Shared by: John Peick newsletter. Contact him at: HCPLAW-list- owner@mail-list.com DOCUMENTATION GUIDELINES (Courtesy of the American Chiropractic Association) Use the following guidelines to help you through the reimbursement process and to get insurers to comply with terms they themselves have proposed as claim handling solutions: 1. The nationally accepted HCFA billing 1500 form must be completed in detail. This means all required fields must be completed. 2. Subjective, objective, and treatment (if rendered) components should be incorporated into patient records on each visit A customized format is not needed but these elements must exist consistently. Any significant changes in the clinical picture (e.g. significant patient improvement or regression) should be noted. 3. All ICD-9-CM diagnosis codes and CPT treatment and procedure codes must be validated in the patient chart and coordinated as to the diagnosis and treatment code descriptors. 4. Uniform chiropractic language should be used within the profession for describing care and treatment. Non-standard abbreviations and indexes should be defined. 5. Documentation for the initial (new patient) visit, new injury or exacerbation should consist of the history and physical and the anticipated patient treatment plan. The initial treatment plan, except in chronic cases, should not extend beyond a 30-45 day interval. Subsequent patient visits should include significant patient improvement or regression if demonstrated by the patient on each visit. As the patient progresses, the treatment plan needs to be reevaluated and appropriately modified by the treating doctor of chiropractic (chiropractic physician) until the patient can be released from care, if appropriate. 6. If the patient is disabled, a statement(s) on the extent of disability and activity restriction is needed at initial and subsequent visits as appropriate over the course of care. 7. Records can be attached to each billing to pre-empt requests; however, it is not mandatory. Local insurers should be contacted for preferences (i.e., No fault PIP insurers may require records every visit while health insurers may not). 8. All records must be legible and understandable, released within the authority given by the patients, in a secure, confidential manner and in compliance with existing state (or federal) statutes. 9. The patient name and initials of the person making the chart notation (especially in multi-practitioner offices) should appear on each page of the medical record. 10. If the above recommendations have been met, then the answers as to why the necessity for continuing treatment are answered. 11. The insurance industry must improve their claim adjusting procedure by using chiropractic consultants. The ACA can use its resources to assist in this initiative. Coding: Recently I have been receiving a spate of calls regarding coding issues. One of the several calls pertained to upcoding to the maximum CMT for five regions all the time for all your patients. I had some grave concerns over this practice and my response has been as follows: As we discussed regarding coding, while we applaud attempts to increase fair compensation for DCs, your coding must reflect actual services rendered, and pass the test of medical necessity and reasonableness. The CMT codes are part of the AMA CPT codes, and the AMA guide is the official arbiter of the code interpretation. The explanation in the AMA Guide makes it clear that normal preservice evaluation and post-service work is included within the applicable CMT code. Furthermore, the CMT code 98942 requires an adjustment in five regions, not merely an evaluation of five regions. In addition, there must be documented medical necessity for adjusting five regions in order to justify the charge code. Personally, I would be concerned that an universal application of CPT 98942 to your patient's care would be a red flag to the audit departments of the carriers. Carriers can easily run reports on the doctors providing services to their insureds, and a disproportionate use of 98942 as compared to the normal utilization in the DC population would be an invitation to an audit. The fact that you have a cash practice and do not directly bill the carriers does not protect you because they will record the off-panel charges by provider and insured in any event. Whenever you are faced with claims of dubious coding protocols, you should ask if it has been cleared by the AMA or by the carriers. If it has not, then it may be the wishful thinking of a practice management firm instead of the appropriate coding protocol to follow. The penalty for up-coding can be not only the embarrassment and expense of a civil audit, but as some chiropractic doctors have learned in the last 12 months, a visit from the Federal Bureau of Investigation. That visit could ruin your day. Any thoughts about this response re validity or am I missing something? John Peick