Denials and refund demands due to the failure to have a treatment plan (Care Plan) documented in the chart.
Over the years, Medicare and others have paid claims based on the information that was only on the claim form. Supporting clinical necessity details from the charts were rarely used.
Primarily, the accepted standard for payment was an appropriate subluxation code linked to the presenting problem/ disorder and treatment. Other requirements for charting were added, but seldom used for payment. In the last decade, payers have discovered that they can save money by denials due to inadequate or missing supporting information in the clinical records. Denial management is now a 20 billion dollar a year industry. In the past five years, Medicare and other payers have redefined their roles as “payers of quality healthcare,” and thus the need to correlate the claim with the chart. Hence, the advent of “electronic medical records” to determine the “quality of care.” Missing supporting information now evokes cries of “Inappropriate Payments” and “false claims” by fraud squads.
Medicare is the accepted standard by many payers. The Medicare Manual (240.1.2) clearly states its chart documentation requirements for the initial and subsequent visits.
“Treatment Plan: The treatment plan should include the following:
Recommended level of care (duration and frequency of visits)
Specific treatment goals
Objective measures to e valuate treatmenteffectiveness.”
There is no “treatment plan” stated in the subsequent visit, but only the associated references to it in the History (“Changes since the last visit”) and the Physical exam (“Assessment of change in patient condition since last visit”).
The Office of the Inspector General (OIG), that oversees Medicare, audited and reported the current status of chiropractic documentation for services. They discovered missing information in chiropractic charts regarding the three required components for the “Treatment Plan.” They reported that fifteen percent (15%) of the claims were missing the “Recommended level of care (duration and frequency)” in the patients’ chart. Seventeen percent (17 %) were missing “Objective measures to evaluate treatment effectiveness,” and forty three (43%) were missing “specific treatment goals.”
If the OIG report is correct, why have doctors failed to record their “specific treatment goals”? Such missing information is a serious matter because the stated “goal” should be the focal point of any treatment plan. Without it for determining progress, there is no benchmark as to when a patient has reached their “maintenance” status or other goals. In football terminology, objective measures are the critical yardsticks in measuring progress. In the “restoration” phase of health care, the “specific treatment goal” is the goal line. Such are the rules in this coding game.
There are many possible reasons for this problem:
Lifetime chiropractic care philosophy, without any regard to phases of care.
Scheduling visits according the maximum allowed in the edits screens (soft caps) of payers.
Failure to understand all three components of the Treatment Plan.
Assumptions that their old habits must be okay because they have never been questioned or evaluated.
Medicare contractors in the past were primarily just the payer of claim, and not purchasers of quality healthcare, and had limited no funds to audit, teach and enforce, even though the rules in their manual had existed for years.
Unfortunately, Medicare rule writers placed the “goal” in the second position of the three. It should have been first to emphasize its importance. Consequently, the “schedule of visit” in the first box appeared to paramount.
Perhaps a limited focus on specific “goals” by many seminar leaders and payers.
It is also important to note that Treatment Plan’s goal is not mentioned in the subsequent visits requirement directly; but only the “changes” that are associated with the goal since the last visit. Clearly, the goal or bench-mark is established in the initial encounter.
Because “specific treatment goals” have been the major missing link in chart information, and now the targeted rationale for denials, it needs the most immediate remedial attention in nearly half of all offices in the nation.
Perform an internal audit today on your patient records; and determine if you meet all three component for your “Treatment Plan” on the initial encounter, and especially your “specific treatment goals” component. If missing, make immediate remedial corrections for improvement in your forms and record keeping habits.
Document on subsequent encounters the “evaluation of treatment effectiveness” and “changes” associated with your initial Treatment Plan and specific goals.
Perform Significant periodic re-evaluations and record updated goals that are commensurate with the patient’s progress or no progress (in such cases, refer out).