codes designates that a service was performed above and beyond the normal requirements.

One example is to separate an exam and the treatment performed on the same day using the -25 modifier. The modifier tells the payer that the exam was performed beyond the normal evaluation included in the treatment codes.

5. Unbundling of Services

Likewise, unbundling certain services that should be considered bundled could be a cause for review.

To “unbundle,” the purpose of each service must stand alone as distinct. Otherwise, it might not be eligible for separate reimbursement.

Hot packs are an example of this; some payers no longer offer separate reimbursements for them. Some payers also bundle mechanical traction with spinal manipulation; therefore, they can’t be billed separately.

6. Excessive and/or Improper Upcoding

Upcoding refers to medical bill codes that reflect a more serious illness or condition than a patient actuallyexperiences or a more expensive treatment than the patient received. Both are examples of a false claim and can carry serious consequences.

If a provider habitually upcodes, it could constitute fraud and expose you to legal proceedings. Thorough documentation of a patient’s chiropractic Dx codes can help combat the potential risk of upcoding.

7. Multiple Procedures Per Visit

It’s common for chiropractors to use a range of modalities to improve patient care. However, offering too many therapies in a single visit may be considered excessive and unnecessary by some payers.

An example of excessive and unnecessary procedures is having too many passive therapies, such as hot or cold packs, electrical stimulation, and therapeutic exercises.

Not having enough active therapies (such as spinal manipulation) with the passive therapies can be a red flag for payers. Too many similar passive therapies during the same visit can also seem unnecessary.

8. Excessive Use of the Same Diagnosis Codes for Every Patient

It’s not surprising that many of your patients will come to you with similar needs and conditions. However, making one-size-fits-all diagnoses for every patient can be a red flag to payers.

Even with similar symptoms and complaints, patients should have a custom plan of care that caters to their needs and diagnoses. These plans should not be identical to another patient’s plan.

Customizing your notes and treatments and providing plenty of detail ensure you’re billing each patient individually.

9. Prolonged Duration of Treatment

It’s natural (and desirable) for patients’ conditions to improve as they continue their chiropractic care. It’s also advisable for patients to continue with maintenance care once their initial condition improves and they no longer require the same treatment intensity and frequency. However, it’s a red flag when patients continue the same treatment months after their initial injury or complaint.

Continual use of recurring or a set of common chiropractic CPT codes for a single patient may be considered excessive medical care.

You may need to change how you code and bill to avoid suspicion of upcoding.

How ChiroTouch Creates Confidence in Chiropractic Billing

Proper documentation and purpose-built billing software can help chiropractors prevent red flags in chiropractic billing. ChiroTouch, the standard in chiropractic EHR, offers completely integrated scheduling, charting, and billing, making documentation easy and accurate.

ChiroTouch Advanced handles the full claims cycle management process, enabling electronic claims submissions and automatic status updates.

Add CT MaxClear to manage all claims in a single place and achieve a 98.06% payer acceptance rate. Our completelyintegrated solution supports you every step of the way, eliminating the need for multiple systems and vendors.