Again, first bullet, “The reviewer noted a high level of care beyond that required by the patients’ diagnoses.” Bullet number two, “Medical necessity of the frequency and duration of care was not substantiated in the records.” Bullet number three, “The daily documentation was vague without relevant medical data.” In other words, we've got to make sure that everything we have documented has a reason, okay? What do we do when you get the request? Review your file. The first aspect of the review from the insurance company is they're going to review that the services that are billed were actually provided. They're not really going to look at medical necessity initially. They're really just going to look to say if you billed four services, were the four services provided? Were they documented? Medical necessity will certainly be reviewed but that's really going to be the second aspect. Let's go through this patient. When a patient comes in what's the first thing we're going to do as an evaluation and management? That's what they're definitely going to look at. Is the level of examination properly documented? I hope that most of you are familiar with the 1997 evaluation and management guidelines. This gives a very good reference on how to choose the proper level of an E&M code. What you would do here is that you will be able to look and know that based on those guidelines it requires to bill a 99203 12 bullets. 12 bullets just means 12 elements of examination, but that way if you are ever denied for an exam and told your exam was too high you could certainly go right back to these guidelines and so long as you meet those bullets you would meet for the exam. The other aspect here, and this is the third bullet, it says, “Do the re- exams demonstrate a significantly separately identifiable service above and beyond the evaluation associated with CMT?” The one thing chiropractors have to be acutely aware of is that an examination is not billable on each visit. The chiropractic manipulation code includes a very small but significant level of evaluation to determine that day's treatment. It is not appropriate to bill an exam each day unless there's some significant factor that caused it. For instance, the patient comes in on a Monday. They have headaches and neck pain. You treat that but then on Friday the patient discusses with you or has questions about, “I have a low-back problem,” and you examine that. That would be appropriate because the exam you did on visit one would be for the neck. The exam on Friday would be for the
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