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

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 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.

 

Requirements for level of E/M services - New Patient

 

99201 - Brief

Requires these three key components:

  1. Problem focused history

  2. Problem focused examination

  3. Straightforward medical decision making

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

 

99202 - Limited

Requires these three key components:

  1. Expanded problem focused history

  2. Expanded problem focused examination

  3. Straightforward medical decision making

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

 

99203 - Intermediate

Requires these three key components:

  1. Detailed history

  2. Detailed examination

  3. Medical decision making of low complexity

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

 

99204 - Extensive*

Requires these three key components:

  1. A comprehensive history

  2. A comprehensive examination

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

*The type of comprehensive examination required to meet this description is generally not consistent with chiropractic care covered by HNS contracted payors.

 

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

 

99205 - Comprehensive*

Requires these three key components:

  1. A comprehensive history

  2. A comprehensive examination

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

*The type of comprehensive examination required to meet this description is generally not consistent with chiropractic care covered by HNS contracted payors.

 

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

 

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 week 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

Requires these three key components:

  1. Problem focused history

  2. Problem focused examination

  3. Straightforward medical decision making

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

 

99212 - Limited

Requires at least two of these three key components:

  1. Problem focused history

  2. Problem focused examination

  3. Straightforward medical decision making

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

 

99213 - Intermediate

Requires at least two of these three key components:

  1. Expanded problem focused history

  2. Expanded problem focused examination

  3. Medical decision making of low complexity

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

 

99214 - Extensive*

Requires at least two of these three 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)

*The type of comprehensive examination required to meet this description is generally not consistent with chiropractic care covered by HNS contracted payors.

 

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

 

99215 - Comprehensive*

Requires at least two of these three key components:

  1. A comprehensive history

  2. A comprehensive examination

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

*The type of comprehensive examination required to meet this description is generally not consistent with chiropractic care covered by HNS contracted payors.

 

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

 

E/M Services - Consultations

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

 

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:  Report of findings visits do not meet the requirements of an E/M Consultation, so providers should not report their standard report of findings visits using an E/M CPT code.

 

HNS has provided a sample Consultation Form we recommend you use if billing for consults. This form is available in Microsoft Word Format under the tab HNS Forms on this website.

 

Requirements for level of E/M services - Consultations

 

99241

Requires these three key components:

  1. Problem focused history

  2. Problem focused examination

  3. Straightforward medical decision making

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

 

99242

Requires these three key components:

  1. Expanded problem focused history

  2. Expanded problem focused examination

  3. Straightforward medical decision making

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

 

99243

Requires these three key components:

  1. Detailed history

  2. Detailed examination

  3. Medical decision making of low complexity

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

 

99244*

Requires these three key components:

  1. A comprehensive history

  2. A comprehensive examination

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

*The type of comprehensive examination required to meet this description is generally not consistent with chiropractic care covered by HNS contracted payors.

 

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

 

99245*

Requires these three key components:

  1. A comprehensive history

  2. A comprehensive examination

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

*The type of comprehensive examination required to meet this description is generally not consistent with chiropractic care covered by HNS contracted payors.

 

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

 

The following chart is provided to assist you with choosing the correct level of E/M service: