OIG Work Reports Chiropractic

The OIG’s Work Plans and Reports: OMG, or NBD?


Remember way back before ICD-10 implementation when Congress passed a “permanent fix” to the former Sustainable Growth Rate (SGR) formula? The fix also put a plan in place that would give doctors who participate with Medicare a payment increase of .5 percent per year for five years.

That was good, right?

Yes. But that legislation also contained a mandate for oversight of the benefit for “manual manipulation of the spine to correct a subluxation.” Well, guess who performs that service? Yep–chiropractors. A whopping nine pages of the new bill outlined how that oversight will take place for DCs. It included a documentation education program for chiropractors along with the promise of even stiffer rules for this oversight by Medicare (and the third-party payers who will inevitably follow suit).

The reason: the chiropractic profession, as a whole, does a pretty miserable job of documentation, with the Office of Inspector General (OIG) putting error rates as high as 90 to 94%. In fact, chiropractic services have the highest rate of improper payments among Part B services, according to the Centers for Medicare & Medicaid Services’ (CMS) Comprehensive Error Rate Testing program.

Our leaders at the ACA stepped up and saved DCs from even more severe discipline, like being removed entirely from Medicare. They argued that chiropractors can and will do better. They promised to spearhead an intensive documentation training blitz that will cover the US and offer some insight into what Medicare is looking for. You can believe the government will be watching closely to see if DCs step up to the plate and improve.


The bill goes on to indicate that beginning January 1, 2017, chiropractors whose claim denial rates are out of line with the rest of the profession will be subject to pre-authorization standards established by the Department of Health and Human Services (HHS). On the other hand, DCs with a good record of claims based on proper documentation and DCs who avail themselves of education programs can avoid those pre-authorization requirements. Pre-authorization review will affect you not only if your billing patterns are out of step with your peers, it will also apply to your documentation error rate is at 85% or higher.

Here are the most common documentation mistakes:

  • A high percentage of what looks like up-coding claims. Only 10% of your chiropractic services should be for the highest code, 98942. Are your percentages off?
  • No primary diagnosis, or a diagnosis not covered by Medicare (note: Medicare will only pay for ACTIVE treatment – do you know the definition and how to distinguish medically necessary from clinically appropriate care?).
  • Claims with no AT Modifier or, conversely, claims with an AT modifier for services that are NOT active treatment!

Don’t miss what’s important here. If your documentation is currently haphazard, incomplete, or, as happens more often than we like to think, non-existent, you have a chance to fix it before the pre-authorization requirements kick in. Clearly, the time to get educated is now.

Here are the important points for you to know if you fall into the group in question:

  • Pre-authorization review is a determination prior to the service being furnished. In other words, you have to submit your treatment plan before you can actually adjust or otherwise treat your patient. Who wants that?
  • Reviews will be required for more than 12 patient visits for any single episode of care, but you can ask for prior authorization before you hit that 12-visit cap.
  • Prior authorization can be obtained for multiple services.
  • Payments will be denied without prior authorization—unless Medicare fails to respond within 14 days.
  • Pre- and post-payment reviews can be used even by MACs or any other contractor except RACs—even when pre-authorization doesn’t apply.

Again, the key takeaway here is that although your Medicare payments may be higher, so will government scrutiny. All chiropractors whose documentation or billing patterns are way less than stellar will be subject to pre-payment authorization review starting in 2017. That sounds like a long way away, but remember when ICD-10 sounded comfortably far off, too? This is no time to get complacent.

While most doctors assume their documentation is mostly fine, statistics—and our own experience helping DCs conduct internal audits–simply don’t bear those assumptions out. Makes sure your documentation is impeccable. And then, the OIG reports will truly be No Big Deal.

This article was by Kathy Mills Chang.  The author’s opinions are their own and DC Aligned does not take responsibility for content statements and opinions. You should seek expert counsel in evaluating opinions, treatments, products and services. For more info see our Editorial Policies.