know the messenger, history and basics: compliance rules

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History and Basics: Compliance Rules, Audits and

Requirements

Yvette Noel, CPCODirector of Education

KMC University

Know the Messenger, Hear the Message

Professional:• Director of Education for KMC University• Certified Professional Compliance Officer (CPCO)

• American Academy of Professional Coders (AAPC)• Currently Enrolled in Certified Practice Biller (CPB)

Certification• Served the Chiropractic Profession for 11 years• Served the Medical Community for 30 years• Public Speaker for different platforms

Personal:• Married to Stephen for 29 years• Proud Mother of 3 married children• Grandma to Norah• Dog mom to 2 rescues and 1 family dog• Piano player for 43 years, singer and songwriter

What is your name?What City is your

office located in?

What is the best

profession on the

planet that we are all

here for today?

The Common Ground

What We Will Cover!• Discuss History & Basics of

Compliance• Define and delineate between

Medically Necessary and Clinically Appropriate Care

• Learn the Medicare PART Process• Discovery the Components of

Documentation for Initial Assessment

• Understanding Payer Contracts regarding Compliance and policy

Let's be clear…• Compliance has been around for decades…not

new• Compliance got it start in 1992 when the General Accounting

Office (GAO) identified Medicare claims to be at high risk for fraud and abuse. So in 1996, the Office of Inspector General (OIG) initiated and audit of the Health Care Finance Administration (later named Centers for Medicare and Medicaid services (CMS) Medicare claims payment system. This resulted in an estimated finding of over $23 billion in improper payments.

•Made mandatory with Affordable Care Act•OIG•HIPAA

• The difference now, is auditors, insurance companies and the government are bothering to look!

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Why Does Compliance Matter?

•Every business has compliance-related activities

•We are scrutinized in healthcare more than in other industries

Types of Compliance

•OIG Compliance: Fraud, Waste and Abuse

•HIPAA Compliance

•OSHA Compliance

•Financial Compliance

•PCI Compliance

•CLIA Compliance• Multidisciplinary and certain tests

A Common Denominator

•All Compliance Includes

• Written Office policy

• Documented Procedures (SOP)

What is the Difference?•Policies

• Are general in nature• Identify company rules• Explain why they exist• Tell when the rule applies• Describe who it covers• Show how the rule is

enforced• Describe the

consequences• Are normally described

using simple sentences and paragraphs

•Procedures

• Identify specific actions

• Explain when to take actions

• Describe alternatives

• Show emergency procedures

• Include warnings and cautions

• Give examples

• Show how to complete forms

• Are normally written using an outline format

OIG Compliance

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HIPAA Compliance

• Contains policies and procedures that relate to • The protection of the privacy of

Protected Health Information (PHI) • The security of the storage and

transmission of Electronic Protected Health Information

• Primarily concerns the privacy and security of the patient’s PHI

• Covers both paper and electronic forms of patient data

• Overseen by the Office of Civil Rights • Overseen by the Office of Inspector General

• Contains policies and procedures that relate to • The detection and prevention of fraud,

waste, and abuse within your office

• Primarily concerns documentation, coding, patient financial matters and billing

• Includes all federal, state and third-party payer regulations

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• Under the guidance of the Department of Health and Human Services

• Policies and procedures must be customized to your practice

• Staff must be trained on the policies and procedures

• Policies and procedures must be reviewed annually to ensure they are still relevant and effective

• Staff must receive refresher training annually

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Your Passion is Also a Regulated Business

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Who Is It?

Who is the OIG?

The Office of Inspector General's (OIG) mission is to protect the integrity of the Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries.

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The 8 Requirements of OIG Compliance

1. Policy and Procedure Install and Management

2. Choose Your Compliance Officer (CO)

3. Comprehensive Education and Training

4. Establish Disciplinary Guidelines

5. Internal Auditing and Monitoring

6. Respond Swiftly to Detected Offenses

7. Develop Open Lines of Communication

8. Avoiding Excluded Individuals

OIG Compliance Not Optional

•On October 5, 2000 the Compliance program was implemented for Individual and Small Group Physician Practices.

OCTOBER 2016

$359

The Collection Coach

million

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THE OUTLIERS ARE AUDITED AND MADE EXAMPLE


2013 2014 2015 2015

“Establish adequate policies and procedures

to ensure that chiropractic services billed to

Medicare are medically necessary, correctly

coded and adequately documented.”

AUGUST 2016


“Establish adequate policies and procedures

to ensure that chiropractic services billed to

Medicare are medically necessary, correctly

coded and adequately documented.”

92% error rate … Refund $339,625 The Collection Coach

DECEMBER 2017

The Collection Coach The Collection Coach

JANUARY 2018

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Who Told Them?



NO MORE WORK PLANS

Portfolios

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Chiropractic ServicesWhat does Medicare Part B cover?Medicare Part B covers medical and other health care services, including chiropractic services

How much does Medicare pay yearly for chiropractic services?

Since 2010, Medicare has paid more than $450 million per year for chiropractic services

What are the coverage rules for chiropractic services?Medicare covers reasonable and necessary chiropractic services provided by a qualified chiropractor to correct spinal subluxation by means of manual manipulation of the spine. Medicare does not cover chiropractic maintenance therapy. To receive payment from Medicare, a chiropractor must have documentation to support the services provided.

Is there a limit to the number of covered chiropractic services that a beneficiary may receive?Medicare does not limit the number of covered chiropractic services that a beneficiary may receive per month or per year. Many private insurance companies impose coverage limits

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Medicare Said It…


The More

You Do

the Higher

the Risk

UNDER THE MAGNIFYING GLASS

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False Claims Act Violations

•Establishes liability when any person or entity improperly receives from or avoids payment to the Feds•Prohibits “knowingly presenting or causing to be presented, a false claim for payment or approval

False Claims Act Violations

• Prohibits “knowingly presenting or causing to be presented, a false claim for payment or approval”• Examples:

•Waiving deductibles or co-payments and not reporting to carriers• Up-coding for higher

reimbursements• Down-coding based on

payer type

Know the Rules that

Govern Healthcare

Follow them to reduce

risk!!

Why Mandatory?

Integrate policies and procedures that are necessary to promote adherence to federal and state laws, statutes, and regulations applicable to the delivery of healthcare services into the physician’s practice

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Policies and Procedures Address THESE Risks

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Avoid Dual Fee Schedules

What is and isn’t a dual fee schedule? Get the facts straight• Misrepresents charges to

carriers • False Claims Act violation• May violate provider

agreements

Compliant Time of Service DiscountsDiscount is based on viable bookkeeping savings•May or may not be

defined•Often not defensible

or unreasonable•May not be

permissible on Federally insured patients•Must be paid in full at

time of service

Other Types of Discounts

•ChiroHealth USA

•Hardship Policies

•Professional Courtesy

•Billing for Family Members

Inducement Violations•Per the OIG: “incentives that are only nominal in value are NOT prohibited by [inducement law]

•No more than $15 per item or $75 in the aggregate annually• Even one free

examination, x-ray, or therapy is a risk

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Anti-Kickback ViolationsA person who offers or transfers to a Medicare or Medicaid beneficiary any remuneration that the

person knows or should know is likely to influence the beneficiary’s selection of a particular provider,

practitioner, or supplier of Medicare or Medicaid payable items or services may be liable for civil money penalties (CMPs) of up to $10,000 for each wrongful act. The statute defines “remuneration” to include,

without limitation, waivers of copayments and deductible amounts (or parts thereof) and transfers of items or services for free or for other than fair market

value.

Do You Own It Too? Stark Law

Imaging and Physical Therapy are DHS

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State and Federal Policy

•Not always specific guidance

•State policy usually superseded by Federal…maybe

•Opinions vs. written rules

•Set policy and procedure based on the best information you have

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What are you trying to say?

Compliance Programs must be properly installed and

operating within your office and must be constantly

monitored and updated, regardless of the size of your

practice.

Who’s Else is Watching?

I’ve Got My Eye On You

The Third Party Payer

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Payer’s Right to Monitor

In Black & White How to Look Up a Medical Policy

1. Determine 3rd party to look up

2. Are you in network directly or through a managed care entity?

3. Go to the 3rd party website and search for policy that fits the code or services best

4. If not available on website do an internet search for the service and the 3rd party Example: “Aetna Chiropractic Policy”

5. Contact provider relations of the 3rd

party if all else fails

Aetna’s Chiropractic Policy

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na’

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hir

op

ract

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olic

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Always Investigate First•When you add a new service, don’t assume it’s covered or billable

•Review third-party payor guidelines

•Ask state organizations-boards

• Item product manufacturers and related research

•Don’t rely on manufacturer’s coding recommendations

Important Facts to Know

•Determine which procedures you may perform that could be deemed experimental, unproven, or investigational

•Know what your board says

•Know what your carriers say

•Have proper informed consent

•Document, code, and bill these procedures correctly

What Are These Procedures?

Experimental, Investigational and Unproven procedures are defined as:

Use of technology, drug, device, treatment, or procedure that has not been recognized as having proven benefit in clinical medicine for any condition, illness, disease or injury being treated

Compliance with Rules is Critical

• Proper disclosure to patients• Can be harmful to

patient/provider reputation• Patients like to do their own

“research” and may not understand findings of “unproven” procedures

• Compliance with state guideline• Unproven procedures are often

reported to state boards for investigation by patients or patient family members

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Procedures Which are Unproven and Require Informed Consent

Obtain Informed ConsentExperimental/Investigational

•What to Include in Your Informed Consent?

•What language is required by your state?

•What is the definition of experimental, investigational and unproven procedures?

Let’s Take a Poll!Do you have current copies of the Medical Review Policies for All of the Payers you submit to?

Who’s Else is Watching?

Now Who?

Nebraska Chiropractic Board Just Some of the Board Rules

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Going to Use Your Staff?

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d A

no

the

r

Board

OIG

Board

HIPAA

Are You In Compliance or Not? Medicare?

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https://www.nebraska.gov/rules-and-regs/regsearch/Rules/Health_and_Human_Services_System/Title-172/Chapter-029.pdf

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1. Provider Must Be Enrolled….Period!

Medicare’s Statement Regarding Mandatory Enrollment for Chiropractors: • https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Downloads/bp102c15.pdfo The opt out law does not define

“physician” to include chiropractors; therefore, they may not opt out of Medicare and provide services under private contract. Physical therapists in independent practice and occupational therapists in independent practice cannot opt out because they are not within the opt out law’s definition of either a “physician” or “practitioner”.

• Tells story of who rendered the service• No substitutions for providers listed

employees• Each DC must register with Medicare

• Can cause enrolled physician to deactivate• Locum Tenens (Fee for Service Compensation

Hidden Dangers of Box 24J

Common Billing Errors

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https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

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Do Not Take This Lightly!

Or This! KMC’s “Either/Or” PrincipleEither covered service or statutorily excluded serviceEither Medicare responsible or patient responsible

Either active treatment or maintenance careEither mandatory ABN or voluntary ABN

Either E/M style or SOAP styleCMT is either AT or GA

AT vs. GA Modifier

•Has to be a Doctor Decision

•Needs to be clarified in the Assessment

•Patient needs to understand the difference

•Definitely Gray Areas

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Mandatory Submission

VoluntarySubmission

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Test Your KnowledgeWhat Modifier Do You Need? MN: Chiropractic Per CMS

Acute and Chronic Subluxation

The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.

The patient must have a subluxation of the spine as demonstrated by x-ray or physical examination (PART)

If above not met or exceeded = Not Medically Necessary! GET AN ABN!

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Analyze the ABN Forms for…

• Are all the “D” categories filled in properly?

• What fees are included on the ABN?

• Was the appropriate option selected with the appropriate outcome? Billing?

• Does it include services excluded by Medicare?

• New ABN Form Deadline Extended to 1/1/2021 (EXP 6/2023)•You will need two

• QMB Requirements

GA Modifier

Go look at YOUR ABNs…

You Must Decide!

• It is up to the office, not the patient, to determine whether the visit is medically necessary or not

• It’s a clinical decision

• It’s not a money decision

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Conduct Internal AuditsCMS Guidelines on Self-Auditing

CMS Rule Again!Conduct Regular Documentation Audits

Review EOBs Monthly

• Set “Random EOB Review” monthly

• Randomly select a handful of payments and EOBs from the prior month, or since the last time you reviewed them

• Review for patterns that could expose you to an audit

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Are You an Outlier?

• Improper documentation coding of full-spine treatment can cause you to look like an outlier

•Hence, subject to more scrutiny, red flags, and even an audit

Conduct Regular Coding Audits - CMT

Evaluation and Management-NP Evaluation and Management-Established Pt.Missing Money Anyone? 2-3X

368 NP Visits x 3 EP Re-exams=110499212 -$65.92

$65.92 x 1104 = $72,775.6899213 - $95.62

$95.62 x 1104 = $105,564.48

Modalities and Procedures

What Might Be the Trigger?

• Overutilization

• Unspecified codes

• Unusual errors

• Billing errors, like lack of Box 14 changing

• Patient complaints

• Your number came up

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CMT Codes

•There are 3 spinal CMT codes defining the number of regions treated:

• 98940: 1-2 regions• 98941: 3-4 regions• 98942: 5 regions

• 98943: Extremity – Billed 1x per visit

Philosophically Driven

•Whether you are subluxation-based chiropractor or simply believe that every patient requires a full-spine adjustment, you need clarity

•Proper documentation, coding and case management for these technique-specific and philosophically driven conundrums need to be defined by you for your office

Chiropractic Adjustments

• Look at your CMT coding ratios to evaluate code usage

• Is it realistic that your diagnosis warrants 98941 or 98942 so frequently?

• 98943

– Are you over or under utilizing?

– Are you doing but not billing?

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S P I N E

Clinically Appropriate – Dr. Thinking

57% 40% 3%

Primary vs Compensatory

Railroad Medicare – Comparative Billing Report

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Today’s Plan: What Not to Do!

• Documentation of an initial visit of an episode that looks like every other visit

• Initial visits of new episodes of care where the patient has no idea why they have pain... did you say “insidious onset”?

• Visits that are spaced at exactly a month apart, being billed as “AT” without proper justification-lack of case management

• Routine visit documentation that doesn’t reflect the presence of a subluxation in each region treated

Lack of Medical Necessity

-Incorrect Coding

-Insufficient Documentation

What Got Us Here Again? Today is About Solutions!

Medicare Likes to be Told a Story

• Medicare’s auditors do not want PART of the story… They want a complete non-fiction story!

• A good story includes: • Background (History)• A relatable/interesting character (Patient with a

medical problem that is examined)• Conflict to overcome (Functional deficit)• Over coming the conflict (Improvement of the

functional deficit)• Realistic events (Appropriate TX for the functional

deficit)• Character’s struggle (Effectiveness of Tx and Tx Plan)• Happy ending (Discharge from MN care)

Medicare & Other Payers Want to Help You Write Better

They have lots of resources to let chiropractors know what is expected in documentation:

• Records request checklists

• Article guidelines (Old LCD)

• Online Training Resources

• Provider representatives

• Medical Review Policies

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Why Do All Your Visits Look The Same One After

Another?

Episodes of Care

E/M vs. SOAP

Initial Visits Should Look Different From Routine

(SOAP) Visits

Medicare Documentation Guidelines

Initial Visit•History•Description of Present Illness -including functional deficit(s)•Proof of Subluxation• PART or X-ray

•Physical Exam (PART)•Assessment & Diagnosis • 1° Subluxation• 2nd Condition

•Treatment Plan•Date of initial treatment

Subsequent Visits•History

•Review of chief complaint

•Physical Exam (PART)

•Document daily treatment

•Progress related to treatment goals/plan (Assessment)

Initial Visit Requirements

• Establish necessity

• Establish goals

• Document subluxation

• Reveal contraindications

Source: CMS Benefit Policy Manual, Chapter 15, Section 240

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The Foundation of Medical Necessity is Found in the History

How Is It That Every One of Your Patient

Conditions is of Insidious Onset?

(Gradual)

History 101 Building a Strong Foundation•Thorough Intake Process•Train staff to look for missed entries in intake paperwork/online portal

•Outcome Assessment Tools•Write better treatment plans to prove treatment effectiveness•Have measurable and objective goals

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Start with Chief ComplaintWhy is the patient coming in to see you?

– It may be a somatic complaint from the patient

• (e.g., “headache” or “Low back pain”)

– It may be the purpose for the visit

Most forgotten part of history!Provider Didn’t Ask Enough

Questions

Not A Good One!

Provider Did a Better Job! – Real Time

Next… HPI, ROS, and PFSH= History

•Don’t think of this as “subjective”

•Patients tend to be poor historians

•First, be a good doctor as you inquire

•Clarify and quantify over and over

HPI Explains More - Often known as “OPQRST”

Timing • When did it start? A month ago, a year ago, a day ago?• Q: How longs has this been going on?

Provocation or Palliation• Modifying Factors (ibuprofen use decreases

symptoms) • Q: Does anything make it better? What makes it

worse? What provokes your pain?

Onset / Duration• Ground level information for the Chief Complaint

• Q: What were you doing when it started? When did the pain start?

Quality • Type of symptom – dull, sharp, tingling, etcetera • Q: Can you describe it to me? Is it sharp, dull, constant,

intermittent?

Region and Radiation• Location of symptom(s)• Q: Does the pain extend anywhere else?• Q: Where exactly does it hurt? Point to where it hurts the

most.

Severity • Scale of 1-10/10 or mild, moderate, severe• Q: On a scale of 1-10, ow much does it hurt?

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Past, Family, and Social History (PFSH)

• The PFSH consists of a review of three areas:–Past History

–Family History

–Social History

Past, Family and Social History (PFSH) – Real TimeBuilding a Strong Case

Next …Review of Systems (ROS) OR 99201

• Constitutional

• Cardiovascular

• Respiratory

• Gastrointestinal

• Genitourinary

• Integumentary (skin and/or breast)

• Musculoskeletal

• Neurological

• Psychiatric

• Endocrine

• Lymphatic

Update on Re-Exam

State Board/Payers May Require

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Review of Systems (ROS) – Real TimeDon’t Skip It – 99201 Territory The Exam (not The End)

Initial Examination – Part One

“What are you learning along

the way”

Initial Examination – Part Two

“Ah, DeepTendon Reflexes

and other findings being

normal rules out significant neuro

deficits”

“May be a good

candidate for active care

rehab!”

Initial Examination-Part Three

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P.A.R.T PART without X-Ray

•P – Pain (expand from subjective•A – Asymmetry (Subluxation)•R – Range of Motion Abnormality•T – Tone/Tonicity

Do I Need X-Rays? Initial Examination-X-Ray Report/Rationale

=A - Assessment

S - SUBJECTIVE• What you learned in the subjective

+O - OBJECTIVE

• What you learned in the objective

ASSESSMENT IN THE NOTE

• Often the most overlooked

section of the initial note

• More than just a diagnosis

• Doctors expect everyone know

what findings mean

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INITIAL ASSESSMENT

Tell the story well……

– Patient Reporting

– Measurements

– Complications

– Co-Morbidity Factors

– Any unusual circumstances

– Diagnosis

– Can include the treatment plan

…Paint the clearest pictureThe Collection Coach

INITIAL ASSESSMENT

• What Do You Know…?

– Interpret what you learned

– Don’t add new facts

– Give your professional

opinion

– Provide judgement

– Tell what you know…


ASSESSMENT IN THE NOTE





what findings mean

INITIAL ASSESSMENT

•What do you know?

•Why is it going on?

•What is making it worse?

•What is limiting recovery?


CCGPP PROGNOSTIC FACTORS

• Older age

• History of Prior Episodes

• Severity of initial episode of injury

• Number of exacerbations

• Duration of current episode longer than 1

month

• Psycho-social factors

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CCGPP PROGNOSTIC FACTORS

• Pre-existing pathology

• Nature of employment

• Waiting more than 7 days to seek

treatment

• Congenital anomalies

• Patient compliance


• Likely people with a high school education with little to no

medical knowledge

• Many auditors doesn’t know the significance of a positive

ortho or neuro test

• Don’t know the what the diagnosis means

• Depend on Assessment for plain English


?The Collection Coach

Say What?

Disclaimer: This is documentation reviewed at KMC University. This is ICD 9 Coding.

Using Co-Morbidities In Assessment

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Using Co-Morbidities In Assessment

Complicating Factor

Assessment Gets Lost in the Sauce ASSESSMENT IN THE NOTE





what findings mean

Diagnosis for Medicare Claims

• The primary diagnosis must be subluxation Subluxation M99.0x

• Supporting musculoskeletal diagnosis Causal from subluxations, such as disc degeneration

Next – The Plan

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History Exam Clinical Decision

MakingMeet the Requirements

• Date of the plan/initial treatment

• Frequency and duration

• Treatment goals for each region/treatment to include long term goal

• An evaluation of treatment effectiveness measurement

Sample Payer MRP Date of Initial Treatment

• Relates to beginning of this treatment episode

• First date provider evaluated patient

• Submitted in Box 14 on the CMS-1500 form

• Referred to in subsequent visit documentation

Frequency and Duration

• Indicate initial part of the treatment

• It’s ok to have an end game projection

• Don’t be so specific that you appear canned or boxed into a plan

• Each section should end with an evaluation

Treatment Goals

• Treatment goals need to be functionally based.

• What functions are we restoring with our treatment plan?

• How will we measure that corrective change?

• What goals are outlined for each type of treatment?

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Evaluate the Effectiveness—Measurably!

• OATS make it easy

• Pain is difficult to track and measure

Pain decrease as a goal

9/10 to 8/10 = goal met

• Use an accepted measure that you can document simply

• Improvement in function = success!!

Initial NDI-73% Disability Initial Low Back Disability Q – 68%

Part Three: Treatment Plan

Treatment Plan (Cont.)

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Mechanic AnalogyWould you want to have your car serviced by the mechanic who says to come into his garage 3x/wk until your car gets fixed?

• Would you want to know what he would do each visit?

• Would you trust that he knows what is wrong with your car?

• Would you question when he would be done with fixing your car?

• How would you know he is done?• Does he even care about your car?• Would you regret even going into his shop?

By not DETAILING your plan of care, you are telling your patient and their third party payer that you don’t really know what is wrong with them, you are unsure what to do to treat them, and you have no idea how long it will take to get them better

Terrible Treatment Plans• 3x /wk until the patient gets better

– What is better? How will you know when they are better?

– Why 3x /wk? For how long? – What are you treating and trying to get better?– What services will the patient get and why?

• Adjust 2-3x /wk for 4 wks then next phase of care– What is the next phase of care?– What are you treating? – Why 4 weeks?– ????Do you want to be treated by this Doctor?

Patient WASN’T Treated

• Patient was advised in using ice at home

• Instructed to return for treatment

• If the patient was treated TODAY then SOAP should be added below the TX plan!!

This Visit Must Include “P” of SOAP if you Treat the same day as Exam!

Treatment is different than treatment plan. On E/M visits where you are establishing a treatment plan, if you execute

treatment the same day, don’t forget to list it.

Make it Shine!

• Home care recommendations

• Prognostic factors

• Inclusion of all possible treatment and DME options

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Signature Guidelines

Subsequent Visits Medicare Said It…

Medicare Documentation Guidelines

ROS

Subsequent Visit Documentation

What is expected for subsequent visits:• History• Exam• Assessment• Treatment • Progress towards goal

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Medicare Said It…

Subsequent Visits Routine Visits: Rule 22 (Sample Colorado Rule)Read This: It isn’t Only There

Routine Visits-Rule 22 (Sample Colorado Rule)Continued

Review of Chief ComplaintWhat’s Changing?

•Step away from the OUCH forms…•Different Chief Complaint Each Day•Patient driving the bus

Most forgotten part of history!

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Subsequent Visit – Physical Exam

• Examine area(s) of spine– They want to see PART

– How has the PART changed due to treatment

• Presence or absence of subluxation (PART) – PART documentation on EVERY

visit!

Subsequent Visit -Treatment

• CMT– List spinal/vertebral areas adjusted that

are MN

– Include secondary areas of compensation that were treated

– Include technique

– Manual manipulation

– Can include handheld device with manual force

– How did patient handle the treatment

• Passive/Active therapies– Document what was done, why is was

done, and how if effected the patient

Subsequent Visit -Assessment

Documentation needs to show what the doctor is thinking:

• Treatment effectiveness

• Assessment of change since last visit

– How and Why

• What is the progress towards the functional goals?

Progress Toward Goals

• Can be unchanged

– For very short term

• Must be quantitative

• Function is the key

Documenting Ancillary ServicesVisit 2-First TX Visit

Number the Visit(s)

P.A.R.T


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Visit 3

Number the Visit(s)

P.A.R.T


Visit 4

Visit 5 Visit 9

The More Comprehensive Re-Evaluation

•Not necessarily required at 12 OVs• When we said “Per CCGPP guidelines” we told them we’d do this• Use data to prove treatment effectiveness• This is a break point in your patient’s documentation story•This is more of an E/M visit, than a SOAP visit

Re-evaluation Guidelines

According to CCGPP (Council on Chiropractic Guidelines and Practice Parameters, re-evaluations to determine your patient’s progress are required every 30 days.

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The 30-Day Rule-CMS

If a patient exhibits no change in the outcome assessment data for a maximum period of three consecutive re-examinations or 60 days, the patient should be considered for a clinical change in treatment. May include the following:

• Modifying treatment approach

• Co-treat with an allied health provider

• Referral for a second opinion

• Determine that the patient has reached maximum improvement

• The clinical decision as to which, change in treatment, path should be followed is dependent on the individual practitioner‘s profession integration of outcome assessment data

Why Re-evaluate?

To Assess Progress:

• Changes in condition(s)• New injury, decreased or increased symptoms,

new co-morbidities…

• Effectiveness of Tx• Did the treatment so far help? How much?

• What is needed to meet therapeutic goals?• Does the patient need more care? Why? How

much more?

Why Re-evaluate?

To Improve Patient Care:– A patient is more than their

diagnosis… they want to see progress from symptoms

– By seeing where they are in their healing, we can effectively change treatment to meet their needs

– Sets clinical, professional, and financial boundaries to care provided

Various Re-evaluations

• Periodic re-evaluation to determine if further care is necessary

• New condition, new injury, new accident

• Evaluations for considering discharge

• Non-treatment related E/M services

The Frequently "Missed” Re-Exam Component?

•You must update the history

•It’s a component of E/M

•If you don’t have the patient fill something out, do it verbally and document it

•EHR systems allow for this

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A Recent IME and AuditComponents of a Periodic Re-Evaluation

The re-exam should be scheduled on a specific date in the treatment plan. At the re-exam you should:

• Update the history; consider getting hand-written update from pt.• Re-examine all positives and significant negatives from the initial

examination• Patient completes new Outcome Assessment Questionnaires; score

them and compare scores with original• Assess the effectiveness of the previous course of treatment, in your

assessment portion of the note • Modify the diagnoses if appropriate and update a new treatment plan, if

needed

PART

Most Overlooked Component of Re-Eval?

• Assessment of the effectiveness of care

• Statements as to what’s next

• Does the patient need more care?

• Why does the patient need more care?

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?

Give Them an Update

Also a Treatment Visit!?

Transitional DX

Change of diagnosis to fit the patient’s current state

– If no longer right sciatica with LBP reduce the severity to what it is now

Time to Discharge

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When to Release from Active Care

• At scheduled re-evaluations review patient’s progress towards:

• ADL goals

• Functional goals

• Symptom free goals• If possible

• Within active treatment if the results warrant

• Reschedule evaluation earlier

– Per CCGPP: When the patient arrives at Final Plateau (maximum therapeutic benefit)

– Complete or partial resolution of the condition and all reasonable treatment and diagnostic studies have been provided

– Patient is unlikely to improve further

When to Release from Active Care

Therapeutic Withdrawal

Administrative Discharge

Final Discharge

Medically Necessary Care

Discharge from Active Care


Final/Administrative Discharge

Discharge Summary

Types of Therapeutic Withdrawal

• Gradual Withdrawal

– Where the patient’s care is tapered off

• Abrupt Withdrawal

– Patient instructed to return if the symptoms recur

– Patient is scheduled for an evaluation at a later date to determine if there is any regression

– Tends to be the typical MD approach

Times a Week # of Weeks

3 2

2 2

1 2

1 every other week 4

Total = 14 visits

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CCGPP (Clinical Compass)

• Therapeutic Withdrawal (TW) is included as proper case management

• Without Therapeutic Withdraw

• There is no way to determine the stability of the spine

• Determine if a patient require on going care


Maintenance – The patient is MAINTAINING THE CURRENT

STATE and not expected to improve.

Therapeutic Withdrawal– The doctor is not 100% convinced that the

patient will not relapse if active care is discontinued. WE’RE TESTING TO SEE IF STABILITY CAN BE MAINTAINED.

–(A short-term trial)

Order After Unsuccessful Therapeutic Withdrawal

Check with payer and don’t assume it is covered!

Medicare covers Chronic Care, but not open ended.

Visit 16-Begin Therapeutic Withdrawal

When to Release from Care

CCGPP Says– Arrive at Final Plateau

(maximum therapeutic benefit)

– Complete or partial resolution of the condition and all reasonable treatment and diagnostic studies have been provided

– Patient is unlikely to improve further

Clinical Discharge

• Releasing from Medically Necessary Care

– The patient doesn’t need treatment to improve function anymore

– Release them so they can fly on their own

– Be the place they can maintain safety

– Discharge puts a “pin” in this active episode

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Discharge Summary• Include:

– Conditions treated

– Initial treatment date

– Date of discharge

– # of Visits

– Services provided

– DME/orthotics RX’ed

– Recap initial exam findings

– Recap radiology and/or lab testing

– Status of patient at discharge

– Your assessment of patient’s treatment

– Recommendation for future care

Final Visit-Discharge! Final Discharge Checklist

❑ You’ve finished a course(s) of treatment

❑ The patient has met or not likely to move closer to reaching goals

❑ You have effectively attempted therapeutic withdrawal or written down why it is not indicated

❑ The patient has been given educational and self management tools about their condition

❑Written discharge is placed in chart

Take Time To Properly Train All Team Members

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know the messenger, history and basics: compliance rules

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