October 2019

October 2019

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Audit Red Flags

Every doctor should know the clinical findings that are the red flags that will raise suspicion of a more serious underlying medical condition, but are you aware of the red flags in your documentation that could trigger an audit?  Sure, some audits are completely random and unavoidable but many times an audit is triggered by a pattern of coding and claim form errors that lead to a record’s request. Once you are in the midst of an audit, it can be difficult to rectify the situation, and it can result in recoupments or stiff penalties. The best approach is to avoid making these mistakes in the first place.

The Audit Cascade

In this day and age, claims are mostly sent electronically. Even claims that are mailed are entered into a computer at some point. Everything about your patients’ conditions and treatment is summed up in a few ICD-10 and CPT codes.  Your computer talks to the insurance payer’s computer. If you submit codes that the payer’s computer doesn’t recognize, you may get an immediate rejection. Even a processed and paid claim doesn’t always mean that you are in the clear. The payer is most likely tracking patterns in your claims. If you happen to be an outlier in the way you bill or code, expect to get an audit letter.

Audits tend to start out small with only a handful of patients or dates of service being requested. You must act quickly because you don’t get much much time to respond. Find out exactly which records are requested and get them sent in. Then prepare to wait. Because the insurance company has a financial incentive to find errors, it will take its time to scrutinize every detail. Sometimes the documentation helps tie up the loose ends that weren’t apparent from the claim form and the insurance company will pay you and leave you alone. If not, the insurance company just hit the jackpot. Odds are that if they find errors in a few claims, there are errors in other patients’ files as well. The payer may just keep expanding the audit until they have recouped all of the payments they can. They may also create a formula that is applied to all the claims you have submitted to the insurance company or Medicare over the last couple of years to determine what you owe. An audit is not something to take lightly and ignoring it can be even worse since you are automatically telling them you don’t have the documentation to support your claims. You can expect serious repercussions.

Common Audit Triggers

Here are a few items to scrutinize in your billing and documentation to  ensure you aren’t directing any negative attention to your practice:

  • Cookie Cutter Care: A chiropractic office is not meant to look like a factory assembly line. Treatment plans should be individualized for patients based on a number of factors including their presenting symptoms, health history, and their response to treatment. If the patient’s treatment looks the same on Day 1 as it does on Day 100, or if most of your patients get the same adjustments and exercises regardless if they are coming in for a neck or low back complaint, chances are you will be asked by the payer to defend your treatment protocols.

  • New Date, Same Old Complaint: Box 14 of the 1500 claim form is the date that treatment started. While it looks bad if the date in Box 14 is a few years old, it is just as bad to keep changing the date when it isn’t actually a new condition. Consider whether or not the patient might actually be in the maintenance phase of their care and if billing is still appropriate.

  • Upcoding or Down coding: It is important to learn what the medical necessity definition is for the various payers  you work with. Not every full spine adjustment is worthy of billing a 98942. This would mean that the patient came in with a complaint in all 5 spinal regions!  If 98942 is being billed out more than 5-10% of the time, consider if it’s being overutilized. Likewise, it would be unusual to see an office that exclusively bills 98940. This might appear that the office is purposely down coding services to avoid charging the patient for the full service that was provided. This is not only a concern for manipulations but may also indicate E/M services and units of timed modalities are also commonly reported incorrectly and could potentially cause an audit.

  • Incorrect use of Muscle Therapy Codes: Manual Therapy and massage have numerous benefits when combined with chiropractic treatment; however, this additional service isn’t always medically necessary. It may also fail to follow the payer guidelines for reimbursement. Many payers state that massage must be performed by a chiropractor to be considered for payment and will not cover it if done by a licensed massage therapist. Improperly billing these services under the doctor’s license is insurance fraud. Massage (97124) is not interchangeable with manual therapy (97140) either. Massage therapy includes techniques such as effleurage, petrissage and/or tapotement. Manual therapy, on the other hand, involves manual mobilization, traction, trigger point therapy, or myofascial release. While patients might enjoy an hour-long massage, it is highly unlikely that an hour of trigger point therapy would be clinically appropriate and might raise eyebrows if multiple units of this code were reported. Be aware, also, of payer policies that do not permit a muscle therapy to be performed in the same region as a manipulation. Report the muscle therapy code with a -59 or -XS modifier to indicate that they are used on different regions of  the body.

The Best Defense is a Good Offense

Unfortunately, it is not a matter of if you will be audited, but a matter of when. Avoiding red flags in your claims and documentation can keep you off the insurance company’s radar. Train the doctors and staff in your practice proper billing and coding procedures. Regular internal audits can also help catch errors. Make sure your documentation supports the services that you are billing so the patients’ files will tell their whole story. Keeping your office compliant will give you peace of mind knowing that you are doing everything you can to keep your chances of being audited to a minimum.


Dr. Karen Sedore has over 10 years of experience working in the chiropractic profession. She began as a manager specializing in billing and medical necessity as well as taking on chiropractic assistant responsibilities so that she could be more involved with patient care. She also has experience with income tax preparation and has helped hundreds of families and small businesses with tax planning. In 2016, Dr. Sedore received her doctorate in Chiropractic from National University of Health Sciences. She joined KMC University in 2017 and assists doctors and their staff in her current role as an Membership Advisor.