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Hey friends, it’s Sam Collins, your coding and billing expert for acupuncture. You of course, as the profession, the American Acupuncture Council, the network, all of that. We’re here to always support you and help you. And one of the things we’ve had some issues coming up is what about audits? Now that many of you are billing more, you might think, uhoh, I’m gonna be audited.
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First thing I’ll tell you is generally you’re not gonna be audited. Very few offices get audited, but we want to talk about when you do what to be prepared for, what do you wanna do preemptively? I don’t want to be reactive, let’s be proactive. So let’s talk about what to do. And particularly if you’re insured with the American Acupuncture Council, they’re really gonna help you.
So let’s go to the slides. Let’s talk about what do you do if you are audited? You’re gonna get that dreaded letter, you’re gonna get it and you’re gonna feel this overwhelming sense of dread. The first thing I’ll tell you, do not panic. You are a good provider. [00:01:00] You’re there offering your best practice of services.
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You’re being helpful. Realize that as soon as someone audits you, I’m also upset like, how dare you think? Because what are they looking for in an audit? You often think of, oh, did I do something wrong? You’ve done nothing wrong. Not at all. It just means maybe they wanna look. Sometimes it’s you’re just lucky or unlucky.
’cause they’re gonna look, there’s a certain amount of government oversight that requires that to make sure that services that are being paid are provided. So do not panic. Read it carefully. The requests, what are they looking for? What type of claim is it? Is it personal injury? Is it insurance? Just what type of claim?
That can tell you a little bit, but also take a look at what data they’re requesting. Sometimes they’re just looking at data to make sure that the services were provided. Think of it, if you’ve never dealt with a VA patient in a weird way, they audit everything you do because they require you send chart notes.
You know what they’re looking for in the chart notes. Honestly, just making sure you did the services. They’re not there looking at the necessity as much as people think they’re looking to make sure, did you do [00:02:00] them and is there a decent outcome? Think of what patient or patients they’re looking for.
Often you might just get a one-off that’s just verifying something. If you get several, that could be a little bit more that they’re looking at, but at nothing I would be overly nervous about. Make sure if you’re a network member with me, get in contact with me when you get this. Let’s review it. Let me audit first often.
You’re gonna be just fine. In fact, I’m gonna say nine outta 10 times for most of you. So think of what are they gonna look for when they’re audit? Just your records. So it is important that you document the services you’ve done. Remember, that’s what notes are there for, to tell that story of the patient.
What do they come in with? How did we help them? What did we do? And what was the outcome? So verify. Basically, if what I billed for is on the claim. If you bill for three sets of acupuncture, I hope there’s three sets in there. You build for a therapy or ENM. That’s all it is. In other words, just make sure the services are there.
So when you feel audit, don’t panic, if you get audited by the IRS. You know what I say? Big deal. Did you lie on your tax form? Did you claim something you [00:03:00] didn’t have? Did you not claim income? If they were to come to me and say, Hey Sam, it looks like you donated money, a certain amount of money to the church.
I sure did. Here’s my receipt. I have no panic whatsoever, but I wanna talk about what things can set you up so you can start to be. A little bit preemptive, or at least be aware what is gonna get. One thing that will definitely get you looked at more than others if you bill high level e and m codes.
Now as an acupuncturist, is it appropriate to bill a high level e and m codes? In some instances, it absolutely is. Think of a patient coming in, maybe they’re post-surgical, maybe they’ve got a lot of issues, might that history be a little bit longer? So therefore, these codes can be based on time. So therefore, if you’re using a 2 0 4.
2 0 5, you better document. How much time did I spend the why? Or is it something that’s severe? I’m not panic about it, just make sure it’s done. Now, here’s one area that definitely can, acupuncturist can run into problems. You cannot bill an e and m code daily. And I’ve had offices that billing and go Sam, I’ve been billing it, they’ve been paying it.
I’m like, I know, [00:04:00] but someone’s eventually gonna look and go, wait a minute, this is every day. Remember, the acupuncture code does include. A small e and m code, A little. How are you doing today? So there’s an embedded exam as part of the acupuncture. This is part of the reason we put modifier 25. Modifier 25 is that indication.
It’s above and beyond. Now realize it’s gonna happen sometimes. What if a person comes on Monday with headaches and then comes on Friday with low back pain? I think it’s appropriate for another exam on Friday because that’s different from the headache. But is that common? No. Most often you’re not gonna see them that frequently.
The other is billing more than four services. Now I do think it’s fairly routine for an acupuncturist to do two, maybe even three sets of acupuncture pretty routinely, which means nothing wrong with that. I think that’s reasonable. But think of therapies a the OR two after. Sure. But what if you’re billing like four additional units of therapies?
That’s like a three or $400 visit. That’s pretty expensive. So I think probably not to say never, but realize that might get [00:05:00] you looked at. ’cause they’re gonna just make sure hey, if you’re billing for that many, did you do them? And then of course, just care. That’s long term. Now keep in mind, medical necessity is the least audited factor when it comes to most services delivered by an acupuncturist.
It really is. I’m not panicked about that as much as people think I’m more panicked to make sure were the services delivered. So again, long-term care or extended care for non-complicated, eh, if it’s a flare up, I’m not gonna be as much of an issue there. Just make sure that it’s reasonable. Okay? But here’s one area.
What if a patient makes a complaint? What if you have an ex staff that’s disgruntled because you fired them? Realize, never compromise yourself with a patient or a staff. Make sure everything’s above board, because now if you have not, it puts you in a vulnerable PO position because you’re knowingly doing something not right.
So don’t give that power away. Make sure everything you do there, if someone makes a complaint. So be it. They can complain. Doesn’t make it right, it just [00:06:00] means they weren’t happy. Okay, so here’s something, take an example. Here’s an Anthem policy that says, now just go to the where it says, as part of our own comp on ongoing claims data, we previously contact you regarding your use of acupuncture services.
And they talk about the letter and it says you indicate, you know that you continue to bill outside the expected ranges. This office is billing three sets every time. Is that necessarily outside of the expected ranges? Maybe slightly. I’m never gonna say, don’t do what you think is necessary, because take a look at the second paragraph in the red, it says, we recognize that many factors may impact the coding of acupuncture services.
In other words, they’re letting you know, okay, you’re billing above. Do you have a reasoning why it cannot be? That’s my style. If someone has a hangnail, okay, I would expect not as many sets of acupuncture compared to severe low back pain. So long as you’ve got that in mind, I think you’re perfectly fine.
I have no issue. For me, it’s always about document what’s there. Because by [00:07:00] example, UnitedHealthcare does this quite a bit where they come back and you’ll see here the coding of the acupuncture code 9 7 8 1 3 and 9 7 8 1 4 both indicate not supported. The medical records do not support. 9 7 8 1 3 was performed.
The documentation submitted does not indicate the time spent with personal one-on-one contact, so you’re gonna notice they’re telling you exactly why the time spent and they say it with each code. So what does it mean? I bet the notes are pretty good. In fact, I know they were, but they didn’t indicate time because notice 9 9 2 1 3, they paid that because what does it say?
It’s supported. They also paid the infrared heat because they indicate it where they did it and the severity of the exam. What I will tell you the big issue for most acupuncturists, please make sure you understand. You must document time, face-to-face for each set of acupuncture. Do make sure for audit protection of yourself, where the services reasonable necessary.
I think that’s always gonna be true. But more importantly, does the e and m [00:08:00] code match? And of course, face-to-face time and points must be there. That’s probably the biggest fault I have. Part of that is ’cause I teach at a lot of schools, frankly, and the schools still sometimes fight back on that. Time is not that important.
I don’t care what we think. It’s what the rule says. Please put time. And of course, if you’re doing therapies and you should to some extent, the what, why, and where you did it I think are important to do. And of course, make sure there’s outcome. Here’s the good news. You know why medical necessity often is never an issue for acupuncture because your pain management, and so long as you’re showing you’re making the patient improve or dealing with flareups pretty much a non-issue.
I can tell you if your notes are just average. Not great, but not terrible, but not great if you show a good outcome. Those are great notes. Here’s why. What is an insurance? What is a patient paying you to do? Make them better. Demonstrate that’s always gonna put you in the right position. Good documentation.
Practice helps ensure that your patients receive appropriate care, okay? And from any other provider can [00:09:00] rely on your records to know what was done. Bottom line is. A couple of things to be careful. Remember inducements and kickbacks, that’s where you get issues from your patients. Make sure if you write off their deductible.
That may be helpful to them, but if they’re mad at you, could they turn you into their insurance company for an inducement? They could. So don’t leave yourself vulnerable. If it’s a hardship, make it a hardship. And do remember incident two and supervision of staff? For the most part, acupuncturists do not have an ability to supervise an unlicensed staff person.
Meaning you cannot have just a massage therapist doing something under your license. There’s a few states that do Massachusetts and part in Arizona come to mind, but most states, whatever you do and bill for, you’ve gotta do unless you have another licensed acupuncturist. So be mindful you cannot have someone else do services that also is not an acupuncturist.
Bottom line, keep it simple. Ackman’s razor. Simple answer. A provider can read your notes and identify the service. If you told me I spent 22 minutes face-to-face and I inserted needles into, UB 34 and heart [00:10:00] seven. That would be adequate. Now, you might think, Sam, that can’t possibly take 22 minutes.
It’s not just about the time of insertion. Remember, as soon as you go in the room with a patient and say, hi, Mr. Jones, how are you feeling today? The time of acupuncture starts. So it’s all that stuff that you do leading up to the insertion plus the insertions, plus the removal, plus the counseling is all there.
So that’s what we’re documenting. But the other thing I want you to keep in mind though is what if you get an audit and you’re a little panicky? I don’t know. I’m scared in this way. Don’t be scared, particularly if you have coverage through the American Acupuncture Council. I wanna highlight to many of you, and I’m not sure why many of you don’t just use this one ’cause it’s simple and straightforward, has great coverage.
And you’ll notice here I put the arrows, you have covered proceedings up to $30,000 or 50, depending board defense, audit, defense. They’re not gonna pay the fine, if you will. If you get that, you know what they’re gonna do. Pay for your defense. I can tell you in my experience in dealing with these. We win [00:11:00] 90% of the time because often they’re looking at something, they’re like, oh, wait a minute.
Let’s look at it with another set of eyes. Make sure you’ve got yourself in place to be protected. I’m gonna tell you, the American Acupuncture Council, myself as the network provider is here to support you. We want you to deliver good services. In fact, if you’re not practicing. We don’t have a business.
We are here to support you. We wanna make sure you’re doing the optimum to make your practice successful, which means I work on the money side. If you want to help to learn how to make more money, take a look at the network service with me and I’ll guarantee you’ll be doing better. Until next time, my [00:12:00] [00:13:00] friends.