HNS Documentation policies

High Standards for documentation, coding and billing have been established for all health care professionals. To assist you in meeting these high standards, the following documentation requirements were developed by our Continuous Quality Improvement (CQI) Committee and information obtained from our managed care partners.

HNS Providers must adhere to the HNS Documentation Requirements as well as to all HNS/Payor Policies.

Both the HNS Documentation Requirements and the HNS/Payor Policies are included in the HNS Practice Protection Plan.

HNS strongly encourages network providers to purchase the ACA Clinical Documentation Manual (2nd edition) as an additional reference guide for proper documentation. This book can be purchased directly from the ACA via their Web site: www.acatoday.org/store or by calling ACA's Sales Office at (800) 368-3083.

HNS Documentation Requirements:

The Patient Health Record

Evaluation and Management Services - New Patient

Evaluation and Management Services - Established Patient

Evaluation and Management Services - Consultations

Chiropractic Manipulative Therapies

Modalities and Therapeutic Procedures

Acupuncture

Patient Education and Instruction

Durable Medical Equipment (DME) Services

Documentation Self Assessment Tool

The Patient Health Record

The patient health record should include clinical documentation of all services performed in the office, as well as, all communication and correspondence from other sources regarding the patient.

Remember, you can't just state what you did, you must state WHY you did it!

The office must assure the confidentiality of the health record and comply with all applicable HIPAA regulations.

1. General Documentation Requirements

A. All health records should be accurate, complete and legible.

B.  A signed Informed Consent Form should be obtained for each patient, prior to treatment, and maintained in the health record. (Informed consent should specifically reference strokes; please see sample "Informed Consent Form")

C. Each page of the health record should include the name of the patient.

D. Each page of the health record should include the signature (or electronic equivalent) of the rendering provider, including the professional designation "DC."

E. Entries to the health record should be made during or closely following the patient encounter.

F. All services rendered on each visit should be clearly documented in the patient record.

G. Entries should be added chronologically.

H. No entries should be erased, deleted, or "whited out." Corrections or changes should be made by marking a single line through the original entry. Both the entry that is marked through AND the corrected entry should be dated and initialed.

I. Copies of any written or verbal communication and/or correspondence should be maintained in the patient's health record. This includes, but is not limited to, consultations, test results, reports, letters, consent forms, pertinent notes from phone conversations with patients, etc.

J. All health records, including electronic records, must comply with state and federal regulations.

K. There should be an individual record for each family member (family members must not be combined in the same file jacket).

L. The record should be organized, neat and bound together.

M. Aging labels should be utilized.

2. Requesting Patient Records - All requests for patient records should be responded to in a prompt and courteous manner. Any requests for copies of healthcare records should be clearly documented in the healthcare record and should include the date of the request and the name of the person or entity that requested the records, as well as the date the copies were sent.

A. Requests from Payors
Network providers must immediately respond to any requests for health care records from a HNS payor and if a “Due Date” is provided in the request, records are must be received by the stated due date. If a “Due Date” is not provided, records must be submitted to the payor within 10 days of receipt of request.

B. Requests from HNS

Network providers must immediately respond to any requests for health care records from HNS. Records must be submitted to HNS by the “Due Date” stated.

C. Requests from Patients
If requested by a patient, network providers must promptly provide patient with copies of the health care record. In all cases, records must be provided within 10 days of receipt of request from patient.

3. Abbreviation Legend - Abbreviations in the health record should be legible. The abbreviation legend should be maintained in the provider's office.

The use of an abbreviation legend provides documentation efficiency and can improve clarity of the documentation. Standard abbreviations common to all health care providers should be used if needed.

4. Patient and Demographic Information

A. Each page of the patient health record should clearly identify the patient. This will assure a health record reviewer that all pages are relevant to the specific patient whose records are being reviewed.

B. The health record should include:

  1. The date the information is obtained from the patient

  2. Patient's full name

  3. Patient's date of birth

  4. Patient's address

  5. Patient's telephone numbers (home, work and emergency contact)

  6. Employer information (name, address and phone number)

  7. Occupation

  8. Spouse information

  9. Social security number (if applicable)

10. Name of parent or guardian, if patient is a minor or incapacitated

11. Emergency contact information

12. Legible copy of patient's current insurance card

13. Verification of Insurance Benefits form

14. If applicable, waiver for specific non-covered services provided

5. Past Health, Family, and Social History

A. Date history is taken

B. Patient's past history

C. Family health history

D. Past and present medical or chiropractic treatment for presenting condition, as well as past treatment outcomes

E. Social history (including the use of drugs, alcohol, or tobacco) and occupational history

6. Vital Signs - Results of vital signs should be clearly documented and should include:

A. Weight

B. Pulse

C. Blood Pressure

7. Chief Complaint and/or Nature of Presenting Problem - Chief Complaint is a concise statement describing the symptoms, problems, conditions or other factors that are the reason for the encounter and is usually stated in the patient's own words.

A. Details of complaint should be clearly documented in the health record.

B. Timing and intensity of complaints should be clearly documented.

C. Causation of the complaint should be documented including accident, injury and etiology.

D. Treatments billed to the payor must be related to the patient's chief complaint.

8. Clinical Exam Findings - Clinical exam findings should be documented and should include specific locations of subluxations. (also list the specific segments)

To demonstrate a subluxation based on a physical examination, two of the four criteria below are required, one of which MUST be asymmetry/misalignment or range of motion abnormality.

Subluxation demonstrated by examination must include an evaluation of the musculoskeletal/nervous system to identify:

• Pain/tenderness evaluated in terms of location, quality and intensity.
• Asymmetry/misalignment identified on a sectional or segmental level.
• Range of motion abnormalities (changes in active, passive and accessory joint movements resulting in an increase or decrease of sectional or segmental mobility).
• Tissue changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle and ligament.

9. Frequency of Visits - When visit frequency exceeds the following guidelines, substantial documentation is required to support the need for additional visits:

A. If visits exceed one per day

B. If one visit per day exceeds one week duration

C. If three visits per week exceed four week duration

D. If visits exceed fifteen in the first month of care

Per the NC BOE Practice Guides:

V. Frequency and Duration of Treatment

A. The frequency of treatment should gradually decline until the patient reaches the point of discharge or converts to supportive or elective care.  An acute exacerbation may require more frequent care.  The treatment time may be extended due to complicating factors.

B. For some patients, the physician may determine, in the exercise of clinical judgment, that a period of trial treatment is warranted.  An initial trial period of up to two weeks may be appropriate.  If re-evaluation shows no improvement, a second trial period, lasting a maximum of two weeks and utilizing a different method of treatment, may be instituted.  If there is still no demonstrable improvement, the physician should refer or discharge the patient.

C. Some patients may require supportive care using passive therapy if efforts to withdraw treatment results in deterioration of clinical status.

VI. Failure to Meet Treatment Goals

A. Healing the sick, injured and infirm is an art, and no health care provider, regardless of professional training or category of license, can guarantee the success of treatment.

B. If a patient's recovery is slower than expected, the physician should search for complicating or extenuating factors by engaging in reassessment interview with the patient, including a review of the patient's activities of daily living.

C. If a patient with an acute condition shows signs of becoming chronic, the physician should review and consider altering the treatment plan to de-emphasize passive care and focus on active care.

D. If a patient with an uncomplicated condition fails to show initial improvement after two treatment cycles, or a patient who initially showed improvement subsequently fails to show further improvement after one additional treatment cycle, the physician should assume that maximum therapeutic benefit has been achieved.  Patients who have reached maximum therapeutic benefit may be candidates for supportive care, elective care, referral or release.

10. Radiology - Radiographs are generally considered medically necessary only for the purposes of diagnosing specific problem area(s) documented as a chief complaint with supporting objective clinical findings verifying their necessity.

Repeat x-rays must be clinically indicated and the reason(s) clearly documented in the clinical record.

For billing purposes, an x-ray "view" is a separate exposure to radiation. Therefore, full spine x-rays cut into sections do not constitute multiple views, unless multiple exposures are taken.

Single view x-rays without opposing views are not considered of diagnostic quality. An occasional "spot shot," or single view, may be performed as a follow-up to review a specific area in question.

IMPORTANT NOTE:

1. Radiology Overreads       Patients with a health insurance plan that is contracted with HNS cannot be billed for radiology overreads.  Remember, you cannot collect more than the patient's co-pay, deductible and/or co-insurance for any covered service provided.

2. CPT 76140      Consultation on x-ray examination made elsewhere.

This code is a service to be used by a radiologist, or other consultant, who performs a subsequent reading of any diagnostic imaging study but DOES NOT actually see the patient. This code should not be reported by HNS providers when reviewing x-rays brought by a patient that were taken elsewhere.

3. Modifier 26     Professional Component

This modifier indicates that the provider is reporting the professional component ONLY for a service - and is often incorrectly reported with radiology codes. Please note that the pre-service work included in the CMT codes includes imaging review and this modifier should not be reported by HNS providers. The review of imaging studies included in the CMT work service applies regardless of whether the studies were performed in your office or if the patient brings films to you that were taken elsewhere. This code would be appropriately reported by a Chiropractic Radiologist who did not actually see the patient but interpreted the study.

Radiology Documentation Requirements

A. HNS providers must document all radiology studies performed and/or interpreted in the office.

B. The area(s) initially x-rayed should be the area(s) of the patient's major initial complaint.

C. A written radiology report to document the provider's interpretation of the radiograph(s) must be maintained in the patient's health record. These reports must be signed or initialed by the provider and should include:

1. Patient identifying information (patient name, d.o.b., etc.)

2. Date of study as well as an accurate description of the radiological findings

3. Impressions

4. Recommendations for follow-up studies that may be needed to reach a final diagnostic impression

D. The specific area(s) x-rayed must be documented

E. The date of the study must be documented

F. The name of the person performing the x-ray study must be documented

G. There should be documented, supporting evidence that the initial clinical findings support the need for the initial x-ray

H. There should be documented, supporting evidence that clinical findings support the need for repeat x-rays

I. All x-ray reports must be signed and dated by the treating provider

J. Routine repetitive x-rays within a 90 day period require the following documentation:

1. Evidence of a new injury reported for the same area as the initially reported area

2. An initially identified pathology or biomechanical aberration requiring further investigation

3. A new symptom in the same area appears which was not present initially

To demonstrate a subluxation by x-ray, the x-ray must have been taken at a time reasonably proximate to the initiation of treatment.

An x-ray is considered reasonably proximate if it was taken:

1. No more than 12 months prior to the initiation of a course of treatment or;

2. No more than 3 months following the initiation of a course of treatment.

11. Diagnostic Impression

A. Diagnosis must be related to a neuromusculoskeletal condition.

B. The provider's working diagnosis or diagnostic impression must be documented in the health care record.

C. The patient's health care record should reflect ALL diagnosis/clinical impressions.

D. Changes in diagnoses should be documented in the patient's health care record.

The diagnosis or diagnostic impression should be reasonable based on the patient's chief complaint(s) and results of the diagnostic tests and other available information.

The provider should utilize the ICD-9 code that appropriately reflects the findings of the patient visit and supports the necessity of care. Primary, secondary and any additional diagnoses should be recorded in the patient health record, when appropriate.

12. Treatment Plans - Once a diagnosis or diagnostic impression has been reached, a plan of treatment must be established for each patient.

A. A properly documented treatment plan for the improvement of the patient's condition should be included in the patient's health record for each course of treatment.

B. The patient's treatment plan should include recommended level of care (duration and frequency of visits), should specifically include the chiropractic manipulation therapy (CMT) recommended, including specific areas to be manipulated with reference to frequency and duration.

C. The patient's treatment plan should include objective measures to evaluate treatment effectiveness.

D. The patient's treatment plan should include phases of care pursued.

E. The treatment plan should include specific, measurable goals that are expected to improve a functional loss experienced by the patient (both short and long term) and outcomes expected.

F. If modalities and therapies are included in the treatment plan, the plan should include areas of application, frequency, and duration, and if time-based therapy is used, the length of time the service will be provided must be included (ex. 30 minutes).

G. A treatment plan should clearly explain WHY you are proposing the particular services and treatment.

H. Patient instructions and home care should be included in the treatment plan.

I. Any recommended DME should be included in the treatment plan.

ALL subsequent visits should reference the patient's progress as it relates to the treatment plan and changes or alterations to the course of treatment that differ from the initial treatment plan should be clearly documented including rationales.

Per the NC BOE Practice Guides:

IV. Treatment Plan

A. Each patient is unique, and each patient's complaints, injuries and circumstances are distinct.  It is the physician's responsibility to develop a treatment plan individually tailored to the patient's condition.  The goals of the treatment plan should be to restore motion, improve strength and function, and reduce pain.

B. At the outset of treatment, the physician should provide the patient with estimates of the time within which to expect initial improvement and the time within which to expect maximum therapeutic benefit.  The physician should adequately explain to the patient the nature of the patient's condition, the goals of treatment, and the treatment strategy.  Because the patient's active participation in the treatment plan is essential to success, the physician should refer or discharge a patient who fails to comply with treatment recommendations.

C. During each office visit, the physician should inquire as to the patient's presenting complaints, perform the treatment called for in the treatment plan, and monitor the patient's clinical picture through the use of objective tests such as range of motion, segmental range of motion, presence or absence of spasm or swelling, presence or absence of positive orthopedic findings, and pain assessment.

D. The physician should re-evaluate the appropriateness of further care after whichever comes first, approximately twelve office treatments or four weeks of care (i.e., one "treatment cycle"). If the patient shows improvement, the physician may recommend another treatment cycle.  For as long as improvement can be objectively demonstrated, the patient may continue treatment cycles.  However, if re-evaluation fails to demonstrate additional improvement after any two consecutive treatment cycles, the physician should assume that maximum therapeutic benefit has been reached.  Patients who have reached maximum therapeutic benefit may be candidates for supportive care, elective care, referral or release.

E. Once the goals of treatment have been realized, the patient may continue to need supportive care in order to prevent deterioration or relapse.

13. Initial Visit

A. Each page of the patient's health record should include the name of the patient.

B. Each page of the patient's health record should include the signature (or electronic equivalent) of the rendering provider and/or reviewing provider and the professional designation "DC."

C. The patient's health record should include informed consent by patient. (Informed consent should specifically reference strokes, please see sample "Informed Consent Form."

D. The patient's health record should include patient and demographic information.

E. The patient's health record should include date history taken.

F. The patient's health record should include past history, family history, and social history (occupation, recreational interests and hobbies).

G. The patient's health record should include chief complaint(s).

H. The patient's health record should include onset, duration, frequency, location and radiation of symptoms.

I. The patient's health record should include aggravating or relieving factors.

J. The patient's health record should include causation, accident, injury, or other etiology.

K. The patient's health record should include past and present medical or chiropractic treatment for this condition and results of that treatment.

L. The patient's health record should reflect that any health risk factors have been identified.

M. The patient's health record should include clinical or examination findings, including vitals.

N. The patient's health record should indicate whether diagnostic tests or patient histories revealed any contraindications warranting x-rays prior to treatment.

O. The patient's health record should include any radiographic studies performed.

P. The patient's health record should include a written radiographic report.

Q. The written radiology report must be signed by the provider.

R. The patient's health record should include the treatment plan.

S. The patient's treatment plan in the patient's health record should include recommended level of care (duration and frequency of visits).

T. The patient's treatment plan should include objective measures to evaluate treatment effectiveness.

U. The patient's treatment plan in the patient's health record should include phases of care pursued.

V. The patient's treatment plan in the patient's health record should include specific goals (both short and long term) and outcomes expected.

W. The patient's health record should include all treatment and services rendered.

X. The patient's health record should include documentation and support of each CPT code reported.

Y. The patient's health record should include documentation to support each ICD-9 code reported.

Z. The patient's health record should include documentation to support any modifier reported.

 

14. Subsequent Visit

A. Each page of the patient's health record should include the name of the patient.

B. Each page of the patient's health record should include the signature (or electronic equivalent) of the rendering provider and/or reviewing provider and the professional designation "DC."

C. Each page of the patient's health record should include the date of service.

D. The patient's health record should include diagnosis.

E. The patient's health record should include any revision of diagnosis.

F. The patient's health record should include a review of the chief complaint.

G. The patient's health record should include significant changes in subjective complaints including, but not limited to, frequency and intensity of pain or discomfort, or review of ADL deficit.

H. The patient's health record should include assessment of changes in clinical impression (if any) since last visit.

I. The patient's health record should include an exam of area involved in diagnosis.

J. The patient's health record should include S.O.A.P. notes as well as ADLs.

K. The patient's health record should include a written, signed radiology report for any repeat or subsequent x-rays.

L. The patient's health record should include the specific segments or regions manipulated.

M. The patient's health record should include all modalities and/or therapies performed, the reasons for the therapies, and if time based, the actual time therapy was performed.

N. The patient's health record should include patient education and/or home recommendations.

O. The patient's health record should include any relevant information regarding DME, if applicable.

P. The patient's health record should include patient's progress as it relates to treatment plan.

Q. The patient's health record should include changes to treatment plan.

R. The patient's health record should include notes regarding patient compliance, if applicable.

S. The patient's health record should include response and changes in treatment.

T. The patient's health record should include evaluation and treatment effectiveness.

U. The patient's health record should include prognosis.

V. The patient's health record should include final diagnosis.

W. The patient's health record should include summary upon discharge to determine final outcome of treatment rendered.

X. The patient's health record should include discharge date.

Y. The patient's health record should include patient status on discharge.

Z. The patient's health record should include all services and procedures performed.

AA. The patient's health record should include documentation and support of each CPT code reported.

BB. The patient's health record should include documentation to support each ICD-9 code reported.

CC. The patient's health record should include documentation to support any modifier reported.

 

Per the NC BOE Practice Guides:

IV. Treatment Plan

C. During each office visit, the physician should inquire as to the patient's presenting complaints, perform the treatment called for in the treatment plan, and monitor the patient's clinical picture through the use of objective tests such as range of motion, segmental range of motion, presence or absence of spasm or swelling, presence or absence of positive orthopedic findings, and pain assessment.

D. The physician should re-evaluate the appropriateness of further care after whichever comes first, approximately twelve office treatments or four weeks of care (i.e., one "treatment cycle"). If the patient shows improvement, the physician may recommend another treatment cycle.  For as long as improvement can be objectively demonstrated, the patient may continue treatment cycles.  However, if re-evaluation fails to demonstrate additional improvement after any two consecutive treatment cycles, the physician should assume that maximum therapeutic benefit has been reached.  Patients who have reached maximum therapeutic benefit may be candidates for supportive care, elective care, referral or release.

E. Once the goals of treatment have been realized, the patient may continue to need supportive care in order to prevent deterioration or relapse.

 

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Evaluation and Management Services - New Patient

Documentation Tip! - Remember to ask yourself this question and make sure that the answer is always "YES!"

Could a health record reviewer clearly understand from my documentation, the rationale for the level of E/M service provided to this patient? Remember, you can't just state what you did, you must state WHY you did it.

Documentation Requirements

• E/M Documentation must clearly reflect the E/M service rendered

• E/M Documentation must include clinical information to show the necessity for the level of E/M service

• E/M Documentation must clearly support the requirements of the E/M code reported have been met.

Note: The provider may need to indicate, by CPT code, that on the day a procedure or service was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond other services provided or beyond the usual pre-service and post-service care associated with the procedure that was performed. This should be reported by adding Modifier 25 to the appropriate level of E/M service.

Definition of a New Patient

A new patient is one who has not received any professional services from the provider (or another chiropractor in the same group practice) within the past 3 years.

Requirements for level of E/M services - New Patient

99201 - Brief

Requires these 3 key components

1. Problem focused history

2. Problem focused examination

3. Straight forward medical decision making

Counseling and/or coordination of care

Counseling is a discussion with a patient or family member concerning one of the following areas:

Diagnostic test results, impression

Prognosis

Risks and benefits of treatment options

Instructions for treatment options

Importance of compliance with chosen option

Risk factors

Education

Usually, the presenting problems are self limited or minor. Providers typically spend 10 minutes face-to-face with the patient or family.

Both the face-to-face time and the total time actually spent with the patient must be documented in the patient health record.

99202 - Limited

Requires these 3 key components

1. Expanded problem focused history

2. Expanded problem focused examination

3. Straight forward medical decision making

Counseling and/or coordination of care

Counseling is a discussion with a patient or family member concerning one of the following areas:

Diagnostic test results, impression

Prognosis

Risks and benefits of treatment options

Instructions for treatment options

Importance of compliance with chosen option

Risk factors

Education

If the visit consists predominantly (more than 50%) of counseling or coordination of care, direct face-to-face time is key to qualifying for a particular level of E/M service.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient or family needs.

Usually, the presenting problems are of low to moderate severity. Provider typically spends 20 minutes face-to-face with the patient or family.

Both the face-to-face time and the total time actually spent with the patient must be documented in the patient health record.

99203 - Intermediate

Requires these 3 key components

1. Detailed history

2. Detailed examination

3. Medical decision making of low complexity

Counseling and/or coordination of care

Counseling is a discussion with a patient or family member concerning one of the following areas:

Diagnostic test results, impression

Prognosis

Risks and benefits of treatment options

Instructions for treatment options

Importance of compliance with chosen option

Risk factors

Education

If the visit consists predominantly (more than 50%) of counseling or coordination of care, direct face-to-face time is key to qualifying for a particular level of E/M service.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient or family needs.

Usually, the presenting problems are of moderate severity. Provider typically spends 30 minutes face-to-face with the patient or family.

Both the face-to-face time and the total time actually spent with the patient must be documented in the patient health record.

* 99204 - Extensive

Requires these 3 key components

1. A comprehensive history

2. A comprehensive examination

3. Decision making of moderate complexity (indicates a moderate degree of mortality without treatment)

*Our managed care partners limit chiropractic care to neuromusculoskeletal conditions; the type of comprehensive examination required to meet this description is generally not consistent with chiropractic care.

Counseling and/or coordination of care

Counseling is a discussion with a patient or family member concerning one of the following areas:

Diagnostic test results, impression

Prognosis

Risks and benefits of treatment options

Instructions for treatment options

Importance of compliance with chosen option

Risk factors

Education

If the visit consists predominantly (more than 50%) of counseling or coordination of care, direct face-to-face time is key to qualifying for a particular level of E/M service.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient or family needs.

Usually, the presenting problems are of moderate to high severity. Provider typically spends 45 minutes face-to-face with the patient or family.

Both the face-to-face time and the total time actually spent with the patient must be documented in the patient health record.

* 99205 - Comprehensive

Requires these 3 key components

1. A comprehensive history

2. A comprehensive examination

3. Decision making of high complexity (indicates a high degree of mortality without treatment)

*Our managed care partners limit chiropractic care to neuromusculoskeletal conditions; the type of comprehensive examination required to meet this description is generally not consistent with chiropractic care.

Counseling and/or coordination of care

Counseling is a discussion with a patient or family member concerning one of the following areas:

Diagnostic test results, impression

Prognosis

Risks and benefits of treatment options

Instructions for treatment options

Importance of compliance with chosen option

Risk factors

Education

If the visit consists predominantly (more than 50%) of counseling or coordination of care, direct face-to-face time is key to qualifying for a particular level of E/M service.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient or family needs.

Usually, the presenting problems are of moderate to high severity. Provider typically spends 60 minutes face-to-face with the patient or family.

Both the face-to-face time and the total time actually spent with the patient must be documented in the patient health record.

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Evaluation and Management Services - Established Patient

Documentation Tip! - Remember to ask yourself this question and make sure that the answer is always "YES!"

Could a health record reviewer clearly understand from my documentation, the rationale for the level of E/M service provided to this patient? Remember, you can't just sate what you did, you must state WHY you did it.

Documentation Requirements

• E/M Documentation must clearly reflect the E/M service rendered

• E/M Documentation must include clinical information to show the necessity for the level of E/M service

• E/M Documentation must clearly support the requirements of the E/M code reported have been met.

Note: The provider may need to indicate, by CPT code, that on the day a procedure or service was performed, the patient's condition required a significant separately identifiable E/M service above and beyond other services provided or beyond the usual pre-service and post-service care associated with the procedure that was performed. This should be reported by adding Modifier 25 to the appropriate level of E/M service.

Definition of an Established Patient

An established patient is one who has received professional services from the provider (or another chiropractor in the same group practice) within the past 3 years.

Requirements for level of E/M services - Established Patient

99211 - Brief

Office visit for the evaluation and management of an established patient. Usually the presenting problems are minimal.

Requires these 3 key components

1. Problem focused history

2. Problem focused examination

3. Straight forward medical decision making

Counseling and/or coordination of care

Counseling is a discussion with a patient or family member concerning one of the following areas:

Diagnostic test results, impression

Prognosis

Risks and benefits of treatment options

Instructions for treatment options

Importance of compliance with chosen option

Risk factors

Education

If the visit consists predominantly (more than 50%) of counseling or coordination of care, direct face-to-face time is the key to qualifying for a particular level of E/M service.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient or family needs.

Usually, the presenting problems are minimal. Providers typically spend 5 minutes performing or supervising these services.

Both the face-to-face time and the total time actually spent with the patient must be documented in the patient health record.

99212 - Limited

Requires at least 2 of these 3 key components

1. Problem focused history

2. Problem focused examination

3. Straight forward medical decision making

Counseling and/or coordination of care

Counseling is a discussion with a patient or family member concerning one of the following areas:

Diagnostic test results, impression

Prognosis

Risks and benefits of treatment options

Instructions for treatment options

Importance of compliance with chosen option

Risk factors

Education

If the visit consists predominantly (more than 50%) of counseling or coordination of care, direct face-to-face time is key to qualifying for a particular level of E/M service.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient or family needs.

Usually, the presenting problems are self limited or minor. Providers typically spend 10 minutes face-to-face with the patient or family.

Both the face-to-face time and the total time actually spent with the patient must be documented in the patient health record.

99213 - Intermediate

Requires at least 2 of these 3 key components

1. Expanded problem focused history

2. Expanded problem focused examination

3. Medical decision making of low complexity

Counseling and/or coordination of care

Counseling is a discussion with a patient or family member concerning one of the following areas:

Diagnostic test results, impression

Prognosis

Risks and benefits of treatment options

Instructions for treatment options

Importance of compliance with chosen option

Risk factors

Education

If the visit consists predominantly (more than 50%) of counseling or coordination of care, direct face-to-face time is key to qualifying for a particular level of E/M service.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient or family needs.

Usually, the presenting problems are of low or moderate severity. Providers typically spend 15 minutes face-to-face with the patient or family.

Both the face-to-face time and the total time actually spent with the patient must be documented in the patient health record.

99214 - Extensive

Requires at least 2 of these 3 key components

1. A detailed history

2. A detailed examination

3. Medical decision making of moderate complexity (indicates a moderate degree of mortality without treatment)

Counseling and/or coordination of care

Counseling is a discussion with a patient or family member concerning one of the following areas:

Diagnostic test results, impression

Prognosis

Risks and benefits of treatment options

Instructions for treatment options

Importance of compliance with chosen option

Risk factors

Education

If the visit consists predominantly (more than 50%) of counseling or coordination of care, direct face-to-face time is key to qualifying for a particular level of E/M service.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient or family needs.

Usually, the presenting problems are of moderate to high severity. Providers typically spend 25 minutes face-to-face with the patient or family.

Both the face-to-face time and the total time actually spent with the patient must be documented in the patient health record.

 

* 99215 - Comprehensive

Requires at least 2 of these 3 key components

1. A comprehensive history

2. A comprehensive examination

3. Decision making of high complexity (indicates a high degree of mortality without treatment)

*Our managed care partners limit chiropractic care to neuromusculoskeletal conditions; the type of comprehensive examination required to meet this description is generally not consistent with chiropractic care.

Counseling and/or coordination of care

Counseling is a discussion with a patient or family member concerning one of the following areas:

Diagnostic test results, impression

Prognosis

Risks and benefits of treatment options

Instructions for treatment options

Importance of compliance with chosen option

Risk factors

Education

If the visit consists predominantly (more than 50%) of counseling or coordination of care, direct face-to-face time is key to qualifying for a particular level of E/M service.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient or family needs.

Usually, the presenting problems are of moderate to high severity. Providers typically spend 40 minutes face-to-face with the patient or family.

Both the face-to-face time and the total time actually spent with the patient must be documented in the patient health record.

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Evaluation and Management Services - Consultations

Documentation Tip! - Remember to ask yourself this question and make sure that the answer is always "YES!"

Could a health record reviewer clearly understand from my documentation, the rationale for the level of E/M service provided to this patient? Remember, you can't just state what you did, you must state WHY you did it.

Documentation Requirements

• The verbal or written request must be clearly documented in the patient's health record including the name of the provider or organization requesting the advice or opinion, and the date it was received. The provider's written report to the requesting physician or appropriate organization, including his opinion, advice and/or any services ordered or performed, must be clearly documented in the patient's health record. A copy of this report must be maintained in the patient's health record.

• E/M Documentation must clearly reflect the E/M service rendered

• E/M Documentation must include clinical information to show the necessity for the level of E/M service

• E/M Documentation must clearly support the requirements of the E/M code reported have been met.

Note: The provider may need to indicate, by CPT code, that on the day a procedure or service was performed, the patient's condition required a significant separately identifiable E/M service above and beyond other services provided or beyond the usual pre-service and post-service care associated with the procedure that was performed. This should be reported by adding Modifier 25 to the appropriate level of E/M service.

Note: Consultation E/M codes should ONLY be billed when the opinion or advice of another physician, insurer, employer, or other appropriate source has requested his/her opinion or advice.

A consultation initiated by a patient and/or family member and not requested by a physician or other appropriate source should not be reported using an E/M consultation code.

Requirements for level of E/M services - Consultation

99241

Requires these 3 key components

1. Problem focused history

2. Problem focused examination

3. Straight forward medical decision making

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient or family needs.

Usually, the presenting problems are self limited or minor. Providers typically spend 15 minutes face-to-face with the patient or family.

Both the face-to-face time and the total time actually spent with the patient must be documented in the patient health record.

99242

Requires these 3 key components

1. Expanded problem focused history

2. Expanded problem focused examination

3. Straight forward medical decision making

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient or family needs.

Usually, the presenting problems are of low severity. Providers typically spend 30 minutes face-to-face with the patient or family.

Both the face-to-face time and the total time actually spent with the patient must be documented in the patient health record.

99243

Requires these 3 key components

1. Detailed history

2. Detailed examination

3. Medical decision making of low complexity

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient or family needs.

Usually, the presenting problems are of moderate severity. Providers typically spend 40 minutes face-to-face with the patient or family.

Both the face-to-face time and the total time actually spent with the patient must be documented in the patient health record.

* 99244

Requires these 3 key components

1. A comprehensive history

2. A comprehensive examination

3. Decision making of moderate complexity (indicates a moderate degree of mortality without treatment)

*Our managed care partners limit chiropractic care to neuromusculoskeletal conditions; the type of comprehensive examination required to meet this description is generally not consistent with chiropractic care.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient or family needs.

Usually, the presenting problems are of moderate to high severity. Providers typically spend 60 minutes face-to-face with the patient or family.

Both the face-to-face time and the total time actually spent with the patient must be documented in the patient health record.

 

* 99245

Requires these 3 key components

1. A comprehensive history

2. A comprehensive examination

3. Decision making of high complexity (indicates a high degree of mortality without treatment)

*Our managed care partners limit chiropractic care to neuromusculoskeletal conditions; the type of comprehensive examination required to meet this description is generally not consistent with chiropractic care.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient or family needs.

Usually, the presenting problems are of moderate to high severity. Providers typically spend 80 minutes face-to-face with the patient or family.

Both the face-to-face time and the total time actually spent with the patient must be documented in the patient health record.

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Chiropractic Manipulative Therapies

Documentation Tip! - Remember to ask yourself this question and make sure that the answer is always "YES!"

Could a health record reviewer clearly understand from my documentation, the rationale for the level of CMT service provided to this patient? Remember, you can't just state what you did, you must state WHY you did it.

CMT includes a pre-manipulation patient assessment and includes a review of radiographs, interpretation of test results, treatment planning, pre-manipulation procedures, manipulation, chart documentation and counseling.

Regardless of how many manipulations are performed in a given spinal region, (cervical, thoracic, etc.) it counts as only ONE region, under the CMT codes.

DOCUMENTATION REQUIREMENTS

There are two ways in which the level of subluxation may be specified:

1. The exact bones may be listed, for example: C5, C6, etc.

2. The area may be reported if it implies only certain bones such as: Occipital-atlantal (occiput and C1 (atlas)), lumbo-sacral (L5 and sacrum), sacro-iliac (sacrum and ilium).

Spinal Manipulations

Includes CPT codes:

98940 - CMT - spinal, one to two regions

98941 - CMT - spinal, three to four regions

98942 - CMT - spinal, five regions

5 spinal regions include:

Extraspinal Manipulations

Includes CPT code:

98943 - Extraspinal - one or more regions

5 extraspinal regions include:

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Modalities and Therapeutic Procedures

Documentation Tip! - Remember to ask yourself this question and make sure that the answer is always "YES!"

Could a health record reviewer clearly understand from my documentation, the rationale for the modality provided to this patient? Remember, you can't just state what you did, you must state WHY you did it.

Time Based Therapies

(Constant Attendance and Therapeutic Procedures)

The inappropriate use and reporting of time based therapies increases your chances of post-payment audits! Payors are paying close attention to ALL time based codes reported with particular attention to CPT codes 97124 (massage) and 97140 (manual therapy).  Nationally, post payment chiropractic audits have revealed that these codes are often reported without the appropriate documentation to establish medical necessity for these services and/or for the number of units reported.

IMPORTANT REMINDER for NC Providers:

BCBSNC Corporate Medical Policy states:

"Constant Attendance Modalities, 97110-97039, and Therapeutic Procedures, 97110-97542, will be limited to a maximum on one hour (4 units) for the combinations of codes submitted."  (The "combination of codes submitted" includes manipulations as well as any other treatment provided on that date of service.)

Health care payors have the ability to review provider billing histories from information reported on health care claims.  Based on these billing histories, payors may conduct a post payment audit to determine if the services were appropriate, were medically necessary, and were properly documented and billed.

With respect to time based codes, triggers for post payment audits include:

• Reporting ANY time based code for more than one unit, with particular focus on massage therapy (97124) and manual therapy (97140)

• Use of 97140 together with a chiropractic manipulation (CMT) code

Helpful Reminders:

1. Documentation contained in the health care record must clearly establish the medical necessity for all covered services reported.

2. Treatment must be consistent with BOE Practice Guides and payor corporate medical policies.

3. When reporting time based codes, the health care record must reflect the actual time the services were performed.

4. There should be a reduction in the use of therapies as the patient's condition improves.

Page 298 of the 2009 ACA Chiropractic Coding Solutions Manual states "...each unit of 97140 describes 15 minutes of office time - it normally does not take 45 minutes to perform manipulative therapy and payers are fully aware of this."

All time based therapies (constant  attendance and therapeutic procedures) are billed in 15 minute increments.  When these services are provided for less than 15 minutes, the code must be appended with Modifier 52.  Please remember that the actual time the service was performed must be documented in the patient's health care record.

IMPORTANT NOTE ON MANUAL THERAPY (97140)

Please remember that manual therapy should be used the same day as a manipulation ONLY in certain circumstances. The ACA Chiropractic Coding Solutions Manual gives the following example of the appropriate use of 97140 on the same day of a manipulation.

Example:

A patient has severe injuries from an auto accident with a neck injury that contraindicates CMT in the neck region. Therefore, the provider performs MANUAL THERAPY to the neck region and CMT to the lumbar region. In this instance, it would be appropriate to report both the 97140 and the CMT.

If it is appropriate to report 97140 (Manual Therapy) together with a CMT, then the manual therapy code (97140) must be appended with a Modifier 59.

At the present time, payor's claims processing systems can accept only one modifier per CPT code.  Manual therapy, when performed together with a CMT code, must be submitted with Modifier 59 to indicate a 'distinct procedural service'.  Even if the service was reduced and would thus normally require the use of Modifier 52 and Modifier 59, always append this code with the Modifier 59, or the service will be denied.  (Note: If no CMT code is being reported on the same date of service as the 97140, and the service was reduced to less than 15 minutes, then append with Modifier 52.) Please remember that the health care record must always reflect the actual time the service was performed.

Modalities - Supervised

Supervised Modalities - DO NOT require direct one-on-one patient contact by provider.

NOTE: Time is NOT a factor in the description of supervised modalities.

Common Supervised Modalities:

97012 - Mechanical traction

97014 - Electrical stim - unattended

IMPORTANT NOTE ON ELECTRICAL STIMULATION

Please remember that it is not appropriate to bill an additional HCPCS code for electrodes when performing electrical stimulation.  The relative value of electrodes is included in the relative value for performing electrical stimulation, 97014, so this code already includes the reimbursement for electrodes.

Two therapies or modalities per visit, in addition to the manipulation, are most commonly accepted as usual and customary. There should be a reduction in use of therapies and modalities as the patient's condition improves.

DOCUMENTATION REQUIREMENTS

When performed, the need for modalities must be clearly documented in the patient's health record and should be consistent with the diagnosis and treatment plan.

Documentation of modalities must be noted in the patient record by one of the following methods.

1. Written Standards

HNS providers may choose to avoid the time constraints associated with repeatedly meeting the requirements for proper modality documentation by establishing written standards for the application of each modality used in your practice. Please see the sample "Standards for Modalities."

2. Appropriate Supporting Documentation in the Health Record

If you elect not to utilize written standards for modalities in your practice, you must adhere to proper documentation requirements in the patient's health record each time a modality is performed.

 

Documentation must include:

Modalities - Constant Attendance (Time based services)

Constant Attendance Modalities require direct one-on-one patient contact by provider.

NOTE: Time IS a factor in the description of constant attendance modalities and cannot exceed 4 (15 minute) units of time.

Documentation must specifically include length of time service was performed, such as 15 minutes of ultrasound therapy.

Common Constant Attendance Modalities:

97032 - Electrical Stim (attended)

97035 - Ultrasound

Two therapies or modalities per visit, in addition to the manipulation, are most commonly accepted as usual and customary. There should be a reduction in use of therapies and modalities as the patient's condition improves.

DOCUMENTATION REQUIREMENTS

When performed, the need for modalities must be clearly documented in the patient's health record and should be consistent with the diagnosis and treatment plan.

Documentation of modalities must be noted in the patient record by one of the following methods.

1. Written Standards

HNS providers may choose to avoid the time constraints associated with repeatedly meeting the requirements for proper modality documentation by establishing written standards for the application of each modality used in your practice. Please see the sample "Standards for Modalities."

Please note: If you incorporate written standards in your practice, you will not need to document the reason for the use of each particular modality on each date of service. However, you must still document the service provided, the area treated, and if time based code, the length of the service, (such as 15 minutes).

2. Appropriate Supporting Documentation in the Health Record

If you elect not to utilize written standards for modalities in your practice, you must adhere to proper documentation requirements in the patient's health record each time a modality is performed.

 

Documentation must include:

Therapeutic Procedures - (Time based services)

Physician or therapist must have direct one-on-one patient contact.

NOTE: Time IS a factor in the description of therapeutic procedures and cannot exceed 4 (15 minute) units of time.

Documentation must specifically include length of time service was performed, such as 15 minutes of therapeutic exercise.

Documentation Tip! - Remember to ask yourself this question and make sure that the answer is always "YES!"

Could a health record reviewer clearly understand from my documentation, the rationale for the modality provided to this patient? Remember, you can't just state what you did, you must state WHY you did it.

IMPORTANT NOTE ON MANUAL THERAPY (97140)

Please remember that manual therapy should be used the same day as a manipulation ONLY in certain circumstances. The ACA Chiropractic Coding Solutions Manual gives the following example of the appropriate use of 97140 on the same day of a manipulation.

Example:

A patient has severe injuries from an auto accident with a neck injury that contraindicates CMT in the neck region. Therefore the provider performs MANUAL THERAPY to the neck region and CMT to the lumbar region. In this instance, it would be appropriate to report both the 97140 and the CMT.

If it is appropriate to report 97140 (Manual Therapy) together with a CMT, then the manual therapy code (97140) must be appended with a Modifier 59.

NOTE: Manual therapy reported the same date of service as CMT is often a trigger for post-payment audits.

NOTE: Two therapies or modalities per visit, in addition to the manipulation, are most commonly accepted as usual and customary. There should be a reduction in use of therapies and modalities as the patient's condition improves.

Common Therapies:

97110 - Therapeutic exercise

97140 - Manual therapy technique

97124 - Massage therapy

DOCUMENTATION REQUIREMENTS

When performed, the need for therapies must be clearly documented in the patient's health record and should be consistent with the diagnosis and treatment plan.

Documentation of therapies must be noted in the daily patient record by one of the following methods.

1. Written Standards

HNS providers may choose to avoid the time constraints associated with repeatedly meeting the requirements for proper therapy documentation, by establishing written standards for the application of each therapy used in your practice. If not performed to written standard procedure, type of therapy, area of application (location), reason for therapy, setting, frequency and time (if a factor) should be clearly noted in the record. 

Please note: If you incorporate written standards in your practice, you will not need to document the reason for the use of each particular therapy on each date of service.  However, you must still document the service provided, the area treated, and if time based code, the length of the service, (such as 15 minutes).

 

2. Appropriate Supporting Documentation in the Health Record

If you elect not to utilize written standards for therapies in your practice, you must adhere to proper documentation requirements in the patient's health record each time a therapy is performed.

 

Documentation must include:

Please note: cannot exceed 4 units of time.

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Acupuncture

IMPORTANT NOTE: To bill for acupuncture, HNS providers must have met all requirements of their respective state licensing board regarding acupuncture.

DOCUMENTATION REQUIREMENTS

Documentation for acupuncture services should include:

Note: Time includes pre-service, intra-service and post-service work.

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Patient Education and Instruction

DOCUMENTATION REQUIREMENTS

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DME Services

DOCUMENTATION REQUIREMENTS

All recommendations for DME should be clearly documented including the rationale for each DME or service.

All recommendations for DME should be consistent with diagnosis and treatment plan and payor policies.

Any DME accepted by the patient should be documented in the health record.

The health care record should indicate all instructions given to the patient regarding the use of any DME. (If written standards are maintained for DME that include specific instructions, reference to the written standard is acceptable.)

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