Q: It used to be that to establish medical necessity for care, you need only submit a copy of your travel card and frequently you got paid. It is not that easy today and the fact that the patient had a subjective complaint is simply not enough. What are the carriers looking for to establish this “mysterious” medical necessity?

A: Active care is outcome driven. Chiropractors must systematically deploy the outcome assessment tools of the Oswestry Questionnaire, Neck Disability Index, Visual Analog Scale, Symptom Diagrams and others, in their practices. It is not enough for us to get our patients well and to return them to normal health; we must prove that we have done so. These tools allow us to effectively establish and communicate functional goals for out patients’ care. These functional goals become the benchmarks for our care. How we document the improvement of our patients’ ability to perform their activities of daily living establishes the medical necessity of our care. In most cases, an insurance carrier’s definition of reasonableness and necessity are linked to whether the treatment provided has helped to return a patient expeditiously to state of well-being.

Documentation drives reimbursement. Effectively employing outcome assessment tools is an important method of establishing the medical necessity of care. Chiropractors must possess a comprehensive understanding and ability to correctly employ CPT and ICD-9 codes. Health insurance claim forms are printed in red ink, not because it is an attractive color, but because those claim forms are optically scanned by a computer. The language in which computers communicate is numbers. A mastery of these numbers will allow chiropractors to communicate what it is that they have done and at which level they should be reimbursed, not to a human being but to a machine. Chiropractors must know how to effectively code for what they do in order for their patients to receive the level of reimbursement that they deserve.

Dr. Mark Sanna is the CEO of Breakthrough Coaching, LLC, a leading resource for personal coaching to chiropractic and multidisciplinary practices throughout the country. He can be reached at Breakthrough Coaching, LLC, by calling 1-800-7-ADVICE.

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