Is this a Need or a Want? Understanding Medical Necessity
DOCUMENTATION
Kathy Mills Chang
MCS-P, CCPC, CCCA
The latest Office of Inspector General (OIG) report landed in late October. It showed how chiropractors are being paid for care for which they should not be paid, and made some drastic suggestions to Centers for Medicare and Medicaid Services (CMS). This report is another in a long line of reports going back a decade that highlight how chiropractors don’t understand the definition of medical necessity and/or don’t know how to document medical necessity in the patient’s record.
According to Forbes, 10,000 baby boomers are enrolling in Medicare every day. Because many of those new Medicare patients started receiving chiropractic treatments back in the 1980s, when insurance coverage for adjustments was relatively generous, it’s not surprising these Medicare newbies are confused by what seems like limited coverage now.
It doesn’t help that many chiropractors are confused about this issue as well. There are more than a few chiropractors who operate under the theory that if the claim goes through, whether through federal or private insurance, all is well.
Not true. While a claim for noncovered care might go through and even be paid, it’s only a matter of time before a third-party payer catches on, and the practice will start receiving the kind of records requests that lead to audits.
The bottom line is that Medicare is probably the subject that confounds both doctors and patients the most. With the CMS on the prowl with ever-increasing scrutiny and audits, it’s essential that doctors leam the standard for reimbursement. Now.
There are many definitions and rules about medical necessity
when dealing with third-party payers, not just Medicare. Because there is rarely a standard of documentation more stringent than Medicare, we recommend becoming familial' with these Medicare definitions and guidelines and applying them in your standard of care for documentation and medical recordkeeping.
A clear understanding of these definitions assists chiropractors with clearly delineating that care which, by definition, should be covered by third-party payers, as opposed to that care which is “clinically appropriate” but not “medically necessary,” and therefore the patient’s financial responsibility.
To be clear, clinically appropriate care could include care you absolutely believe the patient wants and deserves—and no one is prohibiting you from giving it. You just can’t submit a claim for it and you shouldn’t be reimbursed for it.
Medicare’s Medical Necessity Definition:
“The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.”
That’s it. You must have a reasonable belief that treatment will recover or improve your patient’s function. That means this is an episode of care, with a clear beginning, middle, and, most critically, end.
Medicare’s Definitions of Types of Care
Acute: “A patient’s condition is considered acute when the
patient is being treated for a new injury, identified by X-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression of, the patient’s condition.”
Chronic: “A patient’s condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.”
Bummer. Yes, the very treatment that helps patients with chronic pain feel better isn’t covered by Medicare or most anybody else, if there is no functional improvement to be gained. There’s no sweetening this. It is what it is.
Maintenance: “Chiropractic maintenance therapy is not considered to be medically reasonable or necessary under the Medicare program, and is therefore not payable. Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promotes health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration
of a chronic condition. When further clinical improvement cannot reasonably be expected horn continuous, ongoing care, and the chiropractic treatment becomes supportive rather than collective in nature, the treatment is then considered maintenance therapy.”
This is the kind of care your baby boomer patients used to enjoy at liberal discounts; it wasn’t unusual, 30 years ago, for a copay to be something as small as $15. This can be the most difficult aspect of today’s insurance coverage limitations to this age group. They want it, and they’re used to getting it. You know it will improve their quality of life to give it. And yet, here we are.
If you or your patients are still operating with 30-year-old rules, it’s critical that you understand today’s restrictive insurance enviromnent, and that you and your staff be able to clearly explain the limitations before anyone hops up onto your table.
Kathy Mills Chang is a certified medical compliance specialist (MCS-P), a certified chiropractic professional coder (CCPC), and certified clinical chiropractic assistant (CCCA). Since 1983, she has provided chiropractors with reimbursement and compliance training, advice, and tools to increase revenue and
reduce risk. Kathy leads a team of 20 at KMC University and is considered one of our profession’s foremost experts on Medicare, documentation and compliance. She or any of her team members can be reached at 855-832-6562 or infoafmcuniversity.com.
