Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 99

From the Desk of Dr. Mark Studin
Academy of Chiropractic
Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time.

"X-Ray Orders, Prompt Payment and Preventing Retrospective Audits"

A very big concern in compliance is performing tests with no orders. X-rays fall under that category. Do you take x-rays without orders? If so, you have left your practice and yourself exposed to an audit for compliance issues and retrospective reviews for repayment issues.


When I reviewed the records for that doctor that had to pay back $125,000 to the carrier with the same in legal bills, one of the issues in the carrier’s complaint was treating without orders and this was one of the areas we found to be problematic. In fact, taking x-rays without any orders, should he have gone to trial, could have been one very big reason he would have lost the case according to the lawyers that were defending him and the consulting lawyers brought in on the case.


First, I want to acknowledge that this disgusts me to my core. I mean that sincerely. What does this have to do with patient care, the ability of a patient to get better or the level of expertise of the doctor? Nothing! It has to do with money and your license. Two things you will lose if you are not compliant.


This is the standard of your license and the standard of accepted documentation for the reimburser who is seeking to make a windfall profit at your expense. Therefore, you have been forewarned and compliance is required to maintain your license and your income. We both don’t have to like it…we just have to comply.


This part is too simple to ignore. You need an order for everything you perform in your office, whether it’s testing or treatment. If x-rays are indicated, then you need to include that on your evaluation as an order because that is where the rationale for ordering the x-rays is derived. If you have made a clinical decision after the evaluation, then an order with the rationale must be included in the notes. When ordering a test, I strongly recommend that you write the reason for the test. This way, there will be no questions to answer in the future about your clinical rationale.




Testing Orders:


AP, Lateral and Oblique Cervical Spine x-rays are ordered to rule out osseous pathology as a result of the positive clinical findings in that region.


It is that simple and is a must to justify the test. You can add, if you feel compelled, a note about the necessity for oblique’s and the need to see the foramina. However, I feel the above statement will suffice. Afterwards, you need an x-ray report, and I would submit it to the carrier with the HCFA, certifying the test was done. All too often the carrier requests a copy of the report for verification that the service was done. This is a legal mechanism used by the carriers to legally delay payment to you for verification reasons. This holds true for every test performed, as well as every treatment; there must be an order with a rationale.


Remember, we in New York usually get screwed before the rest of the country and the carriers started playing this game with us 10 years ago. I am just starting to hear of this nationally. My solution was to include a copy of every service performed in the billing packet I sent to carriers. It included the SOAP notes, evaluations and test results, stapled to the corresponding HCFA. Once I started this practice, my collections increased over 20%, with very few demands for additional paperwork.


This served 2 purposes. I got paid promptly and avoided retrospective reviews, as the carriers had all of my documentation up front and there was nothing for them to come back to look at. It requires a little more work up front and an increase in paper utilization. However, I slept very well at night knowing this is one area that made me bulletproof.

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