What to Do When Your Chiropractic Exams Are Downcoded

If you are having trouble with exam downcoding in your chiropractic billing - in other words, you bill for a 99204 but the insurance only pays for a 99203 or you bill for a 99213 and the insurance pays for a 99212 - keep reading because this article can potentially put thousands back in your pockets!

Trends in Downcoding
Downcoding is not new, nor is it a passing fad. The practice of an insurance company paying you lower fees and at a lower code that you billed is also not unique to chiropractic.

Basically, from the insurance perspective, here's the inside scoop on how downcoding occurs. (As many of you already know, I fully admit that I used to work as an insurance claims analyst and so I have an intimate knowledge of their methods!)

Everyone is NOT Downcoded
Rest assured, insurance companies do not try to downcode every possible E/M or exam code for every provider every claim. However - certain E/M codes are highly audited in the chiropractic profession and subject to near constant downcoding.

Which ones? For chiropractors, the biggie is 99205. In fact, there are many even within the chiropractic profession who will go on record and state that DC's have no business using that code.

Downcoding 101
While exam codes such as 99205 are pretty much automatically flagged in the chiropractic world, most insurance companies employ sophisticated software tracking systems to determine which codes under which circumstances they will target for downcoding.

How does one get on such a hit list?
Easy. Your coding trends are significantly outside the "normal" values that your peers submit.

Let's look at it this way: if your peers bill 99203 20% of the time and 99202 80% of the time but you bill the reverse - 99203 @ 80%, the software at your friendly insurance carrier is programmed to "kick you out." Once labeled an "outlier" your claims are tracked and either immediately or periodically subject to downcoding.

In other words, the insurance company will try to bring your claims back to the middle - what they consider "normal" patterns.

The Real Issue With Downcoding
No one likes to be an outside, but the real meat behind the issue of downcoding is dollars lost! Every time your claims are downcoded, you are forced to fight to defend your care. Every time you fight, you lose some $$$ just because of staff time spent fighting.

Now, one solution is to not fight back. Bad idea. Call me crazy but I believe that if you truly perform a 99203 then you should be paid for a 99203!

The other solution is to "play it safe" or stay under the radar and downcode yourself. I know many DC's who use this strategy and while it is true that they aren't audited as much, they are also losing thousands of dollars each year by not asking the insurance companies to pay them for what they do.

My Solution
My solution is rather simple: know your stuff and be paid for everything you do.

Knowing your stuff is a problem for some DC's not because they are bad chiropractors, but because they know virtually nothing about billing and coding!

The Most Common Error in E/M Coding
When I audit one of my client's claims or exam notes to determine if they are compliant and correct, here is one near universal mistake that I repeatedly see DC's making.

Neglecting the Review of Systems is by far the easiest way to perform a sub-par exam that will get downcoded!

ROS, the Key to Highly Paid Exams
As you know, each E/M code has criteria - history, exam medical decision making - that you have to meet in order to merit a particular level of exam code.

In other words, you can't bill out a 99205 (the highest level E/M code) while performing a brief exam worthy of a 99202 and expect to be paid fully!

For many DC's the stumbling block that virtually causes their claims to be downcoded is the ROS.

A Complete ROS
For a complete Review of Systems, it is necessary that you cover and document ten (10) individual bodily systems in your examination.

Cover less than this and you will not be eligible to report a complete examination and thus, you automatically pull yourself out of certain billing levels.

Nearly all coding books (if you don't yet have one, get one) have a section detailing which E/M codes require complete exams or more detailed documentation to merit the code.

Frequent Downcoding or Audits
If you are getting dowcoded or audited frequently, chances are your Review of Systems is lacking.

If you are performing a complete exam but not getting paid for it, thereis a high degree of likelihood that your documentation is the problem.

Either way - you are losing out on money for things you are doing - not good in my book!

The Good News
Here's the good news, doc.

Fix your Review of Systems and you are on your way to "earning" the right to code for higher level examinations and also on the right track for reducing your exposure to audits by billing incorrectly!

It's easier than you think and does not require you to spend loads of time in your exam performing every test known to man. You just need to be able to know what the requirements are - and satisfy them.

Now, go back to the office - review your ROS and get paid for EVERYTHING you do!



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