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Are you sending out billing red flags to auditors? Avoid attracting the wrong kind of attention with better billing patterns.

One of the biggest fears for chiropractors and billing personnel is to attract the attention of auditors. Unfortunately, your claim forms and billing patterns might be raising all kinds of bright red flags to the wrong people.

Here’s the good news: when it comes to your billing and coding, there are specific things you can do to avoid audits. In fact, you have tools right at your fingertips that will keep your practice billing protected and help you avoid scrutiny.

In this series, we will explore key areas of your billing patterns and help you identify the red flags that might be attracting auditors. First, take a look at the basics of payable claims.

Seven Elements to Payable Claims

As a reminder, the seven key elements that are fundamental and serve as the foundation critically necessary for a payable claim are:

  1. Medical Necessity
    • Were the services rendered medically necessary?
  2. Services Were Provided
    • Is the service that was billed for the service actually provided?
  3. No Statutory Violations
    • Are the services “tainted” by any statutory or regulatory violation, such as the Stark Law, federal Anti-Kickback or a False Claims Act violation?
  4. Meets all Coverage Rules
    • Do the services meet Medicare’s coverage requirements?
  5. Full and Complete Documentation
    • Have the services rendered been properly and fully documented?
  6. Proper Coding
    • Were the services rendered correctly coded?
  7. Proper Billing Practices
    • Were the services rendered correctly billed to Medicare?

Whether you’re sending in paper or electronic claims, the CMS-1500 is incredibly revealing, and can: prompt an audit; determine medical necessity; identify possible over- or under-coding; identify services that may have not been performed; and identify suspected fraud or abuse.

All of these things can actually be clearly identified – or suspicious – from the claim form alone, without even a glimpse of your documentation. You don’t want to be the one that stands out in any way on your claim forms, particularly with billing and coding.

What are auditors looking for?

Auditors are looking at your overall billing patterns, and the specific information on your claim forms that raise red flags. It’s as if they’re holding a magnifying glass over your claims and looking at what’s taking place in all your billing and coding over a period of time.

Here’s the kicker: most audits are preventable. The majority of errors in data entry, documentation or claim submissions can be identified and fixed before the claim is ever submitted. So your goal should be to find and fix your own errors before the third-party does.

Common Causes for Billing Errors.

  • Inadequate Training
    Information is often passed along from biller to biller, with assumptions and misinformation about codes or modifiers being shared. This creates layers of inaccuracy within your billing process.
  • Not Staying Current
    Coding and billing information is constantly changing, with new codes, definitions and rules in play all of the time. If you don’t stay current – or specifically – if you don’t utilize resources that know what is current –  your data entry and billing will suffer.
  • Incorrect Medical Necessity
    The lack of medical necessity can easily be identified over a period of time by looking at your claims, so coding is key. Sometimes practitioners define medical necessity according to what’s best for the patient. That’s okay from a treatment perspective, but you must use codes according to the standard definition for processing and payment from a third party. The items and services must be reasonable and necessary for diagnosis or treatment of illness or injury to improve function.
  • Complicated Claims
    Keep your claim forms and coding as simple as possible.

Coding: Another Language

The great thing about coding is that you don’t have to have all the codes memorized, and you don’t even have to know all the rules. You simply need to know where to find correct information, and who to reach out to if you have questions.

Think of coding as another language – it’s no different than having to translate a book or text from English to Spanish. Therefore, coding is nothing more than your documentation (one language) being translated into codes (another language). In other words, it must tell the same story, just in a different language.  

For instance, the Evaluation and Management codes that you use – like 99203 and adjustment codes 98940 or therapy codes 97140 codes – are all your CPT codes, or your quick-fix service codes. They say what you are doing with the patient.  The diagnosis codes that you use – the M99s and S codes – say why you are doing that with the patient. So for all of your documentation as well as your claim forms for every service that’s rendered, you must say why and what you are doing.  In other words, you have to support the services with a diagnosis in order to properly bill. If you don’t, you’re looking at one of those red flags.

For example, suppose you’re submitting 98943 along with 97140. A[1]  reviewer looking at your claims might only be able to identify one or two spinal diagnosis, yet you’re billing three to four regions. This is going to be a billing pattern that attracts attention. So an auditor will take a much closer look at your claims, especially over a period of time.

The Importance of Modifiers

Just as service codes and diagnosis codes are the basic part of a language, think of modifiers as the adjectives providing specific details and a clearer description of what’s taking place within the story. Modifiers provide more specific details in your claim forms as to what’s taking place with the patient and why.

The Impact of Claim Forms

Claim forms are extremely revealing, but fairly easy to scrutinize. A relatively inexperienced reviewer can be given a standard checklist and be able to identify basic elements of claim forms. And it won’t take long for them to start noticing things that stand out like a sore thumb. They’ll be looking for details that could signify things like fraud, waste, abuse or error.

Once warning signs are spotted, your claim forms are on the radar. A huge can of worms will open for you if it’s determined that your documentation and your claim forms are not telling the same story. However, if you are following proper documentation guidelines, medical necessity guidelines, and other elements of claim forms, it will ultimately save you heartache and money, You’ll be able to support your billing and claim forms with proper documentation

Up Next

In the next part of this series, we will discuss tools you can use to fix your mistakes, and the differences between active and passive procedures.

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