The Relationship Between Box 14 and Medical Necessity

A provider of service communicates important information about a patient’s episode of care by placing important information in Box 14 of the 1500 billing form. The date that is placed in this important field on the billing form communicates the first date of the current episode of care. This brief training will outline it’s importance in compliant billing.

Proper Patient Case Management

The Case Management Picture

Case management has its roots in the patient’s clinical presentation and the doctor’s training and expertise. Doctors have a fiduciary responsibility to evaluate patients and determine the whole clinical picture to the best of their ability.

The patient evaluation process is quite linear. The doctor begins by gathering the patient’s history and documenting the chief complaint and then s/he follows the patient’s lead. The rest of the journey might look something like the following. The doctor must follow the steps illustrated on the right.

    1. Initial data is gathered via patient paperwork that details his/her previous medical history, or through a short interview conducted by a team member. Ideally, the doctor reviews this data before meeting with the patient for the first time to get a sense of the direction s/he wants to take during the patient interview process.
    2. Once the history is established, the doctor follows-up with a more in-depth consultation, asking general health questions, conducting a review of systems, and completing a thorough evaluation of the chief complaint including Onset, Provocation/Palliation, Quality, Region/Radiation,  Severity, and Time.
    3. After the doctor has completed the history and consultation, s/he begins to formulate a differential diagnosis. Now, these impressions and the history must drive the examination choices. Based on the doctor’s conclusions about the patient’s condition, s/he selects proactive orthopedic and neurological tests to prove or disprove those theories.
    4. When all of the facts about the patient’s physical findings are gathered, the doctor must determine whether there is enough evidence for a conclusive decision about a diagnosis, or if further diagnostic tests are necessary.
    5. The definition of the problem (or the diagnosis of the condition/subluxation) is defined.
    6. A written treatment plan/solution to the defined condition is established.

The treatment plan should include details of the doctor’s recommendations including tissue-specific solutions for the patient’s presenting problem. It is especially important to define the functional deficits that will be addressed through this treatment plan and the functional goals that are targeted in order to achieve a specific result from this treatment when a third-party payer is involved.

The doctor should present the patient with a verbal report of his/her:

    • Findings
    • Recommendations
    • Expected outcomes from the treatment plan
    • Any other options the patient may have (including taking no action at all)

The doctor should inform the patient of the probable outcomes for each of those options so s/he can make an informed decision about how to proceed. The discussion should include information about the patient’s financial responsibility, such as:

    • Billing third-party payers when appropriate
    • Legal means for assistance with payment plans
    • Indigence policies
    • Professional courtesy policies

The intention is to be sure that the patient is clear about the recommendations and to support the patient as you move forward with the recommended care. Remember, the patient always has the right to refuse treatment. If you do a good job of explaining your recommendations, any alternatives, and the potential outcomes for those alternatives including taking no action at all, your patient will feel confident making the decision to proceed.

Usually, patients choose the doctor’s best recommendation. Once the patient has agreed to proceed with a course of care, the doctor is responsible for helping the patient successfully complete that care. Patients that follow through with the recommendations nearly always recover and stay well, and that is the most satisfying part of practice!

Medicare Decision Making Matrix

Download Support Tool

This tool is one of the most useful and important tools in the KMC University Curriculum. Although designed for Medicare using Medicare terminology, the flowcharts apply to any type of third-party insured patient.

An important question is posed as a patient presents to the office: “Is this patient currently in an active episode of care?” If yes, the path is quite simple. If not, follow along the middle and right side of the matrix and note the additional decision-making that is necessary here.

While this tool is not meant to be absolute, it guides providers in the questions to consider when determining whether a visit will be deemed medically necessary or not. Download and review it and save it to your Medicare training materials. You may also wish to laminate a copy or place one in a sheet protector for easy reference.

The KMC University Medicare Decision Making Matrix

Active vs. Maintenance in Medicare

Recognize the Differences Between Active and Maintenance Care

One of the most difficult concepts for providers to grasp is the fine line that exists between the necessity of active treatment and when the care would be deemed maintenance. This distinction is critically important because declaring a visit to be medically necessary, therefore billable to and payable by Medicare, has compliance implications. At KMC University, we believe that this concept…knowing this difference, is one of the most important pieces of business knowledge that providers and team members can know. It’s the difference between risk and safety. This graphic image highlights several important facts that distinguish active care from maintenance care.

Medical Necessity vs. Clinical Appropriateness

Clinically appropriate care is that recommended treatment that is within the doctor’s scope of practice and appropriate for the patient but may not meet the medical necessity guidelines of a third-party payer. Patients have every right to receive this type of care, but both provider and patient must be aware that it is likely paid by the patient. Medically necessary care is both clinically appropriate and in line with the definitions set forth by the payer. A keen understanding of these differences between these two is one of the most important tenets of healthcare compliance. This brief training outlines the differences and starts you on your way to a better understanding of these two important definitions.

Medicare’s Definition of Medical Necessity

Every payer has a definition of medical necessity and Medicare is no exception. Medicare Administrative Contractors (MACs) release a Local Coverage Determination (LCD) where they provide healthcare providers of all specialties their rules and definitions so they can determine if the care they are providing to their patients is payable. The following definitions pertaining to Chiropractic care come directly from Medicare:

Term Definition
Medical Necessity 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 while providing a reasonable expectation of recovery or improvement of function
Acute Care When the patient is being treated for a new injury identified by X-ray or physical exam as specified above. The chiropractic manipulation is expected to result in an improvement in, or arrest the progression of, the patient’s condition
Chronic When the patient’s condition is not expected to significantly improve or be resolved with further treatment, but the continued therapy is expected to result in some functional improvement. Once the clinical status is stable for a given condition, and no additional objective clinical improvements are expected, further manipulative treatment is considered maintenance therapy and is not covered.
Maintenance A treatment plan that seeks to prevent disease, promotes health, and prolongs and enhances the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement is not expected from continuous, ongoing care, and the chiropractic treatment is supportive rather than corrective in nature, the treatment is considered maintenance therapy. Chiropractic maintenance therapy is not considered medically reasonable or necessary under the Medicare program and is not payable.
Acute Exacerbation A temporary, but marked deterioration of a patient’s condition that is causing significant interference with activities of daily living due to an acute flare-up of a previously treated condition. The patient’s clinical record must specify the date of occurrence, nature of the onset, or other pertinent factors that support the medical necessity for treatment. As with an acute injury, treatment should result in an improvement of or an arrest of the deterioration in a reasonable period of time.
Chronic Exacerbation Represents an acute change that is a marked deterioration of the patient’s condition and that is causing significant interference with activities of daily living. “Active treatment” can only occur as long as the patient is achieving significant clinical improvement.