Documentation & Coding Archives

CMT and E/M Reimbursement Solutions Coding Policy

CMT and E/M Reimbursement Solutions Coding Policy from ACA The American Chiropractic Association (ACA) is the profession’s coding authority; payers often seek guidance from them on coding matters. One of the most common questions plaguing our profession is related to the use of Chiropractic Manipulative Treatment (CMT) codes with Evaluation and Management (E/M) Services on…

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They Don’t Pay It, So Why Should I Do It?

This HelpDesk Video walks you through the concept of providing a chiropractic manipulation and an evaluation and management service for an established patient on the same day. This is not always necessary, but when it is appropriate due to normal periodic check ins on patient progress or because of a new complaint, the provider needs…

Documenting the Periodic Re-Evaluation Process

Items to Include in Re-Evaluations Formal re-evaluations after 2-4 weeks of treatment should include the following: Subjective Progress (e.g., reduction in pain, compliance) Objective Progress (e.g., structural exam, notation of lesions, ROM, functional improvement) Progress toward treatment goals Additional treatment required to reach treatment goals Discharge plans and date, if appropriate Required Elements History History…

The Patient Progress Interview

Proper Use of the Patient Progress Interview One of the most important aspects of the periodic re-evaluation is helping patients see the progress they’ve made with their function and pain relief. It’s an opportunity to not only collect the history as required for the E/M service, but also to point patients toward the improvements they’ve…

Know When a Re-Evaluation is Necessary

Re-evaluation Frequency The purpose of formal re-evaluation during an episode of care is to document changes to that point and to determine whether more active treatment is necessary. The frequency of these re-evaluations is at the doctor’s discretion and can vary based on the patient’s condition. The format of these visits follows the Evaluation and Management…

Established Patient Evaluation: Why, When, What and How?

We hear it all the time…” Why would I do a periodic re-eval? The insurance company doesn’t cover it!” Notwithstanding the error of that statement, whether or not something was paid by a payer is not a good reason to avoid a necessary element of documentation. There are several types of re-evaluations. During an active…