For Pinnacol Assurance to authorize payment for medical services to its injured workers, all providers must follow the Colorado Division of Workers’ Compensation (DOWC) clinical practice guidelines unless the providers submit compelling clinical reasons to Pinnacol to diverge from them. Prior to authorizing payment, Pinnacol may require providers to furnish clinical documentation that accurately supports all billing codes submitted for payment. Pinnacol will continue to scrutinize bills and supporting documentation and will deny payment when noncompliance is identified. While the following examples apply to all providers, this article highlights documentation that Pinnacol has received from chiropractic settings.
Illegible and incomplete progress notes
DOWC Rule 16-10 specifies the required elements for medical record documentation, noting that such documentation must be legible. Among the things that must be included in each progress note are an assessment or diagnosis of the patient’s current condition with appropriate objective findings; a treatment plan including specific therapy with time limits and measurable goals; and the treatment status or the patient’s functional response to current treatment. The reasonableness and necessity of billed services cannot be substantiated if medical records lack clarity, a sufficient level of detail, or cannot be interpreted by claims adjustors, nurses, physician reviewers, auditors, bill processors, attorneys, and other providers caring for the same patient. Finally, providers should avoid the use of unusual or nonstandard abbreviations without an interpretive key. Example 1 below is an example of a noncompliant chiropractic medical record. The handwriting is difficult to decipher and the note is excessively vague. It includes no objective, quantitative measurement of functional status or progress, and it may be self-contradictory because some unknown feature of the patient’s subjective condition is both “worse” and “better” at the same time.
Example 1: Illegible documentation
Example 2, while legible, includes virtually no required detail. In essence, it represents a summary of billing codes rather than an actual clinic note.
Example 2: Missing documentation
Based on these incomplete and illegible records, Pinnacol may deny payment for billed services.
Disregarding functional gains and time-to-produce-effect
Incomplete documentation may also involve a failure to assess and attend to functional gains. Functional gains would be reflected in terms of objective, measurable improvements in areas such as strength, range of motion (ROM), endurance, positional tolerances, and physical performance (e.g., lifting, pushing, the ability to perform more activities at work, and activities of daily living (ADLs), such as putting on one’s socks or walking). The DOWC Medical Treatment Guidelines (MTG) specify “time-to-produce-effect” intervals during which functional gains should be observed. These intervals are defined for different types of treatment modalities and categories of injury (see the Utilization Guide for Initial Time to Produce Effect for a summary).
With respect to manipulative treatment, two principles apply. First, because manipulative treatments are passive (they do not require the patient to expend energy), they should be used adjunctively with active therapies (see MTG Exhibit 1, Low Back Pain). Second, for all types of injuries, manipulative treatments require the achievement of meaningful functional gains within the first four to six sessions. If no functional gains are observed within this timeframe, manipulation should be discontinued. If functional gains are realized, payment for a limited number of additional manipulative treatment sessions can be authorized at a rate of one per week. Finally, the MTG specifies a usual maximum duration of manipulative treatments. For example, unless otherwise medically indicated, the maximum duration of manipulation for low back pain is eight weeks (see MTG Exhibit 1, Low Back Pain).
Manipulative treatments that continue without evidence of functional gain may represent excessive treatment, which can contribute to poor outcomes and avoidable cost. Care beyond eight weeks may be indicated for certain chronic pain patients in whom manipulation is helpful improving function, decreasing pain and improving quality of life.
It is important to note that the persistence of pain is not by itself a sufficient reason to continue manipulation. Pain is a pertinent aspect of functional status only when it is meaningfully correlated with objective physical findings or test results (see MTG Exhibit 1, Low Back Pain). Unfortunately, it is very common that chiropractors and other providers overemphasize subjective pain relief as a goal of therapy and fail to document temporal changes in functional status or correlation with objective findings.
Example 3 below, while lacking many required details, is silent about the patient’s functional status and ignores the DOWC’s time-to-produce-effect criteria. Twelve is an excessive number of initial chiropractic sessions, and Pinnacol may deny payment for chiropractic services that are unsupported by functional gains over time-to-produce-effect intervals.
Example 3: Missing functional gains and exceeding the DOWC time-to-produce-effect criteria
Unsupported use of modifier 25
Chiropractors who provide manipulative treatment can attach evaluation and management (E&M) modifier 25 only when there is a new problem related to the work injury or a significant exacerbation of an existing work-related problem. These events must be documented in detail. If a chiropractor is simply treating an ongoing problem, a standard reassessment of the problem is already included as part of the therapy. Billing an E&M with modifier 25 in such circumstances would be rejected.
Unsupported use of modifier 59 with CPT 97140 (manual therapy)
Like modifier 25, modifier 59 is frequently misapplied and overused. Using this modifier to “prepare a region for treatment” is not separately payable. Manual therapy (e.g., tissue mobilization) is considered part of the manipulative treatment. Modifier 59 is allowable only when manual therapy is applied to a separate region or body area and it is medically necessary (when there is a credible and thoroughly documented relationship to the original work injury).
Example 4 below, in which the provider billed code 97140 with modifier 59, illustrates a number of these points. “Traction,” “soft tissue mobilization,” and a “kinesiology technique” applied to the lumbosacral region do not meet criteria for separate, billable services. Moreover, there is no documented clinical justification for performing manual therapy on the thoracic and rib regions, areas not clearly associated with the original work-related injury.
Example 4: Inappropriate use of code 97140 and modifier 59
Additional coding and documentation tips
- In order to support units of therapy, all providers, including chiropractors, must adhere to rules related to the documentation of time (see Tips for Appropriate Documentation of Time-based Therapy Codes). Precise time stamping (actual start and stop times) must be indicated in the documentation; auto-time-stamping or cutting-and-pasting is inappropriate.
- The cloning of documentation, such as when the same history is repeated on every visit, is another potential cause for audit and payment denial (see Cloned Documentation).
- CPT codes 98940 through 98942, spinal chiropractic manipulative treatment, must reflect the correct number of spinal regions that correspond only to the work-related injury areas.
- CPT codes 97110 and 97535, instructions for home exercise or self-care, should only be billed when the documentation supports new or added instructions. These codes should not be billed on every visit.
- It is necessary to explain medical necessity and use the correct billing codes for the strapping or taping of specific body regions.
Carrying out audits and issuing payment denials are time-consuming, costly and unpleasant. However, Pinnacol strives to ensure that injured workers receive high-quality care by promoting adherence to the DOWC’s treatment guidelines, confirming services rendered are appropriate, and requiring complete and legible documentation to support care coordination and successful communication among all stakeholders.
If you have questions or wish to learn about opportunities to improve billing practices in your office, please contact Pinnacol’s billing auditors at email@example.com. They will be happy to assist you and your staff by phone or in person. If you have feedback about this article, I would love to hear from you at firstname.lastname@example.org.