1. No category

How to Solve 98% of
Presented by:
The
Collection Coach
CA 15 years
 My Journey –

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What I did and didn’t know…
Advice from friends (be careful!)
Ces Soyring
Law seminars
Currently…
– Clinics I have worked with

How?
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Eliminate Payment Problems
 Implement
solid systems to
capture information
(documentation) to get you
paid for what you are doing but
NOT getting paid for
 Get you paid for what you are
doing but not billing for
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Getting the Documentation
Right!
50%
CPT Codes:
99201
$39
99202
$68
99203
$99
99204
$155
99205
$194
CPT Codes:
99211
$18
99212
$35
99213
$56
99214
$85
99215
$115
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Doctors of Chiropractic
7-8 years of education and training
 Expertly trained to

– Observe, palpate and treat

Think at a HIGHER level than most
– Biomechanical, neurological, physiological

Claims handlers…DOESN’T COMPUTE!
– Taught to count bullet points!!!
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Wrong!
We are NOT paying you because…
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


“Request more information for date of
service.”
“It’s in review.”
Service was determined to be “not medically
necessary.”
“Service exceeds duration and frequency for
the diagnosis.”
“Not a covered service.”
“Included with another service reported on
same date.”
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Speak the right language
 Clinically
relevant
 Medical necessity
Doctors
Claims Handlers
 Break
in
George’s Line
 Misalignment
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2011 CERT REPORT
Comprehensive Error Rate Testing January to March 2011
98940- Disagree per LCD for Chiropractic
Services (L27480) For services performed
on or after 12/12/2008; SSA
1862(a)(1)(A). Received a progress note
dated 09/28/09 that is missing
documented chiropractic manipulation
treatment . Also missing an initial
evaluation and treatment plan related to
billed date of service to support medical
necessity for continued chiropractic
services.
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2011 CERT REPORT
Comprehensive Error Rate Testing January to March 2011
98940-
Disagree per LCD for Chiropractic Services (L27480) For services performed
on or after 12/12/2008; SSA 1862(a)(1)(A). Received a progress/treatment note
dated 05/06/10 stating, better today after treatment, slept better. Missing
initial evaluation and treatment plan and documented trauma to support
continued chiropractic treatments as billed. In examining all of the
documentation submitted, treatment rendered for 05/06/10 is not related to a
new injury, treatment is for a chronic condition. Per LCD criteria, "A treatment
plan that seeks to prevent disease, promote health and prolong and enhance the
quality of life, or therapy that is performed to stabilize a chronic condition or to
prevent deterioration is not a Medicare benefit. Once the maximum therapeutic
benefit has been achieved for a given condition, ongoing maintenance therapy is
not considered to be medically necessary under the Medicare program. "CWF
confirms approximately 70 chiropractic services from 06/08/09 to 07/06/10.
Submitted documentation includes physical therapy order and
treatment/evaluation notes starting in 2008, x-ray and MRI reports, pain
management MD notes dated 12/15/09, chiropractic treatment notes from
07/01/09 to 07/29/10. Received after tech stop request an attestation from the
billing provider related to dates of service 10/12/09 to 05/06/10 and another
chiropractic in the same practice verifying they are the provider of the
chiropractic services for 09/28/09 and 10/08/09, treatment plans dated from
10/12/09 to 05/06/10, and a typed evaluation dated 10/12/09. Refer to CERT
Medical Director for completion of review.
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What Are Claims Handlers
Looking For?
Specific Information
 Specific Format

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The Auditor’s First Step
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Collection Coach Form
Chief Complaint
Low back pain , hip pain, right knee,
Neck pain, Headaches
Collection Coach Form
Chief Complaint
Use this form:
1. Initial Visit
2. Re-Exams
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HPI for Medicare
Four additional items for Medicare.
CMS Chiropractic Services Manual (pg. 5)
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Collection Coach Form
HPI – History of Present Illness
Medicare
Location
(Associated Symptoms – different page)
Severity
Quality
Duration
Timing
Modifying Factors
Context
Collection Coach Form
Satisfies the 4th component for Medicare History.
Medicare
History for Medicare
Medicare has an additional requirement –
contraindications:
Relative
 Absolute

CMS Chiropractic Services Manual (pg. 8)
- United Health Care has also included this
requirement to their chiropractic utilization
policy !
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Medicare Contraindications
Relative Contraindications:
CMS Chiropractic Services Manual (pg. 8)
Cumadin
Warfarin
Heparin
Absolute Contraindications:
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13 Distinct Contraindications and
Absolute Contraindications
Cumadin
Warfarin
Heparin
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Collection Coach Form
- Be sure to make notes and comment that you talked to the patient
about the risks of CMT if you are going to adjust in these areas.
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History –
Review Of Systems (ROS)
ROS (Review of Systems): An inventory of body
systems obtained through questioning to
identify signs and/or symptoms that the
patient may be experiencing or has
experienced. The ROS is designed to assist in
defining the problem, clarifying the differential
diagnosis, and to identify the need for further
testing.
- CPT 2010
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Collection Coach Form
ROS – ALL 14 Body Systems
Collection Coach Form
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PFSH for Medicare
Medicare only requires:
Past History
 Family History – if relevant

CMS Chiropractic Services Manual (pg. 5)
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Collection Coach Form
PAST HISTORY
FAMILY HISTORY
SOCIAL HISTORY
The Auditor’s Second Step
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1997 Documentation Guidelines
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Collection Coach Form
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What Do We learn From Medicare?
CMS Chiropractic Services Manual 2009, (pg 6)
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The Auditor’s Third Step
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Collection Coach Form
Doctor’s Orders
Read and Mark the X-Rays
Write the report.
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Diagnosis
Record a “complete” diagnosis for each area of the spine
and extremity you are going to treat.
Example:
739.1 Cervical Dysfunction
722.4 Disc Degeneration
847.0 Neck Sprain/Strain
784.0 Headache
Low back pain , hip pain, right knee,
Neck pain, Headaches
Diagnosis for Medicare…
CMS 1500
1. 739.3
2. 722.52
739.1
722.4
847.0
307.81
739.2
722.10
847.1
728.85
3. 739.5
846.8
4. 739.1
739.3
722.52
847.2
724.2
739.4
839.42
846.0
728.85
739.5
846.8
729.1
728.85
Treatment Plan
x
x
x
x
x
3
2
3 4
3 4
3 2
12
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Subjective
2
5
3
10
MUST be filled out COMPLETELY
10
3
Why are symptoms worse???
Patient Signature
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…and is condition
Acute or chronic?
CMS Manual, pg. 6
x
x
Bryan Moore, D.C.
Daily Notes:
P. A. R. T.
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One area.
Two
Threeareas.
Areas!
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What does the ACA say?
SUBJECTIVE / OBJECTIVE FINDINGS NECESSITATING CARE:
“As is commonly taught in all chiropractic educational
institutions, it is appropriate to manipulate/adjust a segment(s)
that may not be symptomatic and/or located in the same spinal
region as the area of chief complaint. These segments are
identified through objective measures and should correlate
clinically and have a direct therapeutic effect.”
http://www.acatoday.org/level2_css.cfm?T1ID=10&ID=10&T2ID=117&searchQuery=97140
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Example: Patient with a chief complaint of
headache. Objective findings of segmental
98940
dysfunction at C.1-2. Further biomechanical
evaluation reveals the presence of lower
lumbar and pelvic segmental problems
contributing to a postural condition
98941
affecting the cervical region. It would be
appropriate to manipulate/adjust all affected
segments and report the appropriate AMA
CPT code, consistent with the level of work
performed (number of body regions
manipulated/adjusted), for that service.
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x
x
x
x x
x x
x x
x
x x
x
x x x
x
x x
x
x x
x x
x
x
x
x
x
x
x x
x x
x
x
x
x
x
x
x
Covered Services
Chiropractic Services Manual , PG. 2
Hands or
Approved Device
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How does the ProAdjuster work?
http://proadjusterlifestyle.com/index.php?do=chiropractic#section5
To better understand, let's examine the idea of
palpation. When a Chiropractor palpates your spine,
they are checking for joint fluidity, motion and or
rigidity. Improper motion effecting the nerve function
is called a subluxation. In a similar fashion to
palpation, the ProAdjuster can determine whether the
vertebra's motion is too rigid or too fluid. The spine
should not be too rigid (hypo-mobile). However,
instead of utilizing the doctor's judgment as to what
areas are hyper-mobile or hypo-mobile, the
ProAdjuster measures precise levels of motion.
http://www.proadjusterlifestyle.com/index.php?do=chiropractic#section5
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Aetna considers the following chiropractic
procedures experimental and investigational:
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Active Release Technique (see CPB 388 - Complementary and Alternative Medicine)
Applied Spinal Biomechanical Engineering
Atlas Orthogonal Technique
BioEnergetic Synchronization Technique
Biogeometric Integration
Blair Technique
Chiropractic Biophysics Technique
Coccygeal Meningeal Stress Fixation Technique
Cranial Manipulation
Directional Non-force Technique
Manipulation for Internal (non - neuromusculoskeletal) Disorders (Applied Kinesiology)
Manipulation Under Anesthesia (see CPB 204 - Manipulation Under Anesthesia)
Moire Contourographic Analysis
Network Technique
Neural Organizational Technique
Neuro Emotional Technique
Sacro-Occiptal Technique
Spinal Adjusting Devices (ProAdjuster, PulStarFRAS, Activator)
What others say…
http://www.aetna.com/cpb/medical/data/100_199/0107.html
Signature Requirements
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Treatment
Treatment Plan
History
Exam
Diagnosis
MDM
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The Guidelines:
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Constitutional - Exam Form
obese
Club foot
Cardiovascular – Exam Form
Lymphatic - Exam Form
Musculoskeletal Exam Form
Examination of Gate and Station
Falls left
Exam Form – “Pain”
If the patient indicated
“pain” in any area on
the intake forms or the
S.O.A.P. note, be sure
to mark it HERE.
Also, mark it, if “pain” is
produced during your
Exam.
Neck pain index indicates…
See Oswestry dated…
Exam Form - Asymmetry
Mark your asymmetrical
Findings.
And
Circle the Subluxations
½
¼
Exam Form - ROM
Observation or Palpation:
Static or Dynamic
Pain,
Crepitation or contracture
Sectional or Segmental
30
20
30
35
60
70
All movements
Right Side
Segmental Fixations:
LPI – C1,7
RPI – C 5,6
Mark all that apply.
ACUTE
97010 Ice
97014 EMS
97035 Ultra Sound
97012 IST
Phase I
97140 Manual Therapy
97124 Massage
97110 Therapeutic Proc.
Phase II
97112 NMR
Phase III
97530 Therapeutic Activities
Exam Form - Skin
Inspect any 4
areas.
Seatbelt bruise
ALL 6 for a
Comprehensive
exam.
scraped
Cut below elbow
Surgery scar on
right knee.
Documenting Neuro / Phych
X
Check 5 areas
of Neuro / Phych
Mark within
normal limits
(WNL) when
findings are normal.
Right side
diminished
X
X
X
X
X
X
X
X
X
X
What Level of Exam
Count up your “bullets”:
11
Want to get paid more?
ONE more “bullet”!
99202
99203
12
$68
$99
Comprehensive Exam
What do you do?
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x x
xx x x
x
x
x
x
27
Form – MDM the Problem
Points
Problem
Points:
Enter the
number of
points and add
the total.
4
4
Data Review
Medicine
Test:
NCV, ROM,
MT, FCE,
Vascular
x
x
3
Risk
Requires ONE from any category to qualify for that level.
What Level of MDM?
4
3
Add up the Problem, Data
and Risk
 Evaluation & Management Codes
Evaluation & Management
New
Established
99201
99211
99202
99212
99203
99213
99204
99214
99205
99215
Three Key Components:
 History = (CC, HPI, ROS, PFSH)
 Exam = Bullet Points
 Medical Decision Making =
Problems,
Data and
Risk
CONTRAINDICATIONS
Now,
the Doctor can
COMPLETE the
HISTORY
CHIEF
COMPLAINT
REVIEW
PFSH
OF SYSTEMS
PAST
Only when paperwork is
FAMILYCOMPLETELY filled out!!!
SOCIAL
History of Present Illness
HPI
Evaluation & Management Codes
Evaluation & Management
New
99201
99202
99203
99204
99205
Established
99211
99212
99213
99214
99215
Three Key Components:
 History
 Exam – Bullet Points
 Medical Decision Making
EXAM
Evaluation & Management Codes
Evaluation & Management
New
99201
99202
99203
99204
99205
Established
99211
99212
99213
99214
99215
PROBLEMS
RISK
2 OF THE 3
Three Key Components:
 History
 Exam
 Medical Decision Making
Problems,
Data and
Risk
DATA
Choose the level of History
Doctor determined level of
E&M
Choose the Level of Exam
Doctor Determined
Exam
27
Choose the Level of MDM
Doctor determined
level of MDM
4
3
Calculating the Level Of E & M
Bringing it all together:
Based on the amount of documentation recorded on the
HISTORY, EXAM AND MDM, the doctor will choose the level of E
& M service to report for billing.
Now you know the level of E & M that should be reported for reimbursement.
 Corrective Care
A complete reconditioning of a injury to return
a patient to pre-complaint status. It includes all
the appropriate Phases of Care:
Corrective Care takes 1 to 2 ½ years
Corrective Care
includes stabilization.
? to 12, 18, 24, 30 visits – depending on the case
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 Relief Care
Treatment of a condition just long enough to
get the patient out of pain. Sometimes called
“Band-Aid Care.”
Without complete healing, discontinuing care now, can set the stage for a relapse.
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 Episode of Care
Treating a patient under a “Treatment Plan” of care that takes
them from the “incident” date or “Date of Onset” (box 14 CMS
1500 Form) to correction or “maximum medical improvement”.
After the correction of the condition is achieved the patient is
then released from care. THAT is the “End of the Episode of
Care.” (treatment from this point on would be maintenance
care)
Release to
Maintenance
If Auto
Accident use
accident date
Episode of Care
 Maintenance
Once the patient’s condition has been corrected (no more
functional improvement could be expected) they are
then moved into the “maintenance”: phase of care.
Maintenance
Corrective Care
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Documenting Pain
“Pain” can be your “observation”, or produced
from “percussion, palpation, provocation” or
other ways…
ACA Commentary on MC Guidelines (pg. 4)
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Documenting Asymmetry
Asymmetry can be documented by “Sectional”
or “Segmental”, based on your palpatory exam.
ACA Commentary on MC Guidelines (pg. 4)
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Documenting ROM
ROM findings can be recorded for an area such
as “cervical” or on a segmental basis by
“observation”, “palpation” or by “device”.
ACA Commentary on MC Guidelines (pg. 4)
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Remember ROM findings also could include a notation of
pain and crepitation or contracture.
1997 E & M Guidelines, (pg. 34)
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Documenting Tissue
Medicare:
1997 Guidelines for Evaluation and Management Services:
ACA:
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Treatment
All services and supplies that you provide
to a patient MUST be attached to a
treatment plan and included in your
diagnosis.
Your diagnosis and treatment plan are a
vital part of the MDM process. MDM is based
off your HISTORY and EXAM.
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Solve Payment Problems By
Speaking the Auditor’s Language
HX
MDM
DX
CPT
EXAM
MOD
SOAP
GOAL
P.A.R.T.
TREATMENT
PLAN
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