Chiropractic Medical Necessity and Preauthorization – Made Easy

Disclaimer: This is a live transcription and has not been edited for spelling, grammar or syntax. Please view the video as you follow this transccript                     

Hi everyone. It’s Sam Collins, your coding and billing expert for chiropractic the HJ Ross Company. And of course, ChiroSecure with another episode to help your practice grow and hopefully make things a little bit simpler, easier, and frankly, get paid today’s program. We’re going to talk a little bit about medical necessity and pre-authorization, but I gonna give a little background story here for all of you.

I’m not sure how many of you have seen me in a lecture before where they’ve attended one of my live seminars, but I’m of course of chiropractic legacy. My dad was a chiropractor as a model. And when I grew up, now, you can remember I’m a little bit older now. So I’m 62. When I was a kid, I remember people saying to me, your father’s not a doctor.

And I knew what they meant because this person, I remember specifically her husband was a medical doctor. She wanted to make sure, I didn’t know. I knew that my dad was just a chiropractor, and I’m saying this because how much have things changed? Look at where we are the expansion of what we’re doing.

And I say a good tip of the hat to the whole profession and really continuing to expand by making people aware of what we do. And the bottom line is you can’t hide chiropractic because it works. But again, thinking of that change to where we are now, the respect level, what we have, I want to continue with that by us demonstrating medical necessity and understanding how to deal with when you have to do pre-authorizations or they’re dealing with the services not being paid because Ooh, we didn’t show enough.

So let’s go to the.

As always here is our website for HTA Ross, as well as my email. Now, a couple of things let’s define medical necessity. Let’s look at what insurance companies say, because that’s, who’s the ones that’s really making this dictation. Obviously a patient’s medical necessity is either you help them feel better.

And if they don’t, they’re going to stop coming while insurance works a little bit the same way, but obviously they need to see it from the other side, which means that our notes. So here’s what Aetna says for a medical necessity. Aetna considers chiropractic services, medically necessary, and notice when all of the following criteria are met.

Number one, they must have a neuro musculoskeletal disorder. So understand for insurance purposes, there’s gotta be a diagnosis. That’s neuromusculoskeletal. Now what if it’s. No problem. That’s still means you can treat, but make sure patients understand not covered by insurance, but again, you can treat the human condition, but for insurance and neuromusculoskeletal, they’re saying they want to see the medical necessity for treatment as clearly documented and improvement.

Now, what do they mean by improvement? It’s documented this way. Improvement documented within the initial two weeks of chiropractic care, meaning we’re showing changes, both subjects. But also objectively. So meaning we have to have some measured values and it says if no improvement is documented within two weeks, additional chiropractic treatment is considered not medically necessary.

So in other words, you have to make a patient feel better. Now think is the beauty of chiropractic though. How many patients have ever been to a medical doctor? And they leave the office saying, oh, I feel so much better right now. I don’t think that really happens in their setting. And I’m not saying that as a negative, but I’ve never been to a medical doctor where I’ve left feeling better.

I guess if I went in and they said it wasn’t. I might feel relieved, but think of how many people come to you with back pain, neck pain, headaches. They get a treatment. Wow. I can’t believe that I feel that much better immediately. There’s a lot of power to that. I want us to continue to have that, but we’ve got to demonstrate it.

So let’s look at another pier. Let’s talk about Cigna. It says medically necessary when all of the following conditions are met and you’ll see here, the same thing, musculoskeletal disorder. And they say the services condition require the unique skills and judgment individual plan. Okay. We get that, but here’s where they get back to it.

They say the individual’s condition has potential to improve. Or is improving and has not reached medical maximum medical improvement. Meaning we can show that the patient has gotten better. How do we do that is saying the patient who feels better adequate? That doesn’t hurt, but it’s not really the best part because it’s not really a measured value.

It says improvement is evidenced by successive objective measurements over a timeframe. Notice that doesn’t indicate subject. But more objective measurements. Now you can turn subjective statements into more objectives and tasks. What we’re going to focus in a little bit on today, but please bear in mind.

Medical necessity has, can I make the patient feel better? That’s obvious, but we want to look at what factors do they look at? Let’s take a look even at CMS. They divide us up into two things, acute or chronic subluxation. It says an acute one is the patient’s condition is considered acute.

When the patient is being treated for a new injury identified by extra physical exam, obviously for Medicare. And it says the result of chiropractic manipulation is expected to be an improvement or an arrest of progression of the patient’s condition. So again, some type of objective change do remember though Medicare does cover chronic conditions, but it says a chronic condition is when it’s not expected to significantly improve or be.

As the case of acute condition, but we’re continued therapy can result in functional improvement. So we’re not saying we’re going to the person cured and perfect and never have a problem, but functional improvement. And what’s that plateaus then we’re released the notice that says once the clinical status has remained stable for a given condition without expectation of additional objective clinical improvements, I’m going to put a big emphasis here on objectivity measure.

When you put someone on a diet. How do you show they feel they’ve lost weight. You don’t say they look better. Heck if you wear certain types of clothes, a belt around your waist, you look trimmer, but they want to know the objective, put them on a scale or use a tape measure. Let’s use one more.

In fact, what I consider for some of you anyway, I know this Ash can be the biggest pain when it comes to necessity. For me, I won’t say that’s true. You know what? The biggest pain for me with Ash, I don’t think that. They’ve been paying the same rate for so long. Now I’m thinking where’s the raise.

Everyone who works for Esh gets a raise, but the doctors don’t, that’s a whole nother conversation. But bottom line is, I don’t think their medical necessity is that complicated. Once you see what they’re looking for, and this is what I want do to get from today, let’s look at what the carrier looks for so we can make sure to have that information.

Number one, they look at a diagnosis, which of course means neuromusculoskeletal, but they do pay attention to things in the past medical. Is it traumatic? Is it repetitive? Is it acute, chronic and so forth? All those factors make a difference into the severity of the condition. So those factors are important when you’re requesting authorization.

Tell me more about that patient. Not just one simple, they have pain, but why and how long and what other factors they do pay attention to comorbidities complications. Let’s say you have a patient that is very overweight, very de-conditioned. Is that going to be different than treating someone’s? How about a patient that’s diabetic or any of the other underlying things.

They may have curvature issues, spondylosis. So many things can add to it, but remember if you don’t document it, it doesn’t exist. So we have to make sure is that information in the file? Is it in a diagnosis? Is it in a report? And then of course your exam findings range of motion, palpation, orthopedic testing, everything quantify.

Don’t tell me that muscle spasm is improved or never use the term there’s taught in tender fibers. That’s just too broad taught and tender. How taught how tender we want more objectivity so I can measure how it’s changed. The bottom line is, and what they say is they want to see functional limitations and they indicate validated outcome assessments.

So I’m going to focus a little bit on making sure. Do you have the right things in place to make this evidence? I will tell you if your notes are little below average, but at least has the basic information with good outcomes. You’ll win a medical necessity debate because at the end of the day, they still got better.

Think of a person that’s on a diet or several people and one person who’s their diet coach writes out a very detailed, this thing is pages and pages of what to eat, what not to eat when to eat it and all that great. Another person gets, puts them on a diet and it’s got direction, but it’s not maybe quite as detailed, not to the industry.

But the person on the ladder diet loses five to six pounds a week, and the other person loses a pound or a half pound, which diet is more effective at the end of the day. It’s what’s effective. And that’s the beauty of what you do. What I will say is if your patient is better, can I look at your notes and see it, not talk to you about it because no, one’s talking to you about it.

It’s gotta be in the notes. So I’m going to say let’s focus on these outcomes and what are the goals of care? The goal is that. So let’s take a look a little bit further. Let’s take a look at Cigna’s guidelines when it comes to documentation of medical necessity. And here it says data collection with objective measurements.

Okay. And determining the effectiveness of care organized in a composite. So in other words, updating that if the patient is getting better, but the big factor is notice below it’s standardized tests for measurements. And it says here measuring outcomes is an important component of chiropractors. Outcome measures are important in direct management of individual patient care for the opportunity they provide for the profession and collecting, comparing data, the use of standardized tests and measures in an episode to establish, establishes a baseline.

And then of course, gives us something to change. So don’t get fancy. Give me a good, simple. Diet cares about how much do they weigh or some other measurement measure have a way to look back on it. Notice also even the VA gets into this social. For those of you dealing with VA patients, it’s the same thing and it’s not different from patient to patient.

Here’s what I’m pointing out. Notice I’m bringing up all these different carriers, but notice the common thing. Here’s the VA, what are they? Significant durable pain, intensity decrease. So that’s the first one that said pain, but notice it says significant. So if you’re using a pain scale, eight points to seven points is not significant.

If you’re not aware of the standard painter. The patient has to be about three points different on that scale, because otherwise it doesn’t have enough real objectivity or nuance. So focus there, there must be significant, not just simply I feel better, but notice the second thing functional improvement demonstrated by clinically meaningful improvement on validated disease-specific outcome instruments.

So again, notice the emphasis, I’m going to say, make your life simple. Remember when Medicare was doing the PQRS. It’s setting us up for this. This is something I think chiropractors should have always done because frankly your care works really well, but does it all work? Demonstrated and that’s the issue.

And they also look at decreased pain pain medication utilization, obviously for the VA with opioids. So certainly that can all be helpful. So you can see here, the leaning towards it. So what we need is a more algorithm that kind of gives us data-driven care. And I would say, even if you don’t use an outcome track restrictions of activities of daily living, don’t tell me the patient feels better.

They feel better. And I can now tie my shoe. I can sit for 30 minutes where I couldn’t sit before something of that nature. Cause it shows then you have a quality care based model. Something that objectively shows here’s what changed. You gotta have a person. I feel better. Let’s face it. If you win the lottery, I think you’re going to feel better.

You don’t really feel better. You just are happy. And that euphoria said. So keep in mind, they want to have objective measurements. So you’re going to hear this term a lot promise. This is the new thing. Patient reported outcome measurement instruments. And I’m going to just give some examples here, like the general pain index you all use to you’ve seen it before or the patient functional patient specific functional scale PFS.

The premise short form or, pain rating scales, and even the ask of Western neck disability. Now I will tell you the Oswestry forms and neck disability are very good, but do you ever notice patients have a hard time filling those out because maybe they’re too long. And so you’ll find you ever have a patient do this.

They fill out a form and they say they feel better, but when you read the form that. Or they tell you they feel better. And last time they said it was a seven. Now they say it’s a six wait a minute. That doesn’t match. So be very careful, the patient filling out some of these pre-treatment ones with electronic health records, without any context, I’m going to suggest we do this with the patient to make sure they understand what we’re looking for to make sure we have the right information.

I would suggest if you’re doing an as Western or neck disability, you should do those on the exams and the patient doesn’t with. As part of the exam, because I think they’re just better questions that we’re going to really have a good objective way where it’s consistent. Let’s talk about this first one, the general pain index.

You’ll notice it’s six questions. It’s simple. It’s why I like this one. And it’s just a simple zero to 10. A zero means it’s fine. A 10 means it’s a mess. So it goes over six factors of daily living things, family and home responsibilities, recreation, social, and. Simple life around the house, if you will yard, work, whatever, but it’s just measuring, what can I do?

The higher, the number, the worst they are as they improve the lumper gets lower. So if you’re doing these every two weeks and the patients consistently improve, is your care working. Yeah. In fact, I’m not saying we’re trying to treat zero, but at least we’re trying to get to a base. Where it’s stable and not changing.

This is a very easy for them to do. I would say every patient would do this every two weeks. The VA though has been pushing this one. It’s called pain and interference. The short form. Now this one, they want it done every seven days. This one is about every two weeks. You’ll notice though, this short form is literally the same as the general pain index.

And it says, how much does your pain interfere with day to day work around the house? It’s all the same six factors. The only difference. This is not quite as. Detailed or a specific, because now you only have five choices. This is still very good. I would just want some context, like if it’s interfering with you work a little bit, in what way?

So always give some context to it, but here’s gonna be the. This is going to be an easy way for you to always make sure you’re showing improvement. So when you’re requesting additional care is going to be very easy to point out the change, because you’re going to have objective evidence. You can show with a form like this.

One of course you are used to the pain scale, but here’s the one for the VA. The fact that all of you for a moment right now, I’m going to give you a free gift today. Pull out your. Take your phone. I have it ready, open up your camera. And this defense and veterans pain scale defense department of defense is the pain scale.

I would suggest you want to start using and get away from the old, VAs scale because when someone says they’re an eight, what does it actually mean? You ever have a patient tell it’s a 10 and they raise their arm all the way up. That’s not it. And so be careful because the subjectivity of that means that it’s going to be hard to really measure.

Whereas this one, yes, it’s measuring pain, but you’ll notice it’s focusing more on function. Notice a five says, interrupt some activities. That’s not talking about how much it hurts, but activities. So this way it allows you to really look at a functional change. Notice we’re moving away from, I feel bad to when you feel bad, what does it mean objectively?

What can’t you. Because of it. And then of course, what’s cool about this one. It’s two-sided on the second side, it has four more questions. One is just general activity, but notice how it does a patient holistically. Like how is it affecting your sleep, your mood and your stress level? Because obviously when someone’s in pain, all these are going to be affected.

So we’ve got a little bit of way of looking at the whole person. I really liked this one and I would suggest this becomes your day to day pain scale. I’m in fact, telling you take this form below. To a poster and put it in every exam or treatment room. So when the patient comes in, you document each and every day where they’re at now, you’re thinking Sam, how do I get that?

For those of you who come to our seminars are members of our network service, or have our digital coding, you have access to it, but everyone else has been well, Sam, that’s great. I’m going to send you an email for it. Now we don’t have to do that. Take out your phone, open up your camera, go to the screen, use that QR code.

Take a moment to do that. When you do that, it’s going to give you an ability to send it to. The text is going to be the word pain to the number 7 1 4 2 8 0 4 6 9 7. Now don’t worry if somehow you’re going to, it’s not working. Don’t panic. Remember you can watch this on a repeat later, but just text 7 1 4 2 8 0 4 6 9 7.

And when you do, it’s going to ask you your name and your email, and we’re going to send you a cool and clean copy in color that you can then take out to your local copy place. Make it bigger, because I want you to have some tools. I know your care worker. My concern is, are we demonstrating it? And so you got to put a lot of emphasis on what am I really doing objectively and get away from the statements of, I feel better or your patient filling out that one right before they come in and they mark stuff down without any context, they don’t really remember how they felt.

I know you can all attest to this. A patient says they feel better. They do yet their pain scales higher. And it’s because you let them do it on their own. You better make sure to have context with all of these medical necessity is something chiropractors are really good at. Just make sure you have the right factors.

In fact, I’ll give you how the VA looks at it. And I’m going to say this works for anyone. So when we’re talking pre-authorization I want you to focus on these five things. Show me the pain intensity decrease in a measured value, but with functional improvement, not just the pain functional change use validated outcomes.

Say I use the general opinion. I’ve used the Promus form, whatever. Give me something that you use consistently. If they’re taking medication document that if they’re taking less Tylenols or whatever, obviously we’re not telling them to or not, but certainly want to measure it. And then notice here, objective measures demonstrating the extent of meaningful clinical improvement and the rationale for continued care.

There’s this improvement and we’re going to get this much more. If you’re showing the patient has improved. Five to 10 points every time, or, 10%, 20%. And that trajectory continues. There’s no reason to stop care. That’s going to be an easy, get to get more care. If you don’t have that, they’re going to go there probably enough better.

Let’s remember one of our complications in chiropractic, it works well. How many times? After two weeks the patients going, wow, I’m feeling really pretty good. What does that mean? Functionally though, feeling good. Just means you’re not feeling as bad and then focus in on the objective. ’cause now we have a goal set that yeah, you’re feeling much better, but you still can’t perform these tasks which are necessary.

And then put us into the factors, including things such as what type of job you have or what things you have to do. Can you complete all of that? And then of course always remember, include any barriers to recovery. This is something I think we don’t emphasize enough. We always want to talk later after the fact something about it.

When we fight medical necessity, but it’s not included how many times you’ve had a patient that has spondylosis and a reverse cervical curvature. When you take an x-ray that type of condition superimposed on any other injury is going to increase the need for care at one and a half to two times. But if it’s not diagnosed, it’s not.

So make sure if there’s something significant, you’ve got to diagnosis and trust me, there is a diagnosis for everything. If you haven’t been to one of our seminars, it’s a great place to go. And we update you all the time. Go to our website, go to our new section, and I’m going to put a note here, and this is going to come in.

ICD 10 codes are coming up. It’s almost September 1st. And in one month we will have new codes. I will tell you if there’s going to be some new codes for a lumbar spine. As well as for concussion among others. So just wet your appetite for those of you that are within our service. If you ever digital coding, they’re already listed, just put in a search for the new codes or the updates.

If you’ve come to one of our seminars, they’re there. So let’s get ready. Don’t be held back by not knowing the codes always have a resource. We are your resource HJ Ross Company, along with ChiroSecure is always going to be here to help you. If you want to get day-to-day help, I become part of your.

Join our network. Take a look at our website. You can do a QR code for a year. We’re going to be here always to make sure your office does well because your success is ours. I wish you all. Next week hosts will be Mike Miscoe until I see again, everyone take care of and continue being that chiropractor because you’re important, but it’s good to be important, but more important to be good.

See you next time, everybody.