"THINK TWICE OR PAY THE PRICE!"
By Dr. Ken Freedman

Medically necessary care is not determined by the state board or statutes.  It is determined by - the insurance carrier!
 
Medically necessary care is care that addresses a clinically appropriate condition with a care plan that is designed to address the functional deficit(s) resulting from that condition.  This means that if  a patient presented with low back pain, if  they had no functional deficits,  they are a wellness case, and  are coded and documented with a variety of wellness codes - NOT insurance reimbursable.   A commonly used wellness diagnostic code may be V70.9 (routine office visit by chiropractor, non-medically necessary).  Some commonly used wellness procedure codes are: S8990 (physical and manipulative therapy performed for maintenance rather than restoration), A9270 (non-covered item or service).   With Medicare, the Q3016, or 98940, 98941, 98942 WITHOUT the AT modifier may be used because it will result in denial.  
 
You may ask - why bother, especially if this care is not being submitted for reimbursement?  Wellness coding is important because it is accurate.   Also, in the event of an insurance audit, it prevents you from appearing as an over utilizer.
 
If a patient has a clinically appropriate condition resulting in a functional deficit, either the patient or you may submit for insurance reimbursement.  Be sure to use the active care codes for DX and TX.  It is the chiropractor’s responsibility to ensure their choice of DX and TX codes accurately reflect the patient's reasonable and necessary care protocol.   You must also have a care plan that addresses how your care of the patient's condition is designed to address their functional deficit(s).  Keep SOAP notes for each visit, and schedule progress exams based upon clinical necessity.  Update the care plan accordingly.  When the functional deficits have resolved, regardless of the number of unused visits left on the patient's insurance plan, code for wellness and direct the patient to pay cash going forward.                        
 
Some common audit triggers are:
    1.  98942 - five areas.  This would require an extraordinary history, with functional deficits relating to each of the 5 areas.  Carriers know this is rare, with supporting documentation even more rare.
    2.  EXTREMITY ADJUSTMENTS - Carriers may suspect no extremity exam was performed, with no record of a functional deficit relating to the extremity problem nor the existence of an appropriate care plan.
    3.  $100 + / visit billing - Carriers may suspect additional services were added without medical necessity.  If this is suspected, carriers may also examine your care trends for your non-insurance cash patients with functional deficits, compared to your insurance-based patients.  They're looking for discriminatory practices, two-tier billing and possible fraud.
 
What action steps can you take?  Many insurance carriers have their compliance guidelines based on the Federal guidelines through Medicare.  Medicare offers inexpensive compliance seminars for chiropractors and staff.   Take responsibility and take your staff with you.  Also, obtain a copy of the 2007 ICD9 book.  ChiroCode has a great value:  their 2007 updated Deskbook, their "Hot Topics" monthly coding newsletter and "Quick Question Support" service for answering basic coding and documentation questions.  ChiroCode provides all 3 services for under $200.00 yearly.  Finally, for an expert's review of your coding and documentation practices, contact a certified coding consultant.
 
Improving your awareness of these keys to better compliance will enable you to take the necessary steps to practice with greater certainty and less stress, while better serving your patients, chiropractic and yourself.

Dr. Ken Freedman is a chiropractor’s chiropractor - expert at technique, strong in philosophy, and with superb prosperity consciousness and meticulous attention to detail, in his office and in his life. His ethics and integrity are the center of his personal power, helping him to become an outstanding communicator and an entertaining and informative presenter. Ken excels at coaching subluxation-based chiropractors to improve their patient compliance through efficient office procedures and effective patient education. Ken is a senior consultant for The Masters Circle. www.themasterscircle.com.

So how do you make your care more specific? There are a number of ways of introducing less force but how do you know exactly where the force should be introduced? By using bio-indicators.

There are a number of techniques that use bio-indicators. Most commonly known are Applied Kinesiology’s muscle weakness reflex and DNFT and Activator’s short leg reflex.

Another, less well-known one is the occipital drop (OD). When a subluxation is made worse (challenged) the OD will drop low (less than a half inch or so) on the left side. That is the body telling you there is a subluxation present. The occipital drop (used in KST) has advantages in that you don’t need a table to analyze patients. With an adjusting instrument you don’t need a table to adjust the patient.

Therefore patients can be checked and corrected (adjusted) in any posture – especially the posture of subluxation/pain/injury. That is important because it is often only in certain postures that the subluxation reveals itself. Correcting the patient in the position of subluxation gives a more complete and thorough correction.

Koren Specific Technique is a low-force, highly specific technique that can adjust any part of the body (including cranials) safely and easily in any position. It’s applicable for newborns to frail elderly people; an adjusting table is not needed, you can check and adjust people in any posture, especially position of subluxation. You can also adjust yourself. Find out more at www.korenspecifictechnique.com

2) Reduce risk by referring patients out. It’s best to refer any non-responding patients to another chiropractor or other healthcare professional whose scope of practice utilizes different techniques or procedures for a second opinion. And, always refer patients to another healthcare professional when treatment for said disorder is beyond the scope of your practice. This can create a co-managing situation with your patient and provides the best protection possible. Willingness to refer can also open the door for a mutual referral relationship with other healthcare providers. Remember, most important; do what is in your patient’s best interest!

3) If you feel you’ve hurt a patient, don’t ignore it! The reported rate of broken ribs (as an example) is particularly high among new practicing doctors. If you suspect that you may have injured a patient in any way, confront the situation by being honest with your patient. Always express your honest concern and compassion as most patients will be forgiving in those circumstances. Let the patient know that you will assist them in correcting any situation that has transpired.
Make sure you notify your malpractice carrier of the incident. In many circumstances doctors are able to avoid a claim by coming forward and following the advice of their malpractice expert. Failure to notify your insurance carrier of a known incident can jeopardize your coverage.
In time you can look back at these situations; there is always be a lesson to learn from them!

Yours for Chiropractic
Dr. David Singer

Dr. Singer has been a consultant for 25 years and developed the most effective new patient procedures to build his own 50 new patients per week practice. His company David Singer Enterprises offers a variety of services and products to generate new patients, educate them on the benefits of corrective and maintenance care, handle finances, run a low overhead stress free practice and effectively train staff to give you more free time. www.dse-inc.com