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You did what? Health care coding horror stories

Horror stories of creative health care coding causing confusion, and the importance of documentation for reimbursement...

Horror stories of creative health care coding causing confusion, and the importance of documentation

We like to quote the famous Farmers Insurance commercial that says, “We know a thing or two … because we’ve seen a thing or two.” Having been at it for as long as we have, we think we have seen it all in health care coding. But inevitably, some new twist shows up on a consultation and we add it to our list.

Sometimes, we must step back and say, “Things that make you go … hmmm!” Here is a collection of creative coding that helps you see what not to do.

The old ‘dual accounts’ workaround

We all know that Medicare only covers spinal adjustments when medically necessary. However, all the statutorily-excluded services can be billed to Medicare, along with the adjustments, to generate an appropriate denial. Why send them if we know they are not covered? Many reasons, not the least of which is that the patient may have a secondary payer that will cover those services.

Often, practices do not know they may be covered because they make the grave error of not verifying all Medicare coverage, both primary and secondary. To “work around” this issue, we encountered a practice that set up two accounts: one for Medicare-covered adjustments, and one for everything else. Unfortunately, the other services are sometimes incorrectly discounted, but the offices felt it was OK because it was not on the Medicare patient’s official ledger.

Either way, this is bad business. Computer software can control what does and does not get billed out to a payer within the program, so there is no reason to make these different accounts. In fact, like the term “cooking the books,” it smacks of something unsavory being done to game the system.

The old ‘unbundle the bundled’ health care coding workaround

Sometimes providers join an insurance network without all the information they should have — such as what they are going to be paid for their services. More and more payers are moving to a flat-fee-per-visit payment system, regardless of what services are performed.

On a recent baseline audit, we encountered a practice that had two ledgers in exactly this circumstance. The patient was insured, and the benefit was to cover only one adjustment and one modality per visit. We found that this office ran a second ledger for any modality and procedure beyond the first one and charged the patient for these additional services in another account.

When agreeing to a fee schedule, even one that includes all-inclusive or bundled services, you get what you get. That is an agreement by contract and charging for additional services is a violation. It should be noted, though, this is a great time to be familiar with the Medical Review Policy of such a plan. Perhaps certain mainstream services you perform fall into the “experimental, investigational and unproven” definition by the payer. For example, kinesiotaping, hydrobed massagers, and even roller table traction can fall into this category. Check to see if the payer allows the patient to pay for these items separately, with a signed waiver of advance notice.

The old ‘pile it on’ protocol

I stand for providers being paid every single dollar they deserve for the work performed. We have encountered providers along the way that seem to think that if two services are good, then seven must be much better. A recent example was an office visit uncovered in a baseline audit in which 23 straight visits looked like this:

It is not the place of a non-DC like me to judge whether a provider chose the appropriate treatment protocols for a patient. But what I can do is comment on whether the documentation establishes the medical necessity of all these services, every visit, for 23 visits.

In this case, the documentation was sorely lacking, and 2-3 of the service codes were disallowed on audit for each visit. One thing that will raise the hair on the back of the neck of an auditor is seeing 97140 billed when 3-4 spinal regions are also being billed. And in this case, even more discouraging was that extra-spinal manipulation was also included.

One must ask, “Where could the manual therapy have possibly been performed that was not a contiguous area to the spinal adjustment?” And in this case, the documentation clearly showed that it was being performed in the same spinal region as the adjustment, and therefore, disallowed every visit.

The old ‘call It S8990 and we can charge cash’ workaround

The Healthcare Common Procedure Coding System (HCPCS) code S8990 is defined as: “Physical or manipulative therapy performed for maintenance rather than restoration.” Generally, this is an all-encompassing code that includes the adjustment and whatever other modalities are deemed appropriate for that visit.

Typically, this code is used in a fee system to denote true maintenance visits for non-Medicare patients. Medicare maintenance visits should be coded with the appropriate CMT code, removal of the AT modifier in favor of the GA modifier, along with a properly executed ABN form. Unfortunately, we have seen practices incorporate all cash-paying visits as S8990, whether for maintenance or active treatment. The motivation for this is usually because they want to offer a cash discounted price for those uninsured, under-insured, or partially insured patients with this workaround.

It is completely inappropriate to employ this health care coding practice to affect a fee issue. Use of a Discount Medical Plan is an easy solution for a practice wishing to legally discount for these categories of patients.

Health care coding must always be driven by documentation. Proper coding compliance dictates that the most appropriate code is used to describe the service. Workarounds and coding sleight-of-hand scenarios have no place in the compliant health care office. For every situation, there is usually a clean, legal and efficient option that keeps the practice safe and protected.


Kathy Weidner, MCS-P, CCPC, CCCA, known as KMC, is a Certified Medical Compliance Specialist (MCS-P), Certified Chiropractic Professional Coder (CCPC), and Certified Clinical Chiropractic Assistant (CCCA). Since 1983, she has been providing chiropractors with reimbursement and compliance training, advice and tools to improve the financial performance of their practices. She leads the largest team of certified specialists in the profession at KMC University and is known as one of our profession’s foremost experts on compliance, Medicare, documentation and CA development.

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