First Coast Service Options (FCSO) is estimating an improper payment error rate of 39 percent for chiropractic services in Florida for the November 2011 CERT report. These payment errors often involve the billing of chiropractic manipulation services that represent maintenance care.
Providers’ adherence to Medicare coverage guidelines for chiropractic services continues to be a significant issue in Florida and the nation.
Based on previous national findings, CMS requested that the Comprehensive Error Rate Testing (CERT) program perform a special study of chiropractic services in 2012. The CERT special study on Florida chiropractic services yielded an overall error rate of 86.91 percent.
The vast majority of the services reviewed were denied for insufficient documentation and for not being medically reasonable and necessary.
Aside from documentation issues, the primary reason for payment errors in chiropractic services is maintenance therapy being billed as active treatment. This continues to be an issue, even after CMS implemented an acute treatment modifier to allow providers to differentiate maintenance from active treatment on submitted claims.
To help reduce and prevent improper payment errors, FCSO is reviewing data to identify beneficiaries receiving chiropractic services at routine intervals for extended periods of time and will develop beneficiary specific edits.
Here are some additional resources:
- FCSO links page for Chiropractic Services
- December First Coast Service Options Bulletin
- Chiropractic Services Checklist
It is the responsibility of the provider of services to ensure the correct submission of all required documentation. Review the following prior to submitting documentation for medical review.
- Please be sure documentation submitted is legible.
- Please submit records for all dates of service on the claim.
- Ensure the medical records submitted supports that the service is “Active treatment,” rather than maintenance.
- Ensure the medical records provide justification supporting medical necessity for the service by submission of the following:
- Progress notes
- Initial and subsequent visits
- Treatment record including plan of care
- Abbreviation list
- Signatures/credentials of professionals providing services
- Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the additional documentation request (ADR) letter.
The Medicare 2010 CERT Report can be found here.