Patient Management and Documentation in a Post-COVID World ...

© All Right Reserved. Copyright Mario Fucinari DC www.AskMario.com 1

Patient Management and Documentation in a Post-COVID World

With Mario Fucinari DC, CIC, CPPM, CPCO

Sponsored by ChiroHealthUSA

Disclaimer: The views and opinions expressed in this presentation are solely those of the author.

Mario Fucinari DC does not set practice standards. We offer this only to educate and inform. The

laws, rules, and regulations regarding the establishment and operation of a healthcare facility vary

greatly from state to state and are constantly changing. Dr. Mario Fucinari does not engage in

providing legal services. If legal services are required, the services of a healthcare attorney should

be attained. The information in these seminar slides is for educational purposes only and should

not be construed as written policy for any federal agency.

NO RECORDING OF ANY TYPE ALLOWED

This Material is Copyright Protected

Unauthorized Audiotaping or Videotaping or Distribution of any presentation materials is illegal.

LEGAL NOTICE: The information contained in this workbook is for educational purposes

and is not intended to be and is not legal advice. Audiotaping and/or videotaping are strictly

PROHIBITED during the presentations. The laws, rules and regulations regarding the

establishment and operation of a healthcare facility vary greatly from state to state and are

constantly changing. Mario Fucinari DC does not engage in providing legal services. If legal

services are required, the services of a healthcare attorney should be attained. The information

in this class workbook is for educational purposes only and should not be construed as written

policy for any federal or state agency. All clinical examples are based on true stories. The

patient names in the clinical examples have been changed to protect the innocent. No part of

this workbook covered by the copyright herein may be reproduced, transmitted,

transcribed, stored in a retrieval system or translated into any language in any form by

any means (graphics, electronic, mechanical, including photocopying, recording, taping

or otherwise) without the expressed written permission of Mario Fucinari DC. Making

copies of this seminar workbook and distributing for profit or non-profit is ILLEGAL.

Mario Fucinari DC assumes no liability for data contained or not contained in this workbook

and assumes no responsibility for the consequences attributable to or related to any use or

interpretation of any information or views contained in or not contained in this seminar

workbook.

CPT® is a registered trademark of the AMA. The AMA does not directly or indirectly assume

any liability for data contained or not contained in this seminar workbook. This seminar workbook

provides information in regard to the subject matter covered. Every attempt has been made to

make certain that the information in this seminar workbook is 100% accurate, however it is not

guaranteed.


About Dr. Mario Fucinari, DC, CIC, CPPM, CPCO

• Graduate of Palmer College of Chiropractic - 1986

• Full-Time Practice for 34 Years in Decatur, Illinois

• Certified Professional Compliance Officer – CPCO (AAPC)

• Certified Physician Practice Manager (CPPM)

• Post-graduate Faculty of Palmer College of Chiropractic, Northeast College of

Chiropractic Sciences (NYCC), Northwestern Chiropractic, D’Youville College, Logan

College, and Life West

• National Speaker’s Bureau for NCMIC, ChiroHealthUSA and Foot Levelers and many

state associations

• Member Medicare Carrier Advisory Committee

• Past Chiropractor of the Year

• Member of ACA and ICS

New information posted regularly at

www.facebook.com/askmario and “Like” us

YOUR PATIENTS IN A “POST-COVID” WORLD

Time to Retool the Practice!

• Reimbursement is down

• Expenses are up

• Medical Necessity is under scrutiny

• Is the Cash Practice the answer?

• Work Smarter, Not Harder

Verify:

• Patient Name

• DOB

• Social Security Number

• Insurance Carrier

• ID Number

• Confirm Coverage Dates

• Are you in or out of network?

• Confirm if service requires authorization

• Confirm out of pocket coverage and amounts

https://www.google.com/imgres?imgurl=http://icons.iconarchive.com/icons/fasticon/web-2/256/FaceBook-icon.png&imgrefurl=http://www.iconarchive.com/show/web-2-icons-by-fasticon/FaceBook-icon.html&docid=ZEEGD9ahPFaJuM&tbnid=KFICJaE2iv0AvM:&w=256&h=256&ei=JA_WUuW9JKnWyQHz0IDgCA&ved=0CAIQxiAwAA&iact=c


The Medicare Card

The Medicare Beneficiary Identifier card will

contain a unique, randomly assigned 11-character

identification number that replaces the current Social

Security-based number. Each MBI identifier will be

randomly generated.

An example of the new identifier would be:

1EG4-TE5-MK73

Part A – Hospital stays, skilled nursing facility care, hospice care, home health care and blood

services.

Part B – Chiropractic care, outpatient hospital services, physical therapy, etc.

Part C – HMO plan. Cannot have part B and Part C

Part D – since 2006. Prescription Drug plans

Medicare Advantage Plan (Part C)

Medicare Advantage (Part C) Benefit Questions:

1. Do you follow the Medicare fee schedule?

2. Do you cover services other than manipulation?

3. Do you accept the AT modifier?

4. Do you accept/honor the ABN form?

Medicare Part B

• In 2021 the deductible is $203

• Only covered services are applied to the deductible

• Co-insurance: 20 percent.

• It is illegal to waive ANY part of the deductible or coinsurance

SECONDARY PLAN

When is Medicare Secondary?

• If still employed and your employer has 20 or more employees, the group health plan

pays first, and Medicare pays second;

• In a worker’s compensation case;

• In a personal injury case; and

• When the patient is cover under permanent disability.

https://www.medicare.gov/Pubs/pdf/02179-medicare-coordination-benefits-payer.pdf


MEDIGAP PLANS

Part F

• Both Part A and Part B deductibles are covered by the plan

• Best if you’ve got serious or chronic health conditions and have a lot of medical expenses

each year.

• Was phased out to new beneficiaries in 2020

Part G

• Same coverage as Plan F except for the Part B deductible, which is $203

• Part F and G are the only Medicare Supplement Plans that offer coverage for Part B

excess charges

• There are no plans to phase out Plan G

Part N

• No coverage for Part B deductible

• No coverage for Part B excess charges

• You may have a co-pay of up to $20 for doctor visits and $50 for hospital visits that don’t

result in admission.

• There are no plans to phase out Plan N

Railroad Medicare

Medicare benefits for eligible railroad retirees.

Palmetto Government Benefit Administrators (Palmetto GBA)

Railroad Medicare Part B

P.O. Box 10066

Augusta, Georgia 30999-0001

1-800-833-4455

THE CLAIM FORM Box 10 –

Box 12 –

Box 14 –

Box 17 –

Box 21 –

Box 24e –

Box 24j –

Box 31 –


THE PANDEMIC

The stress from Coronavirus and the loneliness and disconnection from social distancing has led

to an increase in opioid use

Young and middle-aged adults may suffer more from pandemic restrictions because they have

challenges many older adults no longer have, such as working remotely, caring for or

homeschooling children, maintaining financial stability for the family, etc. Interpersonal

conflicts and other non-pandemic stressors are also more prevalent in younger/middle-aged

versus older adults.

Journal of Gerontology: Psychological Sciences

Over 81,000 drug overdose deaths occurred in the United States in the 12 months ending in May

2020, the highest number of overdose deaths ever recorded in a 12-month period.

Centers for Disease Control and Prevention (CDC).

• Roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them.

• Between 8 and 12 percent develop an opioid use disorder.

• An estimated 4 to 6 percent who misuse prescription opioids transition to heroin.

• About 80 percent of people who use heroin first misused prescription opioids.

https://www.drugabuse.gov/publications/research-reports/prescription-opioids-

heroin/introduction

Working from Home During COVID-19?

Sitting is the New Smoking

“Sitting is more dangerous than smoking, kills more people than HIV and is more treacherous

than parachuting. We are sitting ourselves to death”

Dr. James Levine, director of the Mayo Clinic-Arizona State University Obesity Solutions

Initiative and inventor of the treadmill desk

A study published in the American Journal of Epidemiology found that men and women who sat

more than six hours a day died earlier than their counterparts who limited sitting time to 3 hours

a day or less.

American Journal of Epidemiology, Volume 172, Issue 4, pgs. 419-429.

The effects of COVID-19 infection lingers months after the diagnosis.

Examine for the Effects of COVID.

“Brain fog. Cognitive dysfunction. Headaches. These are just a few of the manifestations of what

the National Institutes of Health has termed post-acute sequelae of SARS COVID-2 (PASC),

more commonly known as long-COVID.”

“In a recent study, “63% of participants who met the inclusion criteria had abnormal results on

function testing” Neurology Review, Neurologists brace and prepare for long-haul COVID

fallout”, June 3, 2021,


• More than 50% of health care workers infected with SARS-CoV-2 report that their sense of

smell has not returned to normal an average of 5 months post infection.

• Among 580 respondents who indicated a compromised sense of smell during the acute phase,

more than half (51.2%) reported not regaining full olfactory function.

Loss of Smell Lingers Post COVID-19, Neurology Reviews, Pauline Anderson, February 24,

2021

• Symptoms of fatigue, memory loss, confusion, stroke, seizures, and encephalitis have been

associated with COVID-19 patients months after being infected.

• Two-thirds of the patients studied had experienced some delirium, coma, or confusion.

• Many patients describe feeling fatigued and in a “brain fog” several months after they were

diagnosed.

European Journal of Epilepsy, Vol. 83, p 234-241, December 1, 2020, Systematic review of EEG

findings in 617 patients diagnosed with COVID-19, Arun Raj Antony, Zulfi Haneef.

https://doi.org/10.1016/j.seizure.2020.10.014

• Analysis of fluid taken in spinal taps did not reveal any sign of the virus, suggesting the

patients had recovered from COVID-19.

• The patients had persistent inflammation and high levels of cytokines, proteins involved with

signaling in the immune system, in their cerebrospinal fluid.

• In some cases of coronavirus, an over-production of these molecules results in what's known

as a cytokine storm, which can cause excessive inflammation and is potentially deadly.

Some report dizziness with SARS-CoV-2 infection. Possible causes?

• Mucous membranes are affected in COVID

• Dehydration

• General malaise

• Decreased blood oxygen levels

• Deconditioning

• Even after symptoms of SARS-CoV decrease, scientists have found the virus in the

brainstem and in the digestive tract.

• Symptoms from COVID-19 include confusion and disorientation.

• Signs from COVID-19 may also include encephalopathy, ataxia, and other neurologic signs

• In other countries, evidence is emerging that COVID-19 can also result in stroke, delirium,

and epileptic seizures.

• Individuals of older age were associated with cerebrovascular disease

The History of Present Illness (HPI)

L, M, N, O, P, Q, R, S, T


Location

Mechanism of Trauma/ Modifying Factors

Numbness

Onset, duration, intensity, frequency, location and radiation

Box 14:

Qualifier:

Provoking and Palliative Factors

Prior interventions, treatments, medications, secondary complaints

Quality and character of symptoms/problem

Radiation of symptoms

Severity

Time

Review of Systems (ROS) –

ROS is an inventory of body systems obtained by asking a series of questions in order to identify

signs and/or symptoms that the patient may be experiencing or has experienced. A series of

questions of body systems that is used to clarify the differential diagnosis (Ddx) , necessary tests,

or for baseline data.

ROS must document that you reviewed the systems with the patient.

“Denies”

“Complains of”

“History of”

Example of ROS:

Cardiovascular: Denies: Shortness of breath, chest pain. Complains of: ___ History of

hypertension

Musculoskeletal: Denies: limb weakness. Complains of: lower back pain, right leg pain into

the fifth toe

Integumentary: Denies any discoloration, blisters, hives or rashes reported

2021 Evaluation and Management (E/M) CPT Codes 99202-99205/99211-99215

E/M Guidelines 2021 for the Chiropractic Office available at

www.Askmario.com

Use promo code “SAVENOW”

© ALL RIGHTS RESERVED. Copyright 2021, Excerpt from “E/M

Guidelines 2021 for the Chiropractic Office” by Mario Fucinari DC, CPPM, CPCO


Since the origination of the 1995 guidelines, evaluation and management coding has been difficult.

Attempts were made to alter the guidelines in 1997. Although the guidelines were adopted, things have

never been right until 2021. Maybe?

Do I have to do an examination?

Medical Necessity of a Service Requirements

• Must be furnished in accordance with accepted standards of medical practice

• Must be furnished in a setting appropriate to the medical needs and condition

• Must be ordered and furnished by qualified personnel

• Must meet the medical need of the patient

Section 1862(a)(1)(A) of the Social Security Act

Effective January 1, 2021

E/M 2021 Guidelines

Medical necessity of a service is the overarching criterion for payment in addition to the

individual requirements of a CPT code. It would not be medically necessary or appropriate to

bill a higher level of E&M service, when a lower level of service is warranted. The volume of

documentation should not be the primary influence upon which a specific level of service is

billed.

New patient vs. Established patient

New patient is a patient never treated in the office or not in the last three years.

The same degree of familiarity is applied for a doctor who is on call for you.

*New Patient codes: 99201-99205

*Established Patient Codes: 99211-99215

• Key Components

- History

- Examination

- Medical decision making

• Contributing Components

- Counseling

- Coordination of care

- Nature of presenting problem; and

- Time

Medical Decision Making (MDM)

– Number and complexity of problems addressed

– Amount and/or complexity of data to be reviewed and analyzed

– Risk of complications and/or morbidity or mortality of patient management

OR

Time Total time (face-to-face and non-face-to-face)


Say Goodbye To 99201

• This is an official code deletion, meaning it will no longer appear in the code book after

2020.

• There are some situations in which you may still need to report 99201, such as those

entities that will not immediately adopt the 2021 CPT code changes (e.g., workers

compensation payers). Time will tell.

• 99201 and 99202 have the same level of medical decision making (straightforward).

• It is not made for doctors! Therefore 99201 was deleted.

Summary of Changes in Determining the 2021 E/M Code Levels

• Documentation of history and physical examination will still need to be medically

appropriate.

• The amount of history or number of elements examined and documented will not factor

into the scoring used to determine the overall E/M level of service.

• The number of systems documented no longer applies

• The provider chooses to document the level of history and exam that are required to treat

the patient.

• The basis for code selection will be the level of MDM performed OR the total time spent

performing the service on the day of the encounter.

• The provider can choose whether to use MDM as the basis for the code selection OR if

time is a more appropriate factor.

• Include the history and examination elements needed to treat the patient.

The basis for code selection will be the level of MDM performed OR the total time spent

performing the service on the day of the encounter.

• When staff brings the patient back to the consultation or examination room, they will

frequently ask the patient relevant questions pertaining to the history of the present illness

(HPI).

• CMS does not require the physician to re-enter the information if they document that they

have reviewed and verified the information. The provider can update additional

information and/or correct any inaccurate information and verify that they have reviewed

the information taken by the historian.

COVID-19 has led to a Paradigm Shift in medicine. Embrace change, adapt and make the most

of everything that comes your way.


Obtaining the history

• The staff may collect information and the patient or authorized representative may supply

information directly by portal or questionnaire. This is then reviewed by the physician or

other health care professional.

• The extent of history and physical examination is not an element in the selection of the

office or other outpatient services code.

Use Technology to Reduce Time in the Office

• Consider using a telephone or video to pre-screen patients (pre-consult)

• Schedule for their virtual consultation appointment

• Clerical staff updates their insurance information

• Clinical Staff updates chief complaint(s),history, new injuries, flare-ups, surgeries,

change in medications

• Any exposure to COVID-19? Self? Family? Quarantined?

• Any work the clinical staff does, the doctor reviews the information on the day of the

appointment. That information gained goes into the Medical Decision Making

(MDM) element.

Medical Decision Making (MDM) Based E/M

If not time, the level of E/M service will be based on the documented Medical Decision Making

Medical Decision Making is defined as the process of establishing diagnoses, assessing the

status of a condition, and/or selecting a management option.

• MDM is most often used.

• MDM used when time is not used as a basis for the level of service

• Types of MDM remains the same:

– Straightforward

– Low

– Moderate

– High

MDM does not apply to 99211

Medical Decision Making is defined by three elements:

1. The ___________________ of problem(s) that are addressed during the encounter.

2. The amount and/or complexity of data to be reviewed ______________. .

3. The _____ of complications, morbidity, and/or mortality of patient management

decisions ____________________ , associated with the patient’s problem(s), the

diagnostic procedure(s), and treatment(s).

The risk of complications, morbidity, and/or mortality of patient management decisions made at

the visit, associated with the patient’s problem(s), the diagnostic procedure(s), and treatment(s).


What was decided and done that day, must be documented.

CLINICAL EXAMPLE

• Lumbar Pain

• Right sacroiliac pain

• Hyperpronation syndrome – Q-angle – Kinetic chain Disruption

• Lumbar DDD

Appropriate Level of E/M Code: ___________________

MDM Effective Jan. 1, 2021

Number and complexity of problems addressed at the encounter

Amount and/or complexity of data to be reviewed and analyzed

Risk of complications and/or morbidity or mortality of patient management

Medical Decision Making is defined by three elements:

1. The number and complexity of problem(s) that are addressed during the encounter.

2. The amount and/or complexity of data to be reviewed and analyzed.

3. The risk of complications, morbidity, and/or mortality of patient management decisions

associated with the patient’s problem(s), the diagnostic procedure(s), and treatment(s).

MDM number and complexity of problems addressed during the encounter

▪ Straightforward (99202/99212)

▪ Self-limited

▪ Low (99203/99213)

▪ Stable, uncomplicated, single problem


▪ Moderate (99204/99214)

▪ Multiple problems or significantly ill

▪ High (99205/99215)

▪ Very ill

MDM amount and/or complexity of DATA to be reviewed and analyzed


▪ Minimal or None

▪ Low (one category only) (99203/99213)

▪ Two documents or independent historian

▪ Moderate (one category only) (99204/99214)

▪ Count: Three items between documents and independent historian; or

▪ Interpret; or

▪ Confer

▪ High (two categories) 99205/99215)

▪ Same concepts as moderate

Documentation required when a Problem is Assessed (overview)


▪ Minimal risk from treatment (including no treatment) or testing. (Most would

consider this effectively as no risk)

▪ Low (99203/99213)

▪ Low risk (e.g., very low risk of severity problems), minimal consent/discussion

▪ Moderate 99204/99214)

▪ Would typically review with patient/surrogate, obtain consent and monitor, or

there are complex social factors in management

▪ High (99205/99215)

▪ Need to discuss higher risk problems that could happen for which physician or

other qualified health care professional will watch or monitor

Risk assessment in the MDM

• Risk includes complications, morbidity and/or mortality, of patient management decision

made at the visit.

• These are risks associated with the patient(s) problems(s), diagnostic procedure(s), and

treatment(s).

• This includes what possible management options were selected and those considered, but

not selected, after shared medical decision with the patient and/or family. (this is new)


TIME – BASED E/M Documentation

Time Documentation for the 2021 E/M Guidelines

• For CPT® Codes 99202-99215

• This is for the TOTAL TIME on the DATE OF THE ENCOUNTER

• Time personally spent by the physician and staff on the day of the encounter

– Includes time spent by a qualified health care professional

– Includes time spent by the doctor

– DOES NOT include time by clerical staff

Activities the Count as Timed Activities

• Preparing to see the patients such as review of tests X-ray, MRI, lab.

• Obtaining or reviewing a separately obtained history (referral).

• Performing a medically appropriate examination or evaluation.

• Counseling and educating the patient/family/caregiver.

• Ordering medications, further tests, or procedures.

• Referring and communicating with other health care professionals.

• Documenting clinical information in the electronic or other health care record.

• Independently interpreting results and communicating the results to the

patient/family/caregiver.

• Care coordination..

This table is only for outpatient services. The pre-service,

service, and post-service times are added to arrive in the

total time taken for the encounter.

CODE TIME RANGE

(Minutes)

99202 15 – 29

99203 30 - 44

99204 45 - 59

99205 60 - 74

99212 10 - 19

99213 20 - 29

99214 30 - 39

99215 40 - 54


Documentation Requirements:

• Documentation must clearly indicate nature of services performed

• “I spent an hour on the phone after patient's appointment is not sufficient.’’

• Documentation must indicate amount of time for the separately reported services was not

included in total time for the E/M level selection

• If reporting both an E/M service by time and minor procedure documenting “ total patient care

time 30 min “ is not sufficient

• Documentation must support medical necessity of time spent on the patient encounter

• If a 50 min visit is documented and billed as 99215 with a diagnosis of cough with no other

The Basics of a S.O.A.P. Note

(The language we speak)

Subjective – What’s going on?

• Reporting of patient pain, limitations, concerns and problems.

• Information that cannot be verified or measured during the encounter.

• You may want to use a quote or summarize what the patient reported.

• A well-done interview seems like a conversation on the surface.

The Medicare SOAP Note

I. History (an interval history sufficient to support continuing need; document substantive

changes)

Review of chief complaints (is this in relationship to the initial visit or treatment for the

exacerbation)

Changes since last visit

System review if relevant

Railroad Medicare: Always address the following: ________________________

II. Physical Exam (interval; document subsequent changes; a full repeat of PART is not

expected)

Exam of area of the spine involved in Dx.

Assessment of change in patient condition since last visit

Evaluation of treatment effectiveness

III. Evaluation of treatment effectiveness

In regard to the recommended level of care, duration, frequency and goals that were

developed at the initial visit or at the time of exacerbation.


IV. Documentation of how the day’s treatment fits within the plan of care (e.g. visit 4 of

planned 7 treatments) and any way the treatment plan is being changed

You must document the actual segments that you adjusted.

Document the response to the adjustment. “patient tolerated treatment without incident”

Objective – What did you find?

• Reporting of all measurable, quantifiable, and observable data obtained during the encounter.

• Present a picture by reporting anything that the provider used their senses (vision, hearing,

smell, touch)

• Does not depend on patient reporting.

• Make certain that it is clear that you were not just a passive observer in the visit.

• Remember that your documentation may be read by those unfamiliar with the shorthand that

health professionals use so freely.

• Use judgment when using abbreviations and keep them standard.

• Include functional status and the positive and significant negative tests that you performed.

Under Part B Medicare, a chiropractor is “approved for treatment by means of manual

manipulation of the spine to correct a subluxation.

P.A.R.T. P.A.R.T.

To demonstrate a subluxation based on physical examination, two of the four criteria

mentioned under the above physical examination list are required, one of which must

be asymmetry/misalignment or range of motion abnormality.

(2 of the 4 Required)

1. Pain/Tenderness - location, quality, intensity

Pain and tenderness findings may be identified through one or more of the following:

observation, percussion, palpation, provocation, etc. Furthermore pain intensity may be

assessed using one or more of the following: visual analog scales, algometers, pain

questionnaires, etc.

2. Asymmetry/misalignment - sectional or segmental level

Asymmetry/misalignment - Asymmetry/misalignment may be identified on a sectional

or segmental level through one or more of the following: observation (posture and gait

analysis), static palpation for the misalignment of vertebral segments, diagnostic

imaging, etc.

3. Range of Motion Abnormality

Range of motion abnormality (changes in active, passive, and accessory joint

movements resulting in an increase or a decrease of sectional or segmental mobility);

and Range of motion abnormality - Range of motion abnormalities may be identified

through one or more of the following: motion, palpation, observation, stress diagnostic

imaging, range of motion measurements, etc.


4. Tissue, tone changes in skin, fascia, muscle, ligament

Tissue, tone changes using descriptions pertaining to the characteristics of contiguous,

or associated soft tissues, including skin, fascia, muscle, and ligament. Tissue/Tone

texture may be identified through one or more of the following procedures: observation,

palpation, use of instruments, tests for length and strength etc.

The Examination:

Don’t forget to Check the Shoes!

On the initial examination or if significant, on

subsequent visits, note the following:

• Inspection Visual and Skin

• Patient build

• Carriage and gait cycle

• Patient movement

• Examine the shoes

• Scoliosis

• Antalgia

• Skin appearance

• Biomechanical Inspection

FAULTY MECHANICS MECHANICAL FAULTS


Function Begins from the Ground Up!!

Evidence-Based Outcomes Assessment Tools (OATS)

Why Outcomes Assessment?

• An objective measure of the patient’s ADL status

• Provides objective documentation regarding the patient’s condition.

• Helps the doctor, patient and insurer to make informed decisions

• A deterrent to malpractice

• Backed up by refereed journals (JMPT, Spine)

Outcomes Assessment Tools

• Have patient complete on initial exam, on re-exam as clinically indicated and at any

exacerbations.

• These tests quantify the amount of patient deconditioning present.

• A measure of the patient’s functional impairment of activities of daily living.

Outcome Assessment Tests

• Visual Analog Scale

• Pain Drawings

• Revised Oswestry Low Back Pain Disability Questionnaire

• Roland-Morris Disability

• Neck Pain Disability Index Questionnaire

• Headache Disability Index

• Bournemouth Questionnaire – Cervical and Lumbar. “Lifestyle illnesses”

• Zung Psychological Assessment Questionnaire

• QuickDASH

• Lower Extremity Functional Scale (LEFS)

• Oswestry/Revised Oswestry


Neck Pain Disability Index Score: Functional Impairment Score

0-8% = None

10-28% = Mild

30-48% = Moderate

50-68% = Severe

>70% = Crippled

Revised Oswestry Score: Functional Impairment Score

0-5% = None

6-20% = Mild

20-40% = Moderate

40-60% = Severe

60-80% = Crippled

80%+ Bed Bound

*If you compare the original score to the score at re-examination, there must be a minimum of a

30% decrease in score to be clinically significant.

OATS Tx Goals

Re-Examination

• Formal re-examination should be done “to determine progress and need for further care”

• Should be done at least every 10-15 visits or every 30-45 days. Medicare is every 30 days.

• Recheck all positive findings and significant negative findings.

A re-examination should include

• A brief consultation about current condition

• Repeat of significant orthopedic tests

• Visual Analog Scale or Borg Scale

• Outcome measures test repeated

After the re-examination, update record with an interim note or report. This will document and

explain the clinical significance of why you did the exam (rationale) and the results of the exam.

This then leads to your treatment plan and treatment goals.

– Any change in diagnosis (if applicable)

– Treatment frequency/schedule

– Treatment goals

– Restrictions

– Referrals or further tests

– Exercise/rehabilitation


The Role of Radiology

Do You Own an X-ray Machine?

Policies and Procedures must be in place to obtain imaging reports, if available, prior to a

consultation.

Clinical Indications for Plain Films

Indications:

• Degenerative conditions

• Inflammatory conditions

• Fracture

• Neoplasms

• Infection

Clinical Indications for MRI or CT

Non-responsive, deteriorating or lingering symptoms after 4 weeks

Assessment – What do you think? (MDM of the SOAP note) • Provider records their professional opinions and judgments as to the patient’s diagnosis, their

progress and/or their functional limitations.

• You interpret the data presented in the objective portion of the note.

• You may also point out inconsistencies, justify your goals, discuss emotional status or indicate

progress in therapy.

• You may also present reasons why certain information was not obtained or deferred.

• Recommendation of further tests or treatment that you think is necessary.

• Recommendation of referral to another provider.

• Do not introduce new data here.

• This is the area where you record your thought processes and concerns.

What is Medical Necessity? In your assessment, answer the following for each region you

are treating:

How is the patient improved?

Why does the patient still need care?

Medicare Medical Necessity

1. The patient must have a significant health problem in the form of a neuromusculoskeletal

condition necessitating treatment, and the manipulative services must have a direct

therapeutic relationship to the patient’s condition. (Medicare does not pay for pain).

2. You must have a reasonable expectation of recovery or improvement of function.

3. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam. A

diagnosis of pain is not sufficient for medical necessity


Acute subluxation - treatment for a new injury, identified by x-ray or physical exam. The

treatment is expected to improve, arrest, or retard the patient’s condition.

Chronic subluxation - A patient's condition is considered chronic when it is not expected to

completely resolve (as is the case with an acute condition), but where the continued therapy can

be expected to result in some functional improvement. Once the functional status has remained

stable for a given condition, further manipulative treatment is considered maintenance therapy

and is not covered.

An acute exacerbation is a temporary but marked deterioration of the patient’s condition that is

causing significant interference with activities of daily living due to an acute flare-up of the

previously treated condition. The patient’s clinical record must specify the date of occurrence,

nature of the onset, or other pertinent factors that would support the medical necessity of treatment.

As with an acute injury, treatment should result in improvement or arrest of the deterioration within

a reasonable period of time.

Maintenance Therapy

▪Once MMI has been reached, Medicare will NOT pay for maintenance or supportive care.

___ Maintenance therapy includes services that seek to prevent disease, promote health and

prolong and enhance the quality of life, or ____ maintain or prevent deterioration of a chronic

condition. When further clinical improvement cannot reasonably be expected from continuous

ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature,

the treatment is then considered maintenance therapy. (CMS Publication 100-02, Medicare

Benefit Policy Manual, Chapter 15, Section 240.1.3A)

1.

2.

The Treatment Plan

Treatment Plan:

1. Treatment Frequency and Duration

2. Treatment Goals

a) Short-term Goals

To decrease pain, spasms and edema

Resolution of any radicular pain in the lower extremity

Low back pain consistently less than or equal to 6/10 with all activities

Resting low back pain with less than or equal to 2/10

Independent with basic self-care ADL without increased low back pain


b) Long-term Goals

Address their ADL

Low back pain at worst less than or equal to 4/10 with all activities

Patient will ambulate 15 minutes at 2.0 miles per hour without increased low back pain

Bilateral hip flexion, multifidus and gluteal strength to 4+ to 5/5

Independent self-management

To prepare the patient for a home-based exercise program

3. Care Plan

In the acute stage: manipulation, EMS (unattended), ice, pulsed ultrasound and patient education as

indicated

In the sub-acute stage: manipulation per palpation, skilled therapeutic rehabilitation exercise to improve

functional capacity, strength and endurance and to decrease pain with ADL and patient education as

indicated

Specific Treatment Goals

What are you trying to accomplish?

Objective measures to evaluate treatment effectiveness

How do you know when the treatment has been accomplished?

Recommended Level of Care

Duration and frequency of visits to accomplish the above goals

Therapeutic Modalities and Rehabilitation

Acute care

Supervised Modalities

• 97010 Heat, ice

• 97012 Mech Traction

• 97014 Electric Stim

• 97016 Vasopneumatic Devices

• 97018 Paraffin Bath

• 97022 Whirlpool

• 97024 Diathermy

• 97026 Infrared

Constant Attendance Modalities (Acute to Sub-acute care)

• 97032 Electric Stim (attended)

• 97034 Contrast Baths

• 97035 Ultrasound

• 97036 Hubbard Tank

Laser Therapy

▪ Device - Low Level Laser Therapy (LLLT) device.; Class IV

▪ Indications - to reduce pain, reduce inflammation, reduce swelling, and accelerate the

healing process while strengthening damaged tissue.


▪ Hazardous to eyes under all conditions

▪ Constant attendance, Supervised modality

▪ Cold laser use 97039 Unlisted modality

- Many times denied

- Patient pays cash

- No recoupment

▪ S8948 Cold lasers coding preferred (15 minutes)

DISC Rehabilitation

• The history for rehabilitation documentation should identify what activity intolerances

are present.

• The rehabilitation care must identify the “patient-centered” goals of care.

• **Restoring those functions becomes the main goal or end point of care.

Every rehabilitation program must start with an assessment of abnormal function (strength,

endurance, coordination, balance and flexibility).

The quantifiable functional deficit is the baseline from which to determine progress

Ask the patient, “What can you NOT do?”

• The physician or therapist is required to have direct one-on-one patient contact.

• DOCUMENT WHO ATTENDED

• The patient must perform the rehab exercises while the doctor instructs, oversees, and

corrects the biomechanics.

• The codes for rehab services are based on 15-minute intervals.

97110 Therapeutic Exercises

97110 is used when the treatment goals are to increase strength, endurance, functional capacity,

range of motion, and/or flexibility.

• Treadmill (endurance), Isokinetic exercises for ROM (weights or theraciser), Lumbar

stabilization exercises (flexibility), Gymnic ball (stretching or strengthening)

• Documentation must show objective loss of range of motion, strength or mobility.

Deconditioning Syndrome

“Diminished ability or perceived ability to perform tasks involved in a person’s usual activities

of daily living.”

Documentation Requirements:

1) What was done

2) Location/Region (lumbar, knee, shoulder, etc.)

3) Amount of time service performed

• Units

• Minutes

• Clock time example: 5:15 pm – 5:30 pm


The 5 Ws of Therapy

1) What was done?

2) Where (Location/Region)?

3) Why (Rationale)?

4) What are the settings/resistance?

5) Who oversaw/attended?

Treatment of the COVID Society

• Examination

• Manipulation

• Rehabilitation

• Orthotic Foundation

• Supplementation

• Inspiration

Modifiers

CPT Modifiers provide additional information about the procedure.

A CPT modifier may describe whether multiple procedures were performed, why that procedure

was necessary, where the procedure was performed on the body, and lots of other information

that may be critical to a claim’s status with the insurance payer.

Medicare Modifiers

GY - Used when an item or service is statutorily excluded or does not meet the definition of

any Medicare benefit. This modifier must be used when physicians, practitioners, or suppliers

want to indicate that the item or service is statutorily non-covered (as defined in the Program

Integrity Manual (PIM) or is not a Medicare benefit (as defined in the PIM). The use of this

modifier will automatically signal Medicare’s software to deny any service that is linked to this

modifier.

• If the service is statutorily non-covered or is not a Medicare benefit, modifier GY

may be used if the beneficiary insists on having Medicare billed.

GPGY – Services delivered under an outpatient physical therapy plan of care (97XXX) As of

January 1, 2018, the GP therapy modifiers are currently required to be appended to therapy

services. In addition to the GP modifier, the GY modifier should also be appended.

An example would be 97110GPGY

Use the GP modifier on therapy for Anthem.

Beginning with dates of service on or after April 1, 2021, Anthem Blue Cross and Blue Shield

has updated Modifiers Impacting Adjudication to include GN, GO and GP to identify speech,

occupational and physical therapy types and K0, K1, K2, K3 and K4 to be identify appropriate

functional level.

GN Services delivered under an outpatient speech language pathology plan of care


GO Services delivered under an outpatient occupational therapy plan of care

GP Services delivered under an outpatient physical therapy plan of care

KX Used to indicate the services rendered are medically necessary

• Submit this modifier with services delivered under an outpatient physical therapy plan of

care.

GZ - Used when an item or service is expected to be denied as not reasonable and necessary.

This modifier must be used when physicians want to indicate that they expect that Medicare will

deny an item or service as not reasonable and necessary and they have not had an Advance

Beneficiary Notification (ABN) signed by the beneficiary.

If the beneficiary is not notified in writing that the provider expects that Medicare will deny the

item or service, she/he cannot be held liable for the charges. The GZ modifier must be used to

indicate that the provider expects that Medicare will deny an item or service as not reasonable

and necessary and there had not been an ABN signed by the beneficiary.

GA - This modifier is used to indicate that a waiver of liability statement is on file. If the

provider believes a service is likely to be denied by Medicare as not reasonable and necessary,

the beneficiary must be so advised, in writing, prior to rendering of the service. The GA modifier

must be used to indicate that the provider expects that Medicare will deny the service as not

reasonable and necessary and the beneficiary has a signed Advance Beneficiary Notification

(ABN) on file.

-AT Modifier

• The –AT Modifier (Active Treatment) will be used with the CMT code in all acute and

chronic subluxation (non-maintenance) spinal CMT cases.

• If the AT modifier is not listed on the code, the CMT will be for maintenance.

• The AT modifier is only to be appended to services that are part of active/corrective

treatment.

Modifiers -96 and -97

• The AMA and CMS require the use of modifier 96 for habilitative services and 97 for

rehabilitative services. These services include occupational therapy, physical therapy

and speech therapy. Modifier 97 is used to identify rehabilitative services

• Since a chiropractor most often will administer rehabilitative services, then the modifier

97 will be used for services.

• Rehabilitative Services - Help a person keep, get back or improve skills and functioning

lost or impaired because a person was sick, hurt or disabled

Rehabilitative Services - Help a person keep, get back or improve skills and functioning lost or

impaired because a person was sick, hurt or disabled


Modifier 25: Significant, separately identifiable E/M service by the same physician on the same

day of the procedure or other service. This modifier may only be appended to an E/M CPT code.

The chart notes MUST indicate that the procedures were separately identifiable. There are

different guidelines for new and established patients.

• A significant, separately identifiable E/M service is defined or substantiated by

documentation that satisfies the relevant criteria for the respective E/M service to be

reported.

• The E/M service may be prompted by the symptom or condition for which the procedure

and/or service was provided. As such, different diagnoses are not required for reporting

of the E/M services on the same date.

The following conditions must be met to report modifier 25:

1. The phrase, “the patient’s condition required” is extremely important. In other words, it was

medically necessary for the patient to have these extra services on the same day that another

procedure or service was performed.

2. The phrase, “a significant, separately identifiable E/M service above and beyond” the other

service provided indicates that this extra service was clearly different from the other procedure or

service that was performed.

3. The phrase, “services beyond the usual evaluation and management care” associated with the

procedure emphasizes the fact that all procedures as defined in the Resource-Based Relative

Value Scale (RBRVS) system of reimbursement that Medicare uses include a certain amount of

preoperative and postoperative care in the reimbursement package. The 25 modifier should be

used if extra work beyond the usual is performed.

A good standard for judging whether the 25 modifier should be used is: Did the provider

document the extra work performed, medical necessity, and what was the extra or unusual work.

Manipulation 98940 – 98943:

• Pre-Assessment

• Manipulation

• Post-Assessment

97140 Manual Therapy

• Used for soft tissue and joint mobilization, manual muscle work (not AK), myofascial

release, connective tissue massage and trigger point therapy.

• When billed together with CMT, manual therapy must be in a separate body region.

• Document goals, procedure used, time of treatment and area of treatment.

• Diagnosis must be linked on the CMS-1500 form.

• DO NOT USE 97124 and 97140 on the same day.


What is Trigger Point Therapy used for?

A Trigger Point (TrP) is a hyperirritable spot, a palpable nodule in the taut bands of the skeletal

muscles' fascia. Direct compression or muscle contraction can elicit jump sign, local tenderness,

local twitch response and referred pain which usually responds with a pain pattern distant from

the spot.

Modifier -59

1. Different session or patient encounter.

2. Different procedure or surgery.

3. Different body site or organ.

4. Separate incision or excision.

5. Separate lesion.

6. Separate injury (or area of injury in extensive injuries).

• When the procedure or service performed is independent from other services performed on the

same day

• When the procedures or services are not normally reported together.

• When no other modifier best explains the circumstances

Modifier 59 - Distinct Procedural Service OR Modifier XE - Separate Encounter: A service that is distinct because it occurred during a

separate encounter

Modifier XS - Separate Structure: A service that is distinct because it was performed on a

separate organ/structure

Modifier XP- Separate Practitioner: A service that is distinct because it was performed by a

different practitioner

Modifier XU - Unusual Non-Overlapping Service: The use of a service that is distinct because it

does not overlap usual components of the main service

‐ Ensure that you have clinical circumstances to justify the modifiers and please do not append

to HCPCS and CPT codes to simply bypass the NCCI edits.

‐ Medicare considers two physicians in the same group with the same specialty performing

services on the same day as the same physician.

Use the -59 or X subset modifier with the following codes, when these services are done with the

adjustment on the same day.

97124 Massage

97112 Neuromuscular reeducation

97140 Manual Therapy


Provider Signature Requirements

For medical review purposes, Medicare requires that the author authenticate services

provided/ordered. Medicare denies many claims due to the lack of an appropriate signature. Here

are some things to keep in mind on signature requirements:

1. The signature must be that of the provider of service. This means the person providing the

service whether that is the physician or a non-physician practitioner (NPP). No one else

can sign for the physician; this includes another physician in a group, the senior nurse, etc.

2. The signature must be hand-written or electronic. Medicare does not accept stamped

signatures.

3. The Centers for Medicare & Medicaid Services (CMS) 1995 and 1997 Documentation

Guidelines (DG) for Evaluation and Management (E/M) services require that the provider's

signature be legible. If your signature is not legible, please provide a signature log or

authentication statement verifying the information.

4. The signature of the transcriptionist is not the same as the physician signature. While your

office may need or require this information, Medicare does not.

5. If you are using electronic medical records, please verify your system and software

products protect against modification. Providers using electronic systems should recognize

the potential for misuse or abuse with alternate signature methods.

6. If you are splitting or sharing services between yourself and a NPP, then both parties must

sign their portion of the service. The NPP cannot sign for the physician.

7. Physician offices should have a protocol in place to have physicians sign their records

within a reasonable time, generally 48 to 72 hours after the encounter, but certainly prior

to submitting the claim to Medicare.

8. You cannot add a signature to a record later (this does not include the brief time to

transcribe the record), instead use an attestation statement.

No signature on progress/treatment note submitted – attestation sample

“I, (name of doctor)_______________, hereby attest that the medical records entry for the date

of service _________ , accurately reflects signature/notations that I made in my capacity as a

D.C. when I treated/diagnosed ___________________________.”

I do hereby attest that this information is true, accurate and complete to the best of my

knowledge and I understand that any falsification, omission, or concealment of material fact may

subject me to administrative, civil, or criminal liability.”

Signature: X _____________________ Date Form Completed X _______________________

The Advanced Beneficiary Notice Form

NEW ABN FORM CMS-R-131 Exp. 06/30/2023 https://www.cms.gov/Medicare/Medicare-General- Information/BNI/ABN

https://www.cms.gov/Medicare/Medicare-General-Information/BNI/Downloads/ABN-Form-

Instructions.pdf


https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ABN-

Tutorial/formCMSR131tutorial111915f.html

Period of Effectiveness

• An ABN can remain effective for up to one year. ABNs may describe treatment of up to a

year’s duration, as long as no other triggering event occurs. If a new triggering event

occurs within the 1-year period, a new ABN must be given.

See § 50.5 – Triggering Events.

1. One ABN for maintenance manipulation and one for non-covered services (“voluntary”)

2. Good for up to one year

3. Signed copy to patient

4. Update as needed

5. Personally signed and dated by the patient

Red Flags of the ABN:

Name:

Identification

Number:

Options:

Signature and Date:

ICD-10-CM 2021

ICD-10-CM

• The increased specificity of the ICD-10 codes requires more detailed clinical

documentation in order to code some diagnoses to the highest level of specificity

• There are “unspecified” codes in ICD-10-CM for those instances when the health record

documentation is not available to support more specific codes

• The benefits of ICD-10 cannot be realized if non-specific codes are used rather than taking

advantage of the specificity ICD-10 offers

ICD-10 Pro Tips:

• Be as specific as possible in coding

• Documentation must support the ICD-10 codes

• Avoid unspecified codes such as lumbalgia and cervicalgia


Get the NEW ICD-10 Book for Chiropractors www.Askmario.com

Signs and Symptoms

• Are acceptable for reporting purposes when a related definitive diagnosis has not been

established (confirmed) by the provider.

• Signs and symptoms that are associated routinely with the disease process should not be

assigned as additional codes, unless otherwise instructed by the classification.

• Additional signs and symptoms that may not be associated routinely with a disease process

should be coded if present.

• If a definitive diagnosis has not been established by the end of the encounter, it is

permissible to assign an unspecified code, until such time that a more definitive diagnosis

has been established.

Other Changes for 2021

Coronavirus Infections

• Code only a confirmed diagnosis of the Novel Coronavirus Disease (COVID-19).

• For a confirmed diagnosis, assign code U07.1

• If the provider documents "suspected," "possible," "probable," or “inconclusive” COVID-

19, do not assign code U07.1.

• For patients with a history of COVID-19, assign code Z86.19, Personal history of other

infectious and parasitic diseases.

M05.7A Rheumatoid arthritis with rheumatoid factor of other specified site without organ or

systems involvement

M05.8A Other rheumatoid arthritis with rheumatoid factor of other specified site

M06.0A Rheumatoid arthritis without rheumatoid factor, other specified site

M06.8A Other specified rheumatoid arthritis, other specified site

M08.0A Unspecified juvenile rheumatoid arthritis, other specified site

M08.2A Juvenile rheumatoid arthritis with systemic onset, other specified site

M08.4A Pauciarticular juvenile rheumatoid arthritis, other specified site

M08.9A Juvenile arthritis, unspecified, other specified site


G44.201 Tension-type headache, unspecified, intractable (stays the same)

G43- to G44- Migraine and other headache syndromes

BUT

R51 Headache (DELETED)

R51.10 Headache with orthostatic component, [NEC]

R51.9 Headache, unspecified

Notables for 2022

The code M54.5 LUMBAGO/LOW BACK PAIN will be a NON BILLABLE CODE and will

be replaced with the following THREE CODE OPTIONS:

M54.50 Low back pain, unspecified

M54.51 Vertebrogenic low back pain

M54.59 Other low back pain

Order the ICD-10 Coding Book for Chiropractors at

www.Askmario.com for the complete list.

What are your local carriers telling you?

ICD-10 Step to UPDATE

1. Gather your last 40 new patient’s charts

2. Make a list of the ICD-10 diagnoses

3. You have your “Top 40 Playlist”

4. Check your EOBs

5. Identify Unspecified Codes and Deleted Codes

6. Convert to 2021 Code Usage

7. Get NEW ICD-10 Book for Chiropractors

www.Askmario.com

General ICD-10 Coding Guidelines: 1. ICD-10-CM codes should be listed at their highest level of specificity and characters.

a. ICD-10-CM diagnosis codes are composed of codes with 3, 4, 5, 6 or 7 characters. Use

three-character codes only if there are no four-character codes within the coding category.

These are the heading of a category of codes.

You will rarely use a three-character code, if ever.

b. Diagnosis codes are to be used and reported at their highest number of characters

available. Use the 4, 5, 6, or 7-digit code to the greatest degree of specificity available.

These provide further detail.

2. Codes that describe symptoms and signs are only acceptable if that is the highest level of

diagnostic certainty documented by the doctor. No other diagnosis has been established

(confirmed) by the provider. Codes that describe symptoms and signs, as opposed to

diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has

not been established (confirmed) by the provider.

www.Askmario.com


3. Signs and symptoms that are associated routinely with a disease process should not be

assigned as additional codes, unless otherwise instructed by the classification.

a. As an example, you would not use a code for muscle spasm along with a strain code,

since the finding of spasms are routinely associated with a strain.

4. The acute condition should always be listed first.

a. The worst goes first!

The ICD-10 Characters

Placeholder “X” character - The ICD-10-CM utilizes a placeholder character “X” The “X” is

used as a 5th and /or 6th character placeholder at certain 6 and/or 7-character codes to allow

for future expansion.

The A, D, or S ending indicates the PHASE of Care of treatment

S13.4xxA

Sprain of neck, initial encounter

7th Character Basic ICD-10 Coding Guidelines:

1. 7th character A:

• Initial encounter (Medicare says to use this during active care)

• Used when the patient is receiving active treatment for the condition

- CMS says this is used as long as the patient is under active care (-AT

modifier)

While the patient may be seen by a new or different provider over the course of treatment

for an injury, assignment of the 7th character is based on whether the patient is undergoing

active treatment and not whether the provider is seeing the patient for the first time.

2. 7th character D:

– Subsequent encounter

– After treatment in the active phase of care and the patient is in the healing or

recovery phase of care

– Examples of this care are cast change, medication adjustment, or other aftercare

following treatment of the injury or condition.

– In chiropractic, this may be used in the phase when the patient is in rehabilitation.

3. 7th character S:

– Sequela also known as “late effects”

– For complication or conditions that arise as a direct result of a condition, such as

deconditioning of muscle after an injury.

– When using the Sequela codes, it is necessary to use both the injury code that

precipitated the sequela and the code for the sequela itself.

– The “S” is added to the injury code only, not the sequela code.

What is the phase of care?


– The 7th character “S” identifies the injury responsible for the sequela.

– The specific type of sequela is sequenced first on the claim form, followed by the

injury code.

The Role of Radiology in Diagnosis. What is YOUR Policy?

Proper Sequencing of Codes in ICD-10

Medicare Subluxation Complex – Segmental and somatic dysfunction

M99.01 ... segmental and somatic dysf.- cervical region

M99.02 ... segmental and somatic dysf.- thoracic region

M99.03 ... segmental and somatic dysf.- lumbar region

M99.04 ... segmental and somatic dysf.- sacral region

M99.05 ... segmental and somatic dysf.- pelvic region

Optimal sequencing of the codes:

• Neurological diagnosis

• Postlaminectomy syndrome

• Disc displacement

• Neuritis

• Structural descriptor diagnosis

• Degenerative Disc Disease

• Spinal Stenosis

• Scoliosis

• Segmental and somatic dysfunction

• Functional diagnosis

• Deconditioning Syndrome (25 different codes!)

• Soft tissue

• Myositis

• Fibromyalgia

• Extremity

• Complicating Factors

• Social Determinants of Health (SDOH)

• External Cause Codes (PI, WC, VA)

Social Determinants of Health (SDOH)

• SDOH: Economic and social conditions that influence the health of people and

communities.

• Examples include:

– Availability of food

– Availability of housing

– Poverty

– Mental health

– Reported with ICD-10-CM codes Z55-Z65


For More Information see the books:

• ICD-10 Coding of the Top 100 Conditions for the Chiropractic Office 2021 –

Eighth Edition by Dr. Mario Fucinari www.Askmario.com

• E/M Guidelines 2021 for the Chiropractic Office by Dr. Mario Fucinari

www.Askmario.com

• Compliance and HIPAA Manuals available at www.AskMario.com

New information posted regularly at

www.facebook.com/askmario “Like” us

Put us in your notifications

If you have questions…

www.AskMario.com

E-mail: [email protected]

Thank You!!

Sponsored by ChiroHealthUSA

http://www.askmario.com/



https://www.google.com/imgres?imgurl=http://icons.iconarchive.com/icons/fasticon/web-2/256/FaceBook-icon.png&imgrefurl=http://www.iconarchive.com/show/web-2-icons-by-fasticon/FaceBook-icon.html&docid=ZEEGD9ahPFaJuM&tbnid=KFICJaE2iv0AvM:&w=256&h=256&ei=JA_WUuW9JKnWyQHz0IDgCA&ved=0CAIQxiAwAA&iact=c

Patient Management and Documentation in a Post-COVID World ...

Documents

Transcript of Patient Management and Documentation in a Post-COVID World ...