Chiropractic has the OIG’s Attention


The OIG’s most recent report on fraud in the chiropractic community identifies seven states that make up more than half of the inappropriate Medicare chiropractic payments:  California, Michigan, Illinois, New York, Kansas, Florida, and New Jersey.  Each of these states have more than 50 chiropractors with questionable billing and payment practices.

In Illinois the Medicare Strike Force is active in both DuPage and Cook counties where 40 chiropractors meet these criteria.  While they didn’t publish any names in the report, they did indicate some of the elements they are watching. 

Some of the practices that have the OIG’s attention include:


  •                 Multidisciplinary practices with unusual utilization
  •                 Chiropractic, occupational therapy and/or physical therapy visits billed on the same date
  •                 High volumes of 98942 billing
  •                 Maintenance therapy billed as active care
  •                 High volume practices


One Illinois practice has been singled out for averaging 88 Medicare visits a day for at least 115 days!


Nationwide the OIG has identified 962 chiropractors with highly questionable practices and finds that these same providers have been substantially increasing their claims volumes each year and show a questionable payment pattern for at least 5 years.  On average, chiropractors with high questionable payments provided services to twice the number of beneficiaries and file four times the claims compared to all other chiropractors.


The OIG acknowledges in its report that 84% of DC’s nationwide have no questionable payment patterns.   The remaining 16% have questionable patterns with 2%, or 962 of these physicians receiving more than 50% of the inappropriate payments. 


The report makes several suggestions for changes at CMS: tightening software denials when inappropriate diagnoses codes are used, collecting overpayments and taking “appropriate” action against those highly questionable practices are among the recommendations.   


While this report is focused on Medicare beneficiaries, the same rules may apply to commercial carriers.  What should you do? 

Review your billing and documentation.


  •  If you consistently bill more than 10% of your patients with a 98942, get your records reviewed to see if the visits meet the medical necessity and daily visit criteria. 
  •  If you are unsure of when to switch your patients to a maintenance program, seek assistance! 
  •  If you are part of a multidisciplinary practice, make sure you are appropriately utilizing providers.  Patient’s treating with more than 1 provider per visit can raise a red flag.


There are many resources available to chiropractors.  Check out,,, and are just a few of the sites with resources and consulting services to assist you.


5 Tips for Implementing ICD-10

ICD 10 arrives October 1st and many of you are in the final stages of preparation for this important transition.  As you prepare, I'd like to offer you a few tips for making sure you're ready.


Tip #1: Sequence your codes appropriately.

ICD-10 provides more rules for sequencing than its predecessor.  The most complex condition is sequenced first, following any code first/code also rules that apply.  If the codes is an injury (Chapter 19) or has neurologic components, this is normally the primary diagnosis.   The second tier of importance are structural codes, followed by functional codes, followed by soft tissue codes.  


Example: Piriformis syndrome, left side G57.02 sequenced before spinal stenosis, cervical region  M48.02


Tip #2:  Initial Encounter Active Care.


That pesky 7th character seems to be throwing everyone for a loop, so I recommend that we simplify our approach for now.  My recommendation at this point in the game is to use only initial encounter active care: the extension A.  Given the information we can discern from the coding guidelines and Medicare LCDs the use of the extension A represents care that meets medical necessity guidelines.  Commercial payers have offered little insight into their interpretation of the new concept, but the value of D (subsequent encounter), appears to be limited to maintenance visits. Sequela (extensions of S) visits have some coverage under Medicare LCDs, but until we get further direction on the expectations surrounding the use of this extension, my advice for now is simply use the active care (extension A)  and avoid the controversy.


As guidance from commercial payers is provided we’ll keep you updated.


Tip #3: Diagnose your patient from 30,000 feet.


What does that mean?  Change your perspective.  ICD 10 is a complete redesign of coding and therefore using a crosswalk to create a one to one relationship between your ICD-9 and ICD 10 codes will often result in incorrect diagnoses for your patients.


Example:  Patient presents in your office with symptoms in only the lumbar area.

Your ICD-9 DX coding is:  

722.10, 724.4, 729.1  (herniated lumbar disc, radiculopathy, myalgia)

Using the crosswalk your code selection may result in this incorrect code selection:

M51.26 – Other intervertebral disc displacement, lumbar region

M54.16 - Radiculopathy, lumbar region

M79.1 - Myalgia 


The correct code selection is M51.16 IVD w/radiculopathy


Less is often more.


Tip #4:  Signs and symptoms are coded when we do not know the underlying cause.


This rule is one that I have discovered doctors are struggling to accept.  In the past, many doctors included codes for all the patient’s symptoms in an effort to paint a more complete picture.  In the previous example the lumbar muscle pain was diagnosed (729.1) in ICD-9, but implied under ICD-10 as it commonly occurs with the primary condition.   This will take practice and discipline to implement!


Tip #5:  Pain is a pain.


Pain coding is one of those areas that complicates tip #4.  If you have identified the cause of the pain, then the need to add a code to identify the symptom is not needed.  Read that sentence again because it is a shift from what you might be used to doing!  If you are treating the underlying cause of the pain, then the pain coding is superfluous. 


When do you code pain?  Pain is coded under two situations:

  1.  The underlying cause of the pain isn’t known.
  2.  The primary reason for the visit is pain control.


You can also add codes to indicate acute vs. chronic pain.


Example:  Patient presents with chronic right elbow pain.  Radiology shows no obvious reason for the pain and the patient denies trauma to the area.  This visit can be coded as:

M25.521 – Pain in right elbow

G89.29 – Other chronic pain



You’ve been working for months on this.  You’re stressed and trying to remember all the rules.  Is it this code or that code?  Add a code?  Drop a code?  What if I miss one?  This ICD-10 transition is giving you an episodic tension headache. 




This is a new adventure and everyone is in the same position.  There will be bumps in the road, clarification from payers, and lots and lots of opinions flying around.  Give it your best shot and make sure your documentation supports your code selection.  If denials happen, get some assistance and be flexible enough to know that changes will happen.  Seek assistance when you need it and try not to sweat the small stuff.  All your preparation will be worth it.


Relax, you’ve got this.



External Cause Coding

External cause coding is an option piece of information in ICD-10.  Physicians are not obligated to provide this information to commercial payers.  However, there are some distinct advantages to the coding, as well as some specific rules you need to know. 

Some of the most entertaining ICD-10 codes can be found in the external cause codes section of the manual.  These codes are used to answer important questions about an injury.  When used, they are sequenced as follows:

                Cause, Place, Activity, Status.

The CAUSE of the accident remains on all claims.  The PLACE, ACTIVITY and STATUS, when provided, are only submitted on the FIRST claim.  You may want to re-read that because it is new with ICD-10. 

Important notes about external causes:

  1. They are in Chapter 20 and start with V, W, X or Y.
  2. They are never the primary diagnosis
  3. Many have a 7th character and it should match the 7th character of the primary diagnosis code.
  4. You can use as many as you need to tell the story
  5. There are some additional sequencing rules for these codes in the chapter 20 guidelines.

External Cause Categories

Cause:  Transportation Accidents?  Start in V.   Slipping, Tripping, Stumbling and Falling?  Look in W00.   Walking into walls?  Start looking around W20.

Place of occurrence codes start in Y92.

Activity codes begin in Y93.

Status codes are used to provide additional details about the encounter at the time of the injury. Y99 is where those status codes are found.

(e.g. Y99.8 – Hobby, Y99.2 – Volunteering)


Today's coding exercises:

  1. ______   Roller skater injured in collision with a train                                   
  2. ______   Fall from a skateboard
  3. ______   Passenger injured when car hits deer on road  
  4. ______   Driver of pickup injured when car hits guardrail
  5. ______   Patient injured after falling off monkey bars   
  6. ______   Patient injured when struck by field hockey stick 
  7. ______   Patient injured when hot coffee spilled in her lap      
  8. ______   Patient was injured in the kitchen of her apartment   
  9. ______   Injury occurred while ice dancing  
  10. ______   Injury occurred while milking a cow   


Answers will arrive in your in-box tomorrow.