HNS Policy 

Initial Examination

To promote the delivery of safe and effective health care, for services provided and billed to HNS contracted payors, clinical examination findings and outcome assessment tools must objectively substantiate the medical necessity of the services to be provided, and such services should be consistent with the patient’s chief complaint, clinical exam findings, diagnoses, and treatment plan.  (Exception: maintenance care)

The examination and all clinical findings must be properly documented in the patient’s health care record.

The health care record must include appropriate documentation to support the type and level of E/M services reported to the payor.

The examination should include a consultation to ascertain history and such relevant orthopedic, neurological, and chiropractic tests as are necessary to establish the extent and severity of the injury or condition.

HNS requires the use of standardized outcome assessment tools as part of the initial examination to establish a functional baseline, and at each re-examination to evaluate and monitor progress toward treatment objectives, and to assist in determining when MMI has been reached.

The health care record must clearly indicate the specific tests performed as well as the results of those tests.

Vital signs must be obtained as part of every examination for which an evaluation/management (E/M) code is billed and results must be documented in the health care record. Mandatory vitals include:

1. Weight

2. Pulse Rate

3. Blood Pressure

Other vitals should be taken as determined by the physician, and should be appropriate based on the level of examination performed.

When a new patient presents requesting only maintenance care, vitals must be taken as part of the initial evaluation.  The physician may exercise clinical judgment as to the frequency of repeating them.

Clinical examinations should include an examination of the area(s) indicated in the patient’s chief complaint.

Written clinical exam findings must include specific segments and location of subluxations.

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)

To report CMT to HNS contracted payors, subluxations must be demonstrated by one of two methods: x-ray or physical examination.

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. 

• 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
  
  

Re-Examinations

Frequency of Re-Examinations

In order to evaluate the effectiveness of the treatment provided and to determine the appropriateness of further care, HNS providers must perform re-examinations after whichever comes first, approximately twelve office visits or four weeks (i.e., one treatment cycle).  

For services provided and billed to HNS contracted payors, clinical re-examination findings must objectively substantiate the medical necessity of the services provided and those services must be consistent with the patient’s chief complaint, clinical exam findings, diagnoses, and treatment plan. (Exception: maintenance care)

HNS requires the use of standardized outcome assessment tools as part of the initial examination to establish a baseline and at each re-examination to evaluate and monitor progress toward treatment objectives and to aid in determining when MMI has been reached.

Tests

The re-examination should include such relevant orthopedic, neurological, and chiropractic tests that objectively evaluate the patient’s progress and should reference the progress as it relates to the treatment plan. 

The health care record must clearly indicate the specific tests performed and the results of each test.

Evaluation of Patient's Progress

Documentation for the re-exam must include evidence the patient's progress was objectively measured against the objective goals of the treatment plan.

The re-examination and all clinical findings must be properly documented in the patient’s health care record.

If re-evaluation fails to demonstrate improvement after two treatment cycles, the provider must assume maximum medical improvement (MMI) has been reached and the patient should be switched to maintenance/supportive care, referred, or released from care.

The health care record must include documentation to support the type and level of E/M service reported to the payor.

Vitals

Vital signs must be obtained as part of every examination for which an evaluation/management (E/M) code is billed and results must be documented in the health care record. Other vitals are left to the discretion of the physicians but should be appropriate based on the level of examination.

Mandatory vitals include:

1. Weight

2. Pulse Rate

3. Blood Pressure

HNS has created exam forms to assist you in clinical evaluations of patients.  All forms are available on this website, under the tab "HNS Forms", and are provided in Microsoft Word format so you may download and customize them for your practice.