Q: I am having trouble understanding how often I can bill for a re-examination. I do understand that I cannot bill an examination or E&M service on each visit, but are there rules for when it is appropriate? I have heard everything from once a week to four weeks, and I wish to be sure I am within the accepted time frame.
A: A re-evaluation or re-examination, as you stated, cannot be billed on each visit, as the acupuncture codes have, as part of their overall service, a portion that is considered pre-service, intra-service and post-service evaluation. In other words, there is a little exam built into the acupuncture treatment. This is the reason that an examination, when billed with the treatment, must have modifier -25 to designate the exam is above and beyond the one associated with the manipulation service.
The pre-service portion involves a review of history, response to prior care, discussion of new/resolved subjective findings, clinical objective findings and diagnostic interpretation.
The intra-service portion includes assessment of the current condition, coordinating/modifying treatment plan, evaluation of new complaints, patient preparation and instruction for the procedure, assessment of the need for additional areas or re-application of the procedure and post-adjustment instruction.
Post-service work includes medical chart documentation, modification of the treatment plan, updating diagnostic impressions, communication and referrals.
To directly answer the question of when a re-exam is to 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 treatment plan.
The patient fails to respond to the treatment, which requires a change in the treatment plan.
The patient's condition reaches maximum therapeutic benefit and the patient is ready for discharge.
The patient reports new and significant complaints, which requires a level of history and exam above and beyond the exam associated with the manipulation service.
The patient has a new injury or an 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 other acupuncture guidelines. Therefore, in the absence of any new complaints or flare-ups, a re-exam is done approximately 30 days after the initial exam.
If the re-exam is done less than 30 days after the initial exam, 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, which dictates a change in the care plan to a more active-based care or, at minimum, some significant change in the treatment plan; or
is ready for release.
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, whether at 30 days or any time sooner or later, there must be documented rationale for the exam in the file. If the above guides are used to demonstrate the necessity of the service, there would be no issue with the time being shorter or longer, since the specific necessity would be documented.
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