HNS Policy   

Billing Policies: 

An appropriate examination must be performed on each patient prior to initiating care to evaluate the appropriateness of treatment, and in order to develop an individualized treatment plan which must include objective, measurable, and reasonable treatment goals intended to improve or resolve a functional deficit. Should a patient drop out of care or fail to comply with the treatment plan, prior to resuming treatment, an examination must be performed to determine if the initial diagnoses need to be updated and/or if the initial treatment goals are still reasonable or need to be modified.

The examination must include an examination of the area of the chief complaint and 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. (Standard outcome assessments must be utilized as part of the initial examination in order to establish a functional baseline by which patient progress can be measured.)

All examinations must be billed to the payor, regardless of whether the plan pays for the examination, and must be billed using an E/M code.  Additionally, HNS requires re-examinations every four weeks or twelve visits (whichever comes first), and all such re-examinations must be billed to the payor, regardless of whether the plan covers re-examinations. Re-examinations must also be billed using an E/M code.

The most appropriate level of E/M code should be reported to HNS contracted payors, and documentation must clearly support the level of E/M service billed.

All E/M services reported to a HNS contracted payor must be medically necessary, properly documented in the patient's health care record, and must be consistent with the chief complaint/clinical findings, diagnoses, and treatment plan.

Report of Findings

Report of findings are part of the E/M service provided.

Report of findings cannot be billed as a separate visit.

Consultation E/M Codes

Consultation codes may ONLY be billed when another physician, insurer, employer, or other appropriate source has requested your opinion or advice. (Many payors no longer cover consult codes, and instead require that consults be reported using the most applicable E/M New Patient or E/M Established Patient code. Please verify this when verifying benefits.)

If such a consultation has been requested: 

• The verbal or written request must be clearly documented in the patient's health care record including the name of the provider or organization requesting the advice or opinion and the date the request 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 care record. A copy of this report must be maintained in the patient's health care record.
  

   

E/M Services - New Patient

The AMA Current Procedural Terminology (CPT) Manual (Evaluation and Management Service Guidelines) state that a new patient is one who has not received any professional services from the same physician, or another physician of the same specialty and same group practice within the past three (3) years.

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.

E/M Services - 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 three years.

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.

To determine the appropriateness of further care, E/M services should be performed approximately every four weeks or every twelve visits (whichever comes first) unless in between the four week/twelve visit protocol, there has been significant change to warrant re-examination that results in a change to the treatment plan.

Requirements for level of E/M services - Established Patient

99211 - Brief

Providers should NOT bill this code. This is a low complexity code which does not require a physician or other qualified healthcare professional to be present in the exam room with the patient. For any re-evaluation, providers should bill the most appropriate code (99212 -99215).