June 22, 2006
Progressive Corrective Action on Chiropractic Manipulative Treatments
The CERT program continues to find errors on review of randomly selected chiropractic services that have been paid by Medicare. These errors have prompted a probe of chiropractic services in Idaho by CIGNA Government Services. Previously, chiropractic manipulations were the focus of another CIGNA Government Services probe in 2004. This most recent probe involved approximately 100 claims from 20 chiropractors. The results of this probe validated the random CERT review findings in that errors were present on a greater scale within the larger provider specialty community. The errors identified in this probe reflected many of the findings noted in the earlier (2004) probe. This article is intended to detail these errors so that providers in all the states that CIGNA Government Services serves can make corrections within their own practices if needed. This would assist providers in avoiding post-payment review errors and the range of progressive corrective actions implemented by the carrier or other entities in effort to resolve any inappropriate Medicare payments. These progressive corrective actions could include recoupment of any identified overpayments, ongoing intermittent requests of records for review, pre-payment "screens" that require review of any future claims and the corresponding supporting documentation before any payment made, and/or referral to the Benefit Integrity contractor.
The errors found can be outlined as follows:
- Insufficient initial visit documentation
- history lacking detail of symptoms
- exam--especially on manually demonstrated subluxation**
- Absent or incomplete
treatment plans
- no measurable goals
- no frequency & duration of treatment
- specific levels being treated and/or modalities not present
- Subsequent visits
fail to establish medical necessity for ongoing care
- no assessment of progress since previous visit
- no assessment against goals from plan of treatment
- use of flow sheets/checklists that document treatment rendered but do not address or include the assessment expected on subsequent visits
- subsequent visits appear to be for maintenance therapy which is not covered by Medicare
- Coding errors
- the level of code billed was not supported by # of regions treated and as documented in the medical record
- notes did not indicate specific levels of subluxation being treated or
- service
rendered was not manual manipulation (which is the only service payable
by Medicare to chiropractors)
Illegible notes
Expected on the initial visit is a thorough history that details the symptoms prompting the patient to seek treatment. Other elements of the history expected to be included are, for example, the onset, duration, location and radiation of symptoms. The following link is to a previously published article itemizing all of the elements that should be included in the history:
http://www.cignagovernmentservices.com/partb/bltin/all/04bltin/04_11/base_november11.html#007
Also required on the initial visit is the diagnosis of subluxation that corresponds to the symptoms the patient demonstrates. In other words, these symptoms must bear a direct relationship to the level of subluxation. The diagnosis of subluxation can be made either by a dated x-ray with results or by a physical exam noting 2** of the 4 following criteria to support a manually demonstrated subluxation:
- Pain/tenderness evaluated in terms of location, quality and intensity
- Asymmetry/misalignment identified on a sectional or segmental level
- Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility)
- Tissue, tone changes in the characteristics of contiguous or associated soft tissues, including skin, fascia, muscle and ligament.
**One of the two criteria documented must be either asymmetry or range of motion abnormality.
A treatment plan should also be generated after the initial visit, and it includes the goals expressed in measurable terms. Besides these goals, the treatment plan should detail the frequency, duration and projected end-point of the therapy. The use of "PRN" or "as needed" for a frequency of treatment does not establish the treatment as medically necessary for an acute condition and suggests treatment is for maintenance of a chronic condition.
Each subsequent visit should update the patient's history, exam and progress toward the treatment plan. This would then help substantiate ongoing care based on any changes in the patient's signs and symptoms, physical findings, response to treatment and any modifications to the treatment plan.
Once the patient's condition has been stabilized, treatment is no longer a Medicare benefit. This would apply even if each treatment of a chronic condition resulted in some temporary improvement. If there is no substantial long-term improvement, this would be considered "chronic maintenance" treatment and not payable by Medicare nor would qualify the service for billing using the AT modifier. In our probe reviews, we did find some patients who were into their 4th year of ongoing chiropractic manipulation without evidence of re-injury or exacerbation. This would appear to be maintenance and should have not been billed to Medicare as a covered service.
Finally, spinal manipulation codes differ according to the number of regions treated. Therefore, the record should identify for each encounter the exact regions treated and that support the code billed. Additionally, spinal manipulation codes cannot be billed for any other service that is not spinal manipulation.
