Evaluation and management rules regarding documentation of a patient's chief complaint(s) indicate the chief complaint(s) should "usually" be stated in the patient's own words.1 The term usually is employed here because there are times patients cannot communicate sufficiently enough to convey their complaints.
In my experience, however, carriers often take "usually" to mean "always." There is an ulterior motive, of course: their intention is to screen for services and costs related to conditions patients did not express as a concern.
The carriers' motives are justifiable to a degree, but the policy relies on the assumption patients are always able to give an accurate accounting of their chief complaints. Patients are often poor historians. A patient may refer to the SI joint as the hip, or identify an area of referred or radiating pain as the source of their problem.
Additionally, from a provider point of view, care of one spinal region is often necessary to assist in the resolution of problems in other spinal regions. A patient may report lower back pain, but lumbar dysfunctions may not respond well without addressing co-existing pelvic problems.
Requiring chief complaints to be in the patient's own words can be taken a step further. Carriers also prefer chief complaints in the patient's own handwriting. The same exceptions apply here; some patients simply cannot comply.
Excluding the exceptions discussed, the solution to the situations described above has always been to provide a space on initial forms for the patient to write in their chief complaint(s). With the mandate of EMR in recent years, this solution still works if entrance forms are completed by the patient and later scanned into the EMR system. This solution is lost, however, if the provider / facility is paperless.
I think we will eventually be (if we aren't already) at the point that patients can write complaints in their own words on a tablet or kiosk.
An Unintended Consequence
You might be reading this and thinking, This isn't a big deal. Point taken. However, despite this being a small detail in documentation and the coding of evaluation and management procedures, it has another effect – an effect I call the "Oh, while you're at it" phenomenon.
The phenomenon occurs in most practices. One typical scenario is a patient being treated solely for a lower back complaint asking during a visit, "Oh, while you're at it, can you adjust my neck?" (Usually they say "pop" or "crack" instead of "adjust.")
In many cases, when the question is asked, there isn't a record of the patient's additional complaint in his/her own words and handwriting, nor are there history or examination findings documented for the complaint. If these items are present, they are often outdated.
I have discussed the phenomenon with other doctors over the years and sadly, the majority say they would comply with the patient's request without additional evaluation and management. Some of the doctors said they would record that the adjustment occurred; other doctors said they would not make record of it.
When "Oh, While You're at It"Becomes a Sticky Situation
For Medicare, the patient has to list each region of complaint and the doctor has to perform an HPI individually for each region or an HPI that incorporates the regions as a group. The doctor must also examine each region for PART findings to establish subluxation diagnoses and subluxation-related symptom diagnoses for each spinal region. These procedures are required prior to initiating adjustments. (Table 1)
| TABLE 1: HISTORY OF THE PRESENT ILLNESS (HPI) AND PART DOCUMENTATION Components of the History of the Present Illness (per region of complaint) Location Quality Severity Duration Timing Context Modifying factors Associated signs and symptoms PART Examination for Medicare (per segment adjusted) Pain Asymmetry Range of motion Tissue tone |
Obviously without direct injury to a region or substantial information establishing a link to another region, the "Oh, while you're at it" request should not be granted for worker's compensation or personal-injury patients. This is especially true if the additional regions are treated and represented in the billing codes, but not in the clinical documentation. This could be considered misuse, if not fraud.
When the "Oh, while you're at it" request is denied, it can be difficult for the patient to understand. Patients do not want to complete additional paperwork or be examined again to establish records for something that to them, should just take a few seconds. It is even worse if the patient is accustomed to full-spine care and treatment is suddenly limited to a particular region.
It's important to provide a full explanation to patients in these situations. Care should not be withheld if it is truly necessary, but the patient has to understand there will be stipulations out of the doctor's control. For Medicare, you must explain the consequences of filing for care that is undocumented, and the difference between covered and non-covered services. The ABN form should be used.
Personal-injury and worker's compensation cases do not employ ABN forms, but the same situation is true. It is the patient's realization that he/she may incur additional cost that usually drives the point home. If the patient attempts to persuade you to ignore the rules, you should reconsider continuing to provide care for the patient.
Editor's Note: This is the first in a series by Dr. Miller based on his book, Chiropractic Medicare Documentation Self-Inventory.
Reference
- E/M Coding Made Easy! 4th Edition. Los Angeles: PMIC, 2006.
Click here for more information about K. Jeffrey Miller, DC, MBA.