Samuel A. Collins
Q: I am having trouble understanding how often I can bill for a re-examination. I understand that I cannot bill an examination or E&M service on each visit, but are their rules for when it is appropriate? I have heard everything from once a week to four weeks. I want to be sure I am within the accepted time frame.
A: As you stated, a re-evaluation or re-examination cannot be billed on each visit. The chiropractic manipulation code has, as part of its overall service, pre-service, intra-service and post-service evaluations. In other words, there is a little exam built into the manipulation code. This is the reason that an examination, when billed with treatment, must have modifier 25 to designate that the exam is above and beyond the one associated with the manipulation service.
The pre-service work includes a review of the history, response to prior care, discussion of new/resolved subjective findings, clinical objective findings and diagnostic interpretation. The intra-servicework includes assessment of the current condition, coordinating/modifying the treatment plan, evaluation of new complaints, patient preparation and instruction for the procedure, assessment of need for additional areas or reapplication of procedure and post-adjustment instruction. The post-service work includes medical chart documentation, modification of the treatment plan, an update of any diagnostic impressions, and communication and referrals.
To directly answer the question of when a re-exam should be done, there is no specific rule that states a hard and fast time. Consider these factors:
- There is a definite measurable change in the patient's condition that requires a significant change in the treatment plan.
- The patient fails to respond to treatment, which requires a change in the treatment plan.
- The patient's condition reaches maximum therapeutic benefit and is ready for discharge.
- The patient reports new and significant complaints. This requires a level of history and exam above and beyond that associated with the manipulation service.
- The patient has a new injury or exacerbation and re-injury.
Based on these five tenets, a time for re-exam can be extrapolated that would fit most claims. The generally accepted time needed for chiropractic services to demonstrate improvement is about 30 days, per the American College of Occupation and Environmental Medicine Occupational Medicine Practice Guidelines, Official Disability Guidelines and the Mercy Guidelines. Therefore, in absence of new complaints or flare-ups, a re-exam is done approximately 30 days after the initial exam.
If the re-exam is within less than 30 days, there should be evidence in the file supporting that the patient:
- has a flare-up or exacerbation;
- has a new injury or significant added complaints;
- has a positive response to care that dictates a change in the care plan to more active-based care or, at minimum, some significant change in treatment plan; or
- the patient is ready for release.
The specific length of time for re-examination is not set by a hard and fast rule for a number of days. However, it is most commonly about 30 days from the previous examination. In any case, there must be documented rationale for the exam in the file. If these guides are used to demonstrate the necessity of the service, there would be no issue with the time being shorter or longer, as the specific necessity would be documented.
