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Good afternoon, everybody. My name is Michael Miscoe with Miscoe health law, and welcome to this week’s, uh, uh, growth without risk presentation, sponsored by ChiroSecure. Um, this week we’re going to talk about, uh, something, uh, look back through the archives we haven’t talked about in a while. Um, and, and I thought it was worthy of bringing back up because I see this issue come up, uh, in some of the post-payment work I’ve been doing recently, and this is, you know, a medical necessity issue, um, that plagues chiropractors, because you tend to have patients, um, who don’t come, they’re treated, they go away and you never see them again. They tend to come back, um, with either new problems or more specifically recurrences of old problems. And, and once a doc, you know, develops, um, a familiarity with a patient and there’s a recurrent symptoms of, of a similar nature, uh, the tendency is, uh, when the patient comes back to just pick up where you left off as if there wasn’t a two month break in care or whatever the break in care was, uh, and, and, uh, you forget your obligations to reinitiate a new course of care.
And what that leads to is determinations that, um, the treatment for the patient is not medically necessary. It’s maintenance care, it’s palliative care. Uh, and sometimes the visit schedule can, can help support that conclusion. So when there’s an interruption in care, for whatever reason, and I’ve seen in the records where docs had been very forthright, you know, the patient’s going on vacation, uh, for a couple of weeks. And so that’s going to interfere with the treatment schedule, um, or they’re, you know, going south for the winter. It’s that time of year. So if you’re in the north, um, you have your, your snowbird patient’s head and spouse. If you’re in the south, you have your snowbird patients showing up out of the blue and you haven’t seen them, uh, for five or six months, uh, and they’re potentially going to resume chiropractic care. And, and you need to be cautious that, um, in, in terms of just doing a same as last treatment, you know, magic button, soap note, uh, and, and pretending like there wasn’t a break in care.
So when these people come back, there’s a couple of things that you need to do. Um, if you look at the documentation guidelines for evaluation management services, you’ll note that a history is supposed to track the patient’s status since, uh, the last encounter. Now, the last encounter might’ve been two days ago, or it might’ve been six months ago. Um, and when that occurs, especially when there’s a substantive break in care, for whatever reason, you need to start off and start the visit note, not today, the patient enters complaining of since the last encounter. Here’s what happened. Okay. Now let’s take the patient that, um, you know, went on vacation, couple superficial problems in the medical necessity argument. They go on vacation, they come back and nothing happened. Um, that’s bad for your medical necessity argument because patient was able to survive without care for a period of weeks, maybe months, um, and nothing happened.
And they just happened to be in the neighborhood and stopped by to use the bathroom. And, you know, Hey, come on back here and let’s, let’s get you adjusted. Um, and that’s the way it looks like to the carrier, uh, when you don’t properly start your note based upon what happened since, um, uh, the, the last encounter. So since the last encounter, the patient did well, blah, blah, blah, blah, blah. However, you know, as a result of these activities or this mechanism, the patient began to notice, blah, blah, blah. And, and it leads you up to their presentation today. You got to close that gap and you have to demonstrate that something happened that led to a worsening, thereby prompting the return. If you’re going to have any prayer of establishing, um, this re uh, restart of the care as being medically necessary. So make sure you do that.
Interval history, do a comparative outcome assessment. Okay. So if you’re using outcome assessment, which I recommend, you know, and you did one, uh, upon their departure, hopefully, um, uh, before you do a new one, you do comparative analysis to demonstrate that in fact their functional status has changed negatively, thereby warranting a return to care. And if you don’t want to do that, you can bring a patient back and you’re treat them on a cash patient said fine, but we’re talking about, you know, submitting a claim to insurance for care that you’re going to argue is, is medically necessary under their standards. And in order to do that, you have to substantiate the why they’re coming back. And it’s got to be, Hey, I’m back from vacation. Hey, um, you know, uh, um, um, back for the winter, uh, because of the, it started snowing, uh, up north, that is not a reason from an insurance carrier perspective for you to be providing treatment to a patient okay.
On the exam. Um, so on the history track there, their historical projection or progression since the last encounter use outcome assessment, uh, don’t forget the mechanism. And the patient says, well, I don’t know what happened, come up with something. I mean, something happened, they did something, uh, it may have had a latent effect. Um, but you know, the, um, you know, an absence of a mechanism really makes it difficult for the payer to, uh, conclude that there was a significant health problem that required medically necessary treatment. Then on the exam, again, I know you want to just hit that magic button and get through the note a very big mistake because you’re starting a new course of care, which means you need to reestablish the diagnosis. Uh, probably make a statement, you know, is this, uh, a chronic condition that is acutely worsened, uh, especially in the ENM medical decision-making analysis, you need to classify what conditions a patient has, uh, what their status is relation to the last encounter and the mechanism.
I mean, glue all that argument together, um, as a basis, uh, for why you’re going to treat this patient, especially in terms of what you expect to accomplish with the care. So, uh, I’m not as concerned about you detailing all the examination methods you’ve performed because you do have a history with this patient, but if there is a recurrence of the prior problem, it, you know, it depends on whether you want to build the ENM or not. Uh, these days under the 2021 guidance, the, the exam detail isn’t that important, but you can say examination revealed a recurrence of these problems, then establish their status as, as an acute flare up, um, you know, complicated, uncomplicated, uh, mild, moderate, severe, you know, whatever, uh, for purposes of your medical decision making, scoring, uh, for the ENM. But then also based upon this recurrence of the problem, you have to establish a course of care.
You know, that I’m going to see the patient three times a week for two to four weeks, um, establish your treatment order. What treatment are you going to provide? Uh, and, and with some degree of detail, because when the detail is lacking, you know, in terms of how you’re going to do stem, what kind of stem, what kind of traction, uh, which exercises, that sort of stuff, um, payers almost unilaterally, whether they have requirements for that detail or not, um, you know, tend to deny and post-payment review. So you can solve those problems by drafting a treatment order almost as if you were going to describe for somebody else how to do the care, um, frequency and revised duration, or, um, and then what, uh, objective goals. I mean, what conditions are you trying to either significantly approve a resolve and, and a technique that I like is if you rate the severity of the condition on presentation, then you can identify what severity scale you want to get that condition to, uh, to substantiate, uh, uh, discharged from care and then, you know, indicate what your discharge date is.
And, and then you have a plan to work from, uh, for that course of treatment. Following that, of course, you know, I don’t care so much about, uh, the detail of the history and the exam. What I care about is what’s going on with the problems that you’re trying to resolve with treatment, um, and, and what impact the care is actually having relative to those problems. And there’s a, uh, um, you know, a way to document that stuff, uh, uh, did a somewhat detailed, and it makes doing medically necessary care somewhat, uh, less cost-effective than you might think because of the documentation burden. But the key is, is to have any chance of bringing this patient back, you know, a couple things, if it’s a one and done, or two and done, uh, probably not worth the documentation effort. And even if it was, you run the risk of the carrier, calling it episodic or palliative care within the rubric of maintenance care and therefore denying coverage, even if you’re going to launch back into a deliberate course of care, um, don’t forget the, you got to address the issue of why the patient needed to come back.
If they went on vacation and it came back and they, they were fine without care. They don’t need to come back. I mean, except maybe for, you know, uh, non-covered care. So the key is in that interval history, you know, document that progression as to, you know, and I realize it’s pain in the neck and you don’t like it, but, uh, if you want to win these medical necessity arguments, you gotta do it. Um, because we don’t have a prayer of convincing the payer that the patient needed to come back without explaining the why of that need. And the, and the way that we do that is start your S your, your history note or your subjective note, as of the last visit and document their progression. Don’t forget the mechanism. And then here they are. And if you can buttress that with a outcome assessment form, um, that demonstrates at least from that scoring basis, a, um, uh, diminished, functional status as a result of this mechanism and progression, then you’ve at least set the case up, uh, you know, for the payer understanding, yes, this is, you know, an exacerbation of a chronic problem, or maybe it’s even a new problem.
Uh, in which case you’re gonna, it’s a little bit more complicated on the exam side. You can’t just regurgitate the old problems and state their status. You’re going to have to, you know, show your exam work to substantiate the new, the new conditions, uh, as well. So, um, hopefully that is a, you know, let’s see we did that in 10 minutes. Um, normally that’d be a 90 minute documentation lecture, but we don’t have that kind of time, unfortunately. Um, but just trying to get you sensitized to the fact that when you have a break in care, uh, the note for the PA the visit coming back has to be a little bit more robust in explaining what happened in between and why they needed to come back and why you get to restart a new course of care. If you do that, you got a much better chance of, of even if there’s some, you know, uh, they don’t like your goals or whatever it is, at least you’ve established the need for care, uh, such that the payer doesn’t feel like they’ve been billed for care. That’s just routine palliative, preventive supportive, or maintenance care. So hopefully that is helpful to you next week. Don’t forget to tune in to Dr. Sherry McAllister. That’s all we have time for today. And until next time have a great day.