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The annual ICD-10-CM code updates, which are reviewed and updated annually, go into effect on October 1st of each year. Occasionally, there are a few significant changes for chiropractors. While these updates aim to improve the specificity of patient records, they also create a period of heightened risk for billing errors and compliance issues. For chiropractic practices, understanding the distinction between fraud and abuse and how the new codes can increase your vulnerability is vital to compliance.

Fraud vs. Abuse: Knowing the Difference

While both are serious, their distinction lies in intent. Fraud is an intentional act of deception for financial gain. This would include knowingly billing for services not performed or consistently upcoding to a higher-paying service. Abuse, on the other hand, involves improper practices that result in unnecessary costs to the healthcare system, even without malicious intent. This can be something as simple as a coding error or billing for a service that is not medically necessary, but it can still lead to audits and penalties.

Why the New Codes Increase Your Risk

New or updated codes create a window of opportunity for both intentional and unintentional FWA (Fraud, Waste, and Abuse).

Confusion and Unintentional Errors: With hundreds of new and revised codes, simple mistakes are more likely. For example, a billing specialist might accidentally use a higher paying, up coded disc degeneration code simply because they are still getting familiar with the updated system. While unintentional, a consistent pattern of such errors could be flagged as abuse.

The “Hiding in Plain Sight” Problem: New codes can be used by dishonest providers to mask fraudulent billing. Payers’ automated fraud detection systems are often built to recognize patterns with older codes. The new codes can make it more difficult for these systems to catch unusual billing behaviors, at least initially.

Lack of Specificity: The new codes demand a higher level of detail in your documentation. For example, the latest disc degeneration codes require a more specific link to the patient’s pain (e.g., lumbar pain with lower extremity pain only). If your documentation doesn’t support the code you’ve billed, a payer could interpret this as an attempt to misrepresent the patient’s condition to justify a more expensive service, even if you did it by mistake.

To protect your practice, it’s essential to be proactive and understand the common pitfalls that attract unwanted attention from auditors:

  • Billing for Unnecessary Services: Medicare only covers active spinal manipulation to correct a subluxation. Billing for “maintenance care” or a treatment plan without a clear endpoint is a major red flag for abuse.
  • Improper Use of Modifiers: Incorrectly using modifiers like the -AT modifier, which signifies an active treatment plan, can lead to denials and audits.
  • Routine Waiver of Copayments: Regularly waiving co-pays and deductibles can be seen as an inducement for patients to use your services, which is a form of fraud.

Safeguarding Your Practice

The best defense is a good offense. To ensure compliance and efficiency, commit to educating your entire team, from front office staff to billing personnel, on the new codes and their specific documentation requirements. Additionally, cultivating a habit of refining your documentation is essential; your notes should provide a detailed account that tells a complete story, effectively justifying the medical necessity of every service rendered.

By being proactive, you can protect your practice from compliance risks and maintain the integrity of your patient care and billing.