Practical Tips Regarding Exam Codes
If you are billing exam codes to PIP insurance then here are some practical tips to avoid getting sued by an insurance company.
Please take note that the requirements for examination codes have been changed since the pandemic started. They were simplified to reduce the risk of an audit. You should familiarize yourself with the new guidelines.
1. Stay away from level 4 or 5 exam codes.
(a) Patient history;
(b) Symptomatology and/or wellness care;
(c) Examination finding(s), including X-rays when medically or clinically indicated;
(d) Diagnosis;
(e) Prognosis;
(f) Assessment(s);
(g) Treatment plan; and,
(h) Treatment(s) provided.
5. Make sure you list the pain scale for each body part! A general pain scale does nothing to track a patient’s improvement. Saying someone has a pain at an 8 over their whole body is not as good as saying “neck 6/low back 10/right shoulder 5.” This would be particularly helpful in a personal injury case.
For instance, I had a client who initially complained about a level 6 in the neck, level 8 in the low back, and a level 10 in the shoulder. After one month the patient had an MRI o the neck and low back. Presumably, the referring doctor didn’t want to send for a shoulder MRI because it was going to use up all the PIP. After two months, the patient complained about a level 4 in the neck, level 6 in the low back, and a level 10 in the shoulder. The insurance company didn’t want to pay for the shoulder injury because the MRI of the shoulder wasn’t done until 110 days. The client had a shoulder surgery and they still claimed the shoulder injury wasn’t related because the MRI wasn’t done right away. Because the chiropractor documented the pain scale for each body part I was able to show in court that the shoulder started at a 10 and stayed at a 10 after two months of therapy, making surgery a viable option and relating the shoulder pain to the accident.
6. Make sure you document x-ray findings.
If you perform x-rays in your office then make sure you document the findings. Something as simple as “no fractures” is sufficient. I can’t tell you how many times doctors will bill for x-rays but not have any written findings. Just like you send your patients to an independent imaging center for x-rays and get a report back, you should have a written report of findings in your file.