Re-evaluations, Are We There Yet?

One of the most common questions we get is whether regular re-evaluations are “required” for justifying ongoing, medically necessary care.

Some say, “I heard that Medicare requires a re-evaluation every 30 days. Others have “heard” that their Blue Cross/Blue Shield payer requires them but doesn’t pay for them. There is a bit of “urban chiropractic legend” built into a smattering of facts, but it’s important to know the details and parameters.

According to the Clinical Compass, neck and lower back pain guidelines, also known as CCGPP (Council on Chiropractic Guidelines and Practice Parameters), re-evaluations to determine a patient’s progress are required every 30 days. Likewise, if one is using Outcomes Assessment Tools (OATs) like the Oswestry or Functional Rating Index, they should be repeated every 30 days. From an auditor’s perspective, continued care beyond 30 days without a re-evaluation is considered medically unnecessary and will be denied.

What is Actually Required?

All of this has led to confusion about what is actually required. It is correct that OATs should be repeated and scored every 30 days and then used as one of the factors in the projection of additional needed care. There is no specific guideline in Medicare, for example, that says you will not be paid for any services beyond the 30-day mark in a treatment plan if there hasn’t been a formal re-evaluation. The context of the Chiropractic Manipulative Treatment (CMT) code that is charged on each routine visit includes a component of evaluation. Therefore, every visit should record progress toward the stated goals, and include subjective comments and objective measurements as part of the documentation. It’s up to the provider to ensure that the necessary documentation exists in the patient’s health record to tell the “story” of that patient’s active treatment plan. This is true whether there is a formal re-evaluation or not.

Benefits of Re-Evaluation

Timely use of the re-evaluation process is critical, however. There are many benefits to a formal re-evaluation process. Keep in mind a re-evaluation is coded with an Evaluation and Management code. That means it includes performing a re-history as well as a re-examination and reassessment of clinical decision making. Be sure you have a way to collect this updated history quickly and easily.

Some chiropractors elect to use the re-evaluation process as an educational opportunity. Some have a team member perform a pre-evaluation, gathering important data for the doctor to quantify in the re-exam. Others use the post-re-evaluation opportunity to deliver a re-report of findings to affirm the patient’s progress and what remains to reach maximum improvement.

Besides the compliance issue and patient education opportunity, periodic re-evaluations affirm each patient’s decision to consult your practice, inspiring them to complete your full recommendations and get the most from their chiropractic care.

If your re-evaluation process needs a tune-up, consider writing down your process, using this helpful outline to provide step-by-step guidance from scheduling through execution.

Be sure to include any additional steps of re-evaluation that are a part of your process. Once this Standard Operating Procedure (SOP) for re-evaluations is complete, train all the team members involved to make sure this important compliance process is implemented.

Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and enjoyed practicing for over 20 years. Her interest in Medical Compliance began when she earned the 100-hour Insurance Consultant/Peer Review certification from Logan University in 2015. She has been a certified Medical Compliance Specialist-Physician since 2016 and a Certified Professional Medical Auditor since 2022. Dr. Auchenbach joined the excellent team at KMC University as a Specialist in 2020, and as a part of this dedicated team is determined to bring you accurate, current, and reliable information. You may reach her by email at info@kmcuniversity.com or by calling (855) 832-6562.