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Palmetto CERT Review Finds ‘Unacceptable’ Chiropractic Medicare Denial Rate

Palmetto to Hold Special Webinar for Chiropractic

Palmetto GBA has released the results of its review of chiropractic Medicare claims and found an “unacceptable” error rate of 68 percent for Northern California and 77 percent for Southern California. These results are very troubling as Congressional leaders have threatened to remove chiropractic from Medicare if the profession did not improve its billing practices. According to Palmetto, due to the “unacceptable” denial rate, its review of chiropractic claims will continue. At CCA’s request and out of grave concern with the high chiropractic error rate, Palmetto will host two webinar training sessions in January and February 2011.

In its review of claims submitted from March through August 2010, Palmetto stated the number one reason for the denials was lack of response to requests for documentation; claims received with no documentation to validate services billed are automatically denied. (Note: In addition to claim denial for not responding to a request for documentation, doctors of chiropractic are also subject to severe financial penalties.)

The review examined 8,913 chiropractic claims in Southern California and 11,736 claims in Northern California with CPT codes 98940, 98941 and 98942. According to Palmetto, the major reasons for claim denial were:

Southern California

  • 55 percent of the total dollar amount denied was due to no documentation received for review

  • 21 percent of the total dollar amount denied was charges that were deemed to be not medically necessary based on the Chiropractic Services LCD (L28249)

  • 9 percent of the total dollar amount denied was due to invalid, illegible or missing provider signature on the documentation received

  • 15 percent of the total dollar amount denied was for a combination of down coded claims, biller errors, illegible documentation, and incorrect or incomplete date of service or patient identification on documentation received

Northern California

  • 50 percent of the total dollar amount denied was due to no documentation received for review

  • 27 percent of the total dollar amount denied was charges that were deemed to be not medically necessary based on the Chiropractic Services LCD (L28249)

  • 9 percent of the total dollar amount denied was due to invalid, illegible or missing provider signature on the documentation received

  • 14 percent of the total dollar amount denied was for a combination of down coded claims, biller errors, illegible documentation, and incorrect or incomplete date of service or patient identification on documentation received

Denial Reason Summary

In addition to the poor response to requests for documentation, Palmetto stated that the second most frequent denial reason was documentation not meeting the requirements for medical necessity. While signature issues were noted as the third leading cause of denials, Palmetto found that there was a notable reduction in both regions of claims denied for this reason.

Palmetto reiterated that documentation submitted for each date of service must be in the form of the original patient record and that documentation for each separate date of service must be complete and able to “stand alone” per the LCD. Palmetto cautioned that summary letters are not acceptable documentation for chiropractic services.

As a result of the unacceptable charge denial rate in both regions, Palmetto announced that medical review of procedure codes 98940, 98941 and 98942 would continue for an additional quarter in Northern and Southern California. According to Palmetto, the review in Northern California will focus on the claims with these codes that have been billed with the “AT” modifier.

Resources

Palmetto will hold two webinars on proper Medicare documentation and billing by the chiropractic profession. Demonstrating the seriousness of the issue, Palmetto’s head person for all chiropractic claims, Arthur Lurvey, MD, FACP, FACE, will personally conduct the programs scheduled for Wednesday, January 26 and Tuesday, February 1, each from 12:30 p.m. to 1:30 p.m. CCA encourages doctors and their staff to participate in these training sessions. Watch for further notices and registration materials from CCA.

In addition, CCA has a tremendous library of resources and expert assistance available to members and their CAs to learn how to bill Medicare correctly, respond to an audit request and prevent denials. Among those resources are:

January 2011

CCA Victorious in Stopping SCIF Policy to Deny DC Post-Op Referrals

Medicare Fee Schedule Victory for DCs

DC Re-licensure Fee Increases in 2011

Palmetto CERT Review Finds ‘Unacceptable’ Chiropractic Medicare Denial Rate

Get Your Medicare Claims In – New Deadlines

CCA Members Get CE
Free
from CCA

Medicare, Health Care Reform, More – Grass Roots Protection of DCs

Medicare: Updates on Palmetto Contact Center, Online Provider Services, Redeterminations

New Restrictions on Flexible Spending Accounts in 2011

DCs Exempted from Costly ‘Red Flag Rules’

BCE Seeking Expert Consultants

Payroll Tax Cuts and Business Tax Incentives for 2011

Study Finds Starting with Chiropractic Saves 40% on Low Back Pain Care

Manipulation Found Effective for Back, Neck Pain in New AHRQ CAM Report

Enhanced CCA Membership Directory Published


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©2010 California Chiropractic Association. This newsletter is intended to inform chiropractors of current developments in the profession. It is not intended to provide legal advice on the subjects addressed. Information is gathered from sources deemed reliable; however, CCA is not responsible for its accuracy. CCA Advantage is provided as a member benefit included in annual dues.