What triggers a Medicare audit?

by Alan D. Bergquist, DC, CCSP

Excellent clinical documentation is essential in proving medical necessity for chiropractic care during a file audit. As important as that is, it is equally imperative to understand some of the triggers for those audits to become more proactive in preventing the file review in the first place.

One of those possible triggers is the “Date of Injury or Onset” - Box 14 on the CMS 1500 claim form. For all practical purposes, Box 14 essentially addresses the initial date of injury or illness. However, it’s important to know that there’s a difference between what commercial carriers (BCBS, etc.) want listed for a date in Box 14 and what Medicare requires.

Commercial carriers require Box 14 to be completed with the date of injury or the date symptoms first appeared. For example, if a patient presented to the office today stating he hurt his back two days ago, the date that would go in Box 14 would be two days ago.

In some cases, especially for chronic “old” injuries where the patient states the problem has been present “for years,” you might need to dig deeper to find out what recent activity caused a significant aggravation or exacerbation of that old injury, forcing her to seek care. During your consultation, find out what that incident was, when it was, and that’s the date you enter in Box 14. If you enter a date of injury in Box 14 from years ago, it has great potential for triggering an audit, just to see if your care is medically necessary.

Medicare is different! Medicare defines Box 14 as “date of initiation of a treatment episode.” This means that the Box 14 date is the date the patient first appeared in your office for a specific episode of care. As much as this makes it easier to know what date to enter, it also becomes easy for data mining programs to kick out claims based on how long the patient’s been treating for a given condition. For instance, some Medicare carriers state that even the most severe diagnosis could require “up to three months of care.” It becomes easy for them to kick out all claims that have a Box 14 date greater than 90 days old. This isn’t to say that the care might not be medically necessary, but they may make you prove it with your documentation.

Some doctors’ answer to this has been to just periodically change Box 14. If they were seeing a Medicare patient for ongoing care over months and months, they would just keep changing the Date of Onset to keep it current. This is a violation of CMS guidelines, so it’s important to know when it’s appropriate and necessary to change that date. There are only two occasions that should prompt this date change: 1) if an established patient suffers a new injury, or 2) there’s any significant aggravation or exacerbation in the patient’s condition requiring a substantial change in his or her diagnosis or treatment plan.

When the date in Box 14 changes, it’s indicating to Medicare that on this date the patient’s health substantially changed requiring a new plan of care. This requires all of the necessary components in the documentation to justify that: new history including a new date and mechanism of onset or exacerbation, new outcome assessment, new examination, updated diagnosis, new specific and measurable treatment goals, and a detailed treatment plan. All of that’s required on the initial visit date, regardless if the patient is new or established.

These guidelines were addressed in a recent Medicare bulletin. Because of poor documentation, claim auditors couldn’t tell when a treatment program for a specific episode began and when it ended. This forced them to assume that care was ongoing maintenance care and thus medically unnecessary.

It’s important for every member of the clinic team to pay more attention to the date listed in Box 14, know when to change it, and make sure there’s appropriate, supporting documentation.

(Dr. Alan Bergquist is one of the co-founders of Chiropractic Compliance Solutions, LLC. CCS teaches chiropractors and their teams how to stay compliant, while at the same time giving quality care to a large number of patients. More information about CCS services can be obtained at http://www.compliantchiro.com)