Chiropractic Billing Patterns: Auditor Red Flags, Part 2

Are you attracting the attention of auditors just from incorrect or incomplete claim forms? Here are the most common mistakes.

In the first part of this series, we explored key areas of chiropractic billing patterns that might draw attention from auditors and reviewers. We also highlighted some specific things you can do to eliminate all those red flags that could lead to dreaded audits.

Common Claim Form Mistakes

In this second part of the series, we’ll discuss some of the “yellow” flags you could be sending as a result of an incomplete or incorrect claim form. Here, we’ve highlighted some of the most common from the previously recorded webinar, How Clean Are Your Claims?, presented by Brandy Brimhall. Although this does not serve as instructions for completing the CMS 1500 form, you can find more details about common claim form mistakes by listening to the recorded session online.

Field 14: Date of Current accident/injury/illness.

Medicare requires this date to be the date the patient presented for care for the current episode of treatment, but it is often neglected or randomly updated. In either case, the aged date or the random updates of this date field over time will display a pattern, and capture the attention of third party payers and auditors.

Field 21: Diagnosis

This is the diagnosis field, and providers must adequately support services rendered using applicable diagnosis. Use of the same diagnosis on every visit and/or on every patient can be “yellow flags” for reviewers.

Field 24D: CPT/HCPCS (Service/Supply codes)

Appropriate CPT codes and necessary modifiers are required for field 24D. These must appropriately define the services that were rendered and be supported by the daily visit documentation. If applicable, the appropriate modifier must be appended as well.

Errors in this field may often be coding errors or inappropriate use of modifiers. Inappropriate use or overuse of CPT/HCPCS codes can be identified over time on claim forms. As such, this is a common risk area.

Field 24E: Diagnosis Pointing

This diagnosis pointer field is necessary to link the supporting diagnosis from Field 21 to the service code identified in individual line items on the claim. Diagnosis codes must adequately support the service rendered. This is also an area where common errors occur on claims due to:

• Diagnosis codes not reported in Field 21 (and therefore not able to be properly pointed to in Field 24E, resulting in lack of support for the service(s) rendered)
• The same diagnosis code should not typically be pointing to multiple services. This may be an indicator of lack of medical necessity for one or more services.

Field 24F: Charges

The Charges field may be attention-getting by third parties or reviewers in the event the charges appear to be excessive or outside (above/below) what peers charge for the same service(s). Though Major Medical policies have allowed fees for covered and payable services, unusual billed amounts are still subjects of concern in some types of audits/reviews.

Field 24G: Days/Units

For timed services, this is the field where the appropriate number of units is documented. It is common for units to be reported inappropriately due to a lack of understanding as to what is considered a single or multiple unit. Here is a chart which identifies how units are determined for timed services:

Field 24J: Rendering provider ID

This is the field where the NPI of the provider that rendered services is to be listed. For practices with multiple providers, this often easily becomes a confused field and the incorrect provider is reported for services he/she did not render. Due to this, there can be scrutiny on this particular field and may be a risk area for some practices.

Brandy Brimhall is a recognized expert in chiropractic billing, coding & compliance. She is a Certified Professional Coder, Certified Professional Compliance Officer, Certified ChiroCode Professional Coder, Certified Medical Compliance Officer, and Certified Professional Medical Auditor. Brandy is a sought after speaker at state and national chiropractic conferences, and is a regular contributor to multiple chiropractic publications.