Chiropractor Study CERT Documentation Center Analysis of Requests for Additional Documentation (RADs); Top 10 Categories
On November 20, 2009 the President issued Executive Order 13520 - Reducing Improper Payments and Eliminating Waste in Federal Programs. This order further intensifies efforts to eliminate payment error, waste, fraud, and abuse in Federal programs, while continuing to ensure that the right people receive the right payment for the right reason at the right time. The executive order requires federal agencies to conduct semiannual studies to identify and reduce vulnerabilities in high risk areas. The Centers for Medicare & Medicaid Services (CMS) is conducting these studies under the Comprehensive Error Rate Testing (CERT) program.
Chiropractic services claims paid under the Medicare Part B Program were selected as an area of focus. Chiropractic services were chosen as a focus area for several reasons. Medicare pays only for medically necessary acute chiropractic treatment. When further improvement cannot reasonably be expected from continuing care, the services are considered maintenance therapy and are not payable under Medicare. A recent Office of Inspector General (OIG) study found that significant vulnerabilities exist in connection with chiropractic claims, particularly concerning Medicare payments for maintenance therapy. In addition, the 2009 Medicare fee-for-service (FFS) error rate for chiropractic services was 31.7% with $174.1 million in projected improper payments.
A total of one hundred thirty-five (135) RADs Chiropractor Claim Identifiers (CIDs) were identified by the CERT Documentation Center during the timeframe of September 2009 through April 2010. Of these 135 CIDs, a random sample of 50 CIDs was reviewed to analyze the various reasons for the requests for additional documentation and the findings are as follows:
| TOP 10 Categories for Chiropractor Requests for Additional Documentation (Missing Information) | RADs/ Percentage Rate | |
|---|---|---|
| 1. | Primary Care Physician Notes
|
(35) 70% (25) 50% (2) 4% |
| 2. | Documentation to Support Chiropractor Services
|
(35) 70% (7) 14% (2) 4% (2) 4% |
| 3. | Initial Evaluation/Visit Missing | (29) 58% |
| 4. | Documentation indicating that the patient had Chiropractor Services for the period covering the preceding 6-12 months Missing (depending on the regular CERT sample versus the supplemental measure Chiro study). | (29) 58% |
| 5. | Documentation to Support Chiropractor HCPCS Code Missing | (17) 34% |
| 6. | Type and Location of Manipulation Treatment /Supportive Notes Missing | (16) 32% |
| 7. | Legibility
|
(16) 32% |
| 8. | Other Pertinent Information
|
(12) 24% |
| 9. | Attestation of Medical Record Entry for Services Rendered Missing | (11) 22% |
| 10. | Abbreviation List to Support Chiropractor Missing (The list of abbreviations is needed because Chiropractor abbreviations vary among Chiropractors) | (5) 10% |
| NOTE: There were a total of 50 CIDs reviewed for RADs; resulting in some RADs having multiple missing/insufficient documentation. | ||

