Optimizing Insurance Reimbursement for Integrative Medicine

Transcription

1 + Optimizing Insurance Reimbursement for Integrative Medicine

2 + Billing Basics See a patient Bill the services to their insurance Get paid

3 + Billing Realities Intake new patient Generate Bill Setup insurance case Scrub for errors and omissions Policy, Group, Co-Pay, Insured, Payer ID Scrub for coding errors Privacy Agreement, Financial & Medical Release Informed Consent Non-Covered Services Consent Pre authorize services with payer Send Bill Via paper on preprinted red ink forms Via electronic submission ANSI 5010 compliant Validate referral Receive Payment See Patient Process EOB Assess Condition Write off adjustments Determine Therapeutic Approach Explain benefits Apply Therapies Re-bill errors Recommend continuing care Re-bill to secondary payers Document Encounter Bill Patient for Remaining balances Setup Visit & Codify Services & Assessment Send out billing statements Assign appropriate CPT codes Assign Appropriate ICD-9 codes Follow up on referral with report Assign Appropriate Modifiers

4 + Processing Claims Consolidate the Services Information Determining what needs to sent, and to which payer Filling out CMS 1500 forms Sending to payers

5 C M S Fi el ds +

6 + Patient & Claim Information 1. Insurance Type 1a. Insured s Policy or Group Number 2. Patient Name 3. Patients DOB 5. Patient s Address 6. Relationship to Insured 8. Patient Status 10. Patient s condition a. Employment b. Auto accident (State) c. Other accident d. Reserved for your use

7 + Insured s Information 4. Insured s Name 7. Insured s Address 11. Insured s Policy or Group number 11a. Insured s DOB & Gender 11b. Insured s Employer or School 11c. Insured s Plan or Program 11d. Is there another benefit

8 + Additional Benefits? Additional Benefit Plans 9. Other Insured s Name 9a. Other Insured s Policy # 9b. Other Insured s DOB & Gender 9d. Insurance Plan or Program Name

9 + Authorized Patient Signatures 12. Medical Release on file Authorizes release of medical information to payer for claim processing 13. Financial Release on file Authorizes payment to the physician

10 + Care Details 14. Date of Onset of Current Illness or Injury 15. Date of onset of similar illness 16. Dates unable to work 18. Dates hospitalized 17. Referring Provider 17a. ID 17b. NPI 19. Reserved for your use 21. Diagnosis Codes of Services on Claim 20. Outside lab charges 22. Medicaid resubmission 23. Prior authorization code

11 + Services Performed 24a. Dates of Service 24b. Place of Service (11) 24d. CPT & Modifiers 24f. Charges (Total) 24g. Units 24j. Rendering Provider NPI 24e. Diagnosis Pointer (1,2,3,4)

12 + Bottom of the Form 25. FIEN of Provider 26. Patients ID with Provider 27. Accepts assignment 28. Total Charge 29. Amount paid 30. Balance Due 31. Provider Signature Includes Credential 32. Facility Address & NPI 33. Billing Entity Address & NPI Associated with Tax ID in 25

13 + Sending Claims Paper Filing Print on Preprinted CMS 1500 forms from medical supplier Send to address specified on patients insurance case Submit in electronic standardized format ANSI 837 Electronic Filing Most software can assist you with this.

14 + CPT Codes Common Procedural Terminology

15 + Common E/M Codes E/M (Evaluation and Management) Initial Patient Office Established Patient Office New Patient Consults Referred Office New and Existing Visits In Patient s Home Preventative Medicine Services Office Extended Time with or without patient Telephone and Online E/M Office

16 + Common Procedure Codes Performed By Provider Psychiatry and Psychotherapy Bio Feedback Allergy and Immunotherapy Physical Medicine Acupuncture Osteopathic Manipulation Chiropractic Manipulation Performed by staff Medical Nutrition Therapy Education and Training for Patient Self Management Non physician Telephone and Internet management

17 + Evaluation & Management Office and Outpatient Services

18 + Components of an E&M Code History * Examination * Medical Decision Making * Counseling Coordination of Care Nature of Presenting Problems Time * Key components

19 + Choosing an E&M Code New patient Office or Home visits All key components required Established Office or Home Visits 2 Key components required When counseling or coordination of care takes over 50% of the face to face time with patient or family members Time shall be considered the key or controlling factor to qualify The extent of the counseling must be documented.

20 + Charting for Insurance

21 + Extent of History Problem Focused Chief complaint (CC), brief history of presenting problem (HPI) Expanded Problem Focused CC, brief HPI, problem pertinent review of system (ROS) Detailed CC, extended HPI, pertinent past, family and or social history directly related to the patients problem. Comprehensive CC, extended HPI, pertinent ROS, complete ROS, complete past, family and social history.

22 + Extent of Exam Problem Focused Limited exam of affected area or organ system Expanded problem focused Limited exam of affected body are or organ system, and related symptomatic systems Detailed Extended exam of affected systems and symptomatic related organ systems Comprehensive General multi system exam or complete examination of a single organ system

23 + Extent of Exam Charting Problem Focused One to five bullets from one or more organ systems Expanded Problem Focused At least six bullets from any organ systems Detailed Exam At least two bullets from six organ systems or 12 bullets from two or more organ systems Comprehensive At least 2 bullets from each of nine organ systems

24 + Examination Areas & Organs Areas Head (including face) Neck Chest (including breasts & axilla) Abdomen Genitalia, groin, buttocks Back Each Extremity Organs Eyes Ears, nose, mouth, and throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic, Lymphatic,

25 + Charting S:// History S:// Subjective (Patient History) History of Present Illness Past Medical History Family History Social History Review of Systems Medications and Supplements

26 + Charting O:// Exam O:// Objective (Exam findings) Problem Focused One to five bullets from one or more organ systems Expanded PF At least six bullets from any organ systems Detailed Exam At least two bullets from six organ systems or 12 bullets from two or more organ systems Comprehensive At least 2 bullets from each of nine organ systems Organ Systems 1. Constitutional 2. Eyes 3. Ears, nose, mouth and throat 4. Neck 5. Respiratory 6. Cardiovascular 7. Chest (breasts) 8. Gastrointestinal (abdomen) 9. Genitourinary (male) 10.Genitourinary (female) 11. Lymphatic 12. Musculoskeletal 13. Skin 14. Neurologic 15. Psychiatric Physical Exam. (2013) retrieved January 20, 2013 from

27 + Charting A:// Assessment Assign Proper Dx Codes

28 + Charting P:// Plan Document Time Spent Face to face Counseling Coordination of Care Manual Therapies Separate Procedures Clarify Medical Need Discuss the reasoning for each procedure and the need for its timing

29 + Determining Medical Complexity (MDM) The complexity of establishing a diagnosis and/or selecting a management option Factors: The number of possible diagnosis or management options The amount and complexity of medical records, diagnostic tests and other information that must be obtained reviewed and analyzed The risk of significant complications, morbidity or mortality as well as comorbidities associated with the diagnosis or the management options

30 + Medical Decision Making (MDM) The number, complexity and risk of the problems or management options involved in the providers decision making process. Number Amount of presenting problems or management options Complexity The risk to the patient

31 + MDM: Qualitative Assessment of Complexity of Medical Decision Making Number of diagnoses or management options Amount and/or complexity of data to be reviewed Risk of complications and/or morbidity or mortality Level of Complexity of Medical Decision-Making Minimal Minimal or None Minimal STRAIGHTFORWARD Limited Limited Low LOW COMPLEXITY Multiple Moderate Moderate MODERATE COMPLEXITY Extensive Extensive High HIGH COMPLEXITY

32 + MDM: Quantitative Assessment of Complexity of Medical Decision Making Overall MDM Problem Points Data Points Risk Straightforward 1 1 Minimal Complexity Low complexity 2 2 Low Moderate Complexity 3 3 Moderate High Complexity 4 4 High Medical Decision Making (2013). Retrieved January 20 th, 2013 from

33 + MDM: Nature and Number of Clinical Problems (Problem Points) Problems Points Self-limited or minor (maximum of 2) 1 Established problem, stable or improving 1 Established problem, worsening 2 New problem, with no additional work-up planned 3 (maximum of 1) New problem, with additional work-up planned 4 Medical Decision Making (2013). Retrieved January 20 th, 2013 from

34 + Amount and Complexity of the Data Reviewed (Data Points) Data Reviewed Points Review or order clinical lab tests 1 Review or order radiology test (except heart catheterization or echo) 1 Review or order medicine test (PFTs, EKG, cardiac echo or catheterization) 1 Discuss test with performing physician Independent review of image, tracing, or specimen 1 2 Decision to obtain old records 1 Review and summation of old records 2 Medical Decision Making (2013). Retrieved January 20 th, 2013 from

35 + MDM: Risk Assessment Presenting Problems Minimal Risk One self-limited or minor problem Low Risk Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated illness or injury Moderate Risk One or more chronic illness with mild exacerbation or progression Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis Acute illness with systemic symptoms Acute complicated injury High Risk One or more chronic illness with severe exacerbation or progression Acute or chronic illness or injuries which pose a threat to life or bodily function Medical Decision Making (2013). Retrieved January 20 th, 2013 from

36 + MDM: Risk Assessment Diagnostic Procedures Minimal Risk Lab tests Chest X-ray EKG/EEG Urinalysis Ultrasound/Echocardiography KOH prep Moderate Risk Physiologic tests under stress Diagnostic endoscopies with no identified risk factors Deep needle or incisional biopsies Cardiovascular imaging studies with contrast and no identified risk factors Obtain fluid from body cavity Low Risk Physiologic tests not under stress Non-cardiovascular imaging studies with contrast Superficial needle biopsies ABGs Skin biopsies High Risk Cardiovascular imaging studies with contrast with identified risk factors Cardiac EP testing Diagnostic endoscopies with identified risk factors Discography Medical Decision Making (2013). Retrieved January 20 th, 2013 from

37 + MDM: Risk Assessment Management Options Minimal Risk Moderate Risk Rest Gargles Elastic bandages Superficial dressings Minor surgery with identified risk factors Elective major surgery with no risk factors Prescriptions drug management Therapeutic nuclear medicine IV fluids with additives Low Risk Over-the-counter drugs Closed treatment of fracture or dislocations without manipulation Minor surgery with no identified risk factors High Risk Physical therapy Occupational therapy IV fluids without additives Elective major surgery with identified risk factors Emergency major surgery Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis Medical Decision Making (2013). Retrieved January 20 th, 2013 from

38 + Quantitative Assessment of Complexity of Medical Decision Making Overall MDM Problem Points Data Points Risk Straightforward Complexity 1 1 Minimal Low complexity 2 2 Low Moderate Complexity 3 3 Moderate High Complexity 4 4 High Meet two of the above criteria to determine complexity Medical Decision Making (2013). Retrieved January 20 th, 2013 from

39 +

40 x: Hx: blem Expanded cused PF Hx: Compreh ensive Hx: Detailed Hx: Compreh ensive Ne w Pa tie nt - O ffi ce +

41 Office - New Patient A Problem focused history A Problem focused exam Straightforward medical decision making Includes: Counseling and coordination of care consistent with the nature of the problem Typically: Self limiting problems 10 minutes time face to face

42 Office New Patient An expanded problem focused history An expanded problem focused exam Straightforward medical decision making Includes: Counseling and coordination of care consistent with the nature of the problem Typically Low to moderate severity 20 minutes time face to face

43 Office New Patient A detailed problem focused history A detailed problem focused exam Medical decision making of low complexity Includes: Counseling and coordination of care consistent with the nature of the problem Typically Moderate severity 30 minutes time face to face

44 Office New Patient A comprehensive history A comprehensive examination Medical decision making of moderate complexity Includes: Counseling and coordination of care consistent with the nature of the problem Typically Moderate to high severity 45 minutes time face to face

45 Office New Patient An comprehensive history An comprehensive examination Medical decision making of high complexity Includes: Counseling and coordination of care consistent with the nature of the problem Typically Moderate to high severity 60 minutes time face to face

46 + Established Patients Patients seen within the last 3 years at your facility by a provider of the same specialty and subspecialty. Includes the patients of absent primary providers being relieved by a substitute

47 ny Hx: it from Problem atient Focused Hx: Compreh ensive Hx: Hx: detailed Ex: Es ta bli sh ed Pa tie nt s +

48 Office Established Patient A Problem focused history A Problem focused exam Straightforward medical decision making Includes: Counseling and coordination of care consistent with the nature of the problem Typically: Self limiting problems 10 minutes time face to face

49 Office Established Patient An expanded problem focused history An expanded problem focused exam Straightforward medical decision making Includes: Counseling and coordination of care consistent with the nature of the problem Typically Low to moderate severity 20 minutes time face to face

50 Office Established Patient A detailed problem focused history A detailed problem focused exam Medical decision making of low complexity Includes: Counseling and coordination of care consistent with the nature of the problem Typically Moderate severity 30 minutes time face to face

51 Office Established Patient A detailed history A detailed examination Medical decision making of moderate complexity Includes: Counseling and coordination of care consistent with the nature of the problem Typically Moderate to high severity 25 minutes time face to face

52 Office Established Patient An comprehensive history An comprehensive examination Medical decision making of high complexity Includes: Counseling and coordination of care consistent with the nature of the problem Typically Moderate to high severity 40 minutes time face to face

53 Hx: Consultations are provided at the request Problem of another physician Focused Hx: Expanded PF Hx: Compreh ensive Hx: Ne w Detailed Ex: Hx: Pa tie nt - Co ns ult s + Compreh ensive

54 41 : Hx: Care provided in a private residence Hx: lem Expanded Detailed sed PF Ex: Hx: Hx: Compreh Compreh ensive ensive Ne w Pa tie nt H o m e +

55 47 : Hx: Care provided in a private residence lem Expanded Hx: sed PF Detailed Hx: Compreh ensive Ex ist in g Pa tie nt H o +

56 Beyond E/M time First Hour w/ Each additiona l Each additiona l First Hour w/o Pr ol on ge d Se rvi ce s +

57 >30 minutes in team conference Multi-disciplinary team Me dic al Te am Co nf er en ce +

58 + Without direct contact Supervi sion of Managing External care plan More than Supervi sion of Ca re Pl an More than Supervi sion of More than 30 Ov er si gh t

59 + CPT Modifiers

60 + What are Modifiers Modifiers are ways to communicate with the payer details about the use and context of services rendered They can help to clarify that multiple services done on the same day where justified They can also help to show that an E/M service was beyond the E/M component of another procedure preformed at on the same day

61 + Common Modifiers 25 Unrelated E/M on the Same Day Significant, Separately Identifiable E/M Same provider on the same day of a procedure or service Can be for same Diagnosis Codes 51 Multiple Procedures Multiple non E/M procedures are performed on the same day Append the 51 to additional procedures beyond the primary procedure 59 Distinct Procedural Service Identifies that a service is distinct from another service performed on the same day Documentation support different session, different procedure, different site, different organ system, separate lesion, separate injury

62 + Less Common Modifiers 22 - Increased Procedural Services When the work for a procedure is substantially greater than normal Documentation must support the additional work Increased intensity, time, technical difficulty, severity of concern. Physical or mental effort required Not to be used with E/M 26 - Professional Component Some procedures have technical and professional components use when reporting the professional component 32 Mandated Services Service related to a mandated consultation 90 Reference Laboratory Lab procedures that are performed outside of the office 91 Repeat Diagnostic Test 99 Multiple modifiers Used when you need to add multiple modifiers

63 + Physical Therapy Codes Physical therapy evaluation Physical therapy re-evaluation Occupational therapy evaluation Occupational therapy re-evaluation Athletic training evaluation Athletic training re-evaluation

64 + Modalities Supervised Hot or Cold Packs to one or more areas Traction, mechanical Electrical stimulation (not acupuncture) Vasopneumatic devices Paraffin bath Whirlpool Diathermy Infrared Ultraviolet Attended Electrical stimulation Iontophoresis contrast baths (/ 15m) Ultrasound (/15min) Hydrotherapy Immersion Unlisted modality s

65 + Therapeutic procedures Therapeutic Exercises (/15min) Neuromuscular reeducation Aquatic therapy Gait training Development of cognitive skills (attention, memory, problem solving) (/ 15min) Sensory integrative techniques (/ 15min) Self care / home management training (ADL, meal preparation, safety procedures, use of adaptive equipment) Massage (/15min) Unlisted Manual Therapy (/ 15min) Group therapy (1 per patient) Community work reintegration training (shopping, transportation, money management, work environment/ modification analysis, work task analysis) Wheel chair management Work hardening / conditioning (1 st 2hrs) Each additional hour

66 + Therapeutic Procedures Wound Care Management Debridement 1 st 20sqcm Each additional 20sqcm Removal of devitalized tissue w/o anesthesia Negative pressure wound therapy 1 st 50sqcm Each additional 50 sqcm Tests & Measurements Physical performance test (15min) Assistive technology assessment (15min) Muscle Testing extremity with report Muscle Testing hand w/o comparison Total evaluation of body w/o hands Total ealuation of body w/ hands ROM report each extremity and trunk segment Muscle testing, manual or electrical,

67 + Therapeutic Procedures Medical Nutrition Non physicians Initial Assessment and intervention (15min) Re-assessment and intervention (15min) Group nutrition therapy (30min) Orthotic Management Orthotic management and training (/15min) Not with (Gait training) Checkout for Orthotic use (/15min) Acupuncture First 15 min Ac w/o electric stim Each additional 15min First 15 min Ac w/ electric stim Each additional 15min

68 + Physical Medicine Osteopathic Manipulation Chiropractic Manipulation Patient Education & Training (Non Physician) Education and Training for patient self management patients patients

69 + Psychotherapy Coding Diagnosis Psychiatric diagnostic evaluation Psychiatric diagnostic evaluation with medical services Crisis Psychotherapy for crisis (60 min) each additional 30min Psychotherapy 30 minutes with Patient and/or Family Psychotherapy 30 minutes with separate E/M Psychotherapy 45 minutes Interactive Complexity Psychoanalysis Psychotherapy 45 minutes with separate E/M Family Psychotherapy w/o Pt Psychotherapy 60 minutes Family Psychotherapy w/ Pt Multiple family group psychotherapy Psychotherapy 60 minutes with separate E/M Group psychotherapy Pharmacologic management

70 + Diagnosis Codes ICD-9 CM

71 + DX Codes : infectious and parasitic diseases : neoplasms : endocrine, nutritional and metabolic diseases, and immunity disorders : diseases of the blood and blood-forming organs : mental disorders : diseases of the nervous system : diseases of the sense organs : diseases of the circulatory system : diseases of the respiratory system : diseases of the digestive system : diseases of the genitourinary system : complications of pregnancy, childbirth, and the puerperium : diseases of the skin and subcutaneous tissue : diseases of the musculoskeletal system and connective tissue : congenital anomalies : certain conditions originating in the perinatal period : symptoms, signs, and ill-defined conditions : injury and poisoning E and V codes: external causes of injury and supplemental classification

72 + ICD-9-cm vs. ICD-10-cm

73 + ICD-10 the effective implementation date for ICD-10-CM is: October 1, 2014

74 + Bringing it all together For each visit you will See the patient Chart Accordingly Code your visit Determine Complexity Choose Services (CPT) Apply Modifiers Assign Diagnostic Codes (ICD9)

75 + Case Studies See case studies work sheet

76 + Improving Reimbursement for Naturopathic Care Limit the use of E/M Bill for procedures Bill for every thing that you do Study the CPT code manual Maybe there are codes for what you are doing Enhance your charting Focus on meeting the criteria Be concise and thorough Use an EMR Use Electronic Billing Speeds up delivery Scrubs for errors

77 + Dual Degree Factors Bill separately for each degree Sign the CMS with the corresponding credential Credential with Insurance Companies as each type of provider

78 + Non Covered Services Consent Non-Covered Services Medical Consent Form I,, understand that some services may not be considered eligible benefits (e.g., services and/or supplies may be determined to not be medically necessary, noncovered or investigational) by my health insurance provider. I understand that my health insurance coverage has certain restrictions and limitations, such as authorization requirements and noncovered services. Examples of these non-covered items include, but are not limited to, report writing, conferences and/or meetings and supplies. I agree to be financially responsible for any and all related charges if they are not covered by my health insurance. Common non covered services Filling out forms or writing letters for you at your request (includes work and school absence excuse letters, pre-employment forms, health club medical clearance forms, letters to airlines, family medical leave forms, forms for disability parking stickers, extended care facility applications, etc.) Physician phone consultations and assistance, including calling in prescriptions and prescription refills: when you are traveling out of town; and in management of an urgent health problem, when you are offered an appointment but decline to come to the office Writing, calling in or faxing prescriptions to mail-order pharmacies Writing and refilling prescriptions, when these services are done for you without an appointment Guardian Signature: Date: Prior authorization for medications and tests Writing letters and/or phoning your insurance company on your behalf: To appeal denied claims for services provided by this office or other offices, or for laboratory services or imaging studies To petition for coverage of uncovered drugs, services, diagnostic testing or procedures, and for requests for evaluations by out-of-network physicians outside of Cincinnati Social service and home-care assistance, such as arranging for at-home or in-hospital, private-duty nursing services, arranging for delivery of durable medical equipment, arranging

79 + Summary

80 + Billing is Great for Naturopathic Physicians Billing is an opportunity for us to show the world what we are about Billing is a way for us to get paid for our care We need to take our billing seriously for the sake of the profession Billing can contribute to the knowledgebase about the approach and efficacy of our profession

81 + Thank you for your time If you would like to reach Dr. Meager You can contact him at: Or look him up at or or Or contact him at (970) x7011

82 + Exam Minimums Constitutional 1) Three vital signs 2) General appearance Eyes 1) Inspection of conjunctivae and lids 2) Examination of pupils and irises (PERRLA) 3) Ophthalmoscopic discs and posterior segments 1997 Document Guidelines for Evaluation and Management. (1997) retrieved January 20, 2013 from ACR/Documents/PDF/Economics/1997%20Document%20Guidelines%20for%20Evaluation%20and%20Management.pdf

83 + Exam Minimums Ears, Nose, Mouth, and Throat 1) External appearance of the ears and nose (overall appearance, scars, lesions, masses) 2) Otoscopic examination of the external auditory canals and tympanic membranes 3) Assessment of hearing 4) Inspection of nasal mucosa, septum and turbinates 5) Inspection of lips, teeth and gums 6) Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx Neck 1) Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position, crepitus) 2) Examination of thyroid 1997 Document Guidelines for Evaluation and Management. (1997) retrieved January 20, 2013 from ACR/Documents/PDF/Economics/1997%20Document%20Guidelines%20for%20Evaluation%20and%20Management.pdf

84 + Exam Minimums Respiratory 1) Assessment of respiratory effort (e.g., intercostal retractions, use of accessory muscles, diaphragmatic movement) 2) Percussion of chest (e.g., dullness, flatness, hyperresonance) 3) Palpation of chest (e.g., tactile fremitus) 4) Auscultation of the lungs Cardiovascular 1) Palpation of the heart (location, size, thrills) 2) Auscultation of the heart with notation of abnormal sounds and murmurs 3) Assessment of lower extremities for edema and/or varicosities 4) Examination of the carotid arteries (e.g., pulse amplitude, bruits) 5) Examination of abdominal aorta (e.g., size, bruits) 1997 Document Guidelines for Evaluation and Management. (1997) retrieved January 20, 2013 from ACR/Documents/PDF/Economics/1997%20Document%20Guidelines%20for%20Evaluation%20and%20Management.pdf

85 + Exam Minimums Lymphatic Palpation of lymph nodes two or more areas: 1) Neck 2) Axillae 3) Groin 4) Other Chest (Breasts) 1) Inspection of the breasts (e.g., symmetry, nipple discharge) 2) Palpation of the breasts and axillae (e.g., masses, lumps, tenderness) Gastrointestinal (Abdomen) 1) Examination of the abdomen with notation of presence of masses or tenderness 2) Examination of the liver and spleen 3) Examination for the presence or absence of hernias 4) Examination (when indicated) of anus, perineum, and rectum, including sphincter tone, presence of hemorrhoids, rectal masses 5) Obtain stool for occult blood testing when indicated 1997 Document Guidelines for Evaluation and Management. (1997) retrieved January 20, 2013 from ACR/Documents/PDF/Economics/1997%20Document%20Guidelines%20for%20Evaluation%20and%20Management.pdf

86 + Exam Minimums Genitourinary (Male) 1) Examination of the scrotal contents (e.g., hydrocoele, spermatocoele, tenderness of cord, testicular mass) 2) Examination of the penis 1) Digital rectal examination of the prostate gland (e.g., size, symmetry, nodularity, tenderness) Genitourinary (Female) Pelvic examination (with or without specimen collection for smears and cultures, which may include: 1) Examination of the external genitalia (e.g., general appearance, hair distribution, lesions) 2) Examination of the urethra (e.g., masses, tenderness, scarring) 3) Examination of the bladder (e.g., fullness, masses, tenderness) 4) Examination of the cervix (e.g., general appearance, discharge, lesions) 5) Examination of the uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or support) 6) Examination of the adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity) 1997 Document Guidelines for Evaluation and Management. (1997) retrieved January 20, 2013 from ACR/Documents/PDF/Economics/1997%20Document%20Guidelines%20for%20Evaluation%20and%20Management.pdf

87 + Exam Minimums Musculoskeletal Examination of gait and station Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes) Examination of the joints, bones, and muscles of one or more of the following six areas: a) head and neck b) spine, ribs, and pelvis c) right upper extremity d) left upper extremity e) right lower extremity f) left lower extremity The examination of a given area may include: a) Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, b) defects, tenderness, masses or effusions c) Assessment of range of motion with notation of any pain, crepitation or contracture d) Assessment of stability with notation of any dislocation, subluxation, or laxity e) Assessment of muscle strength and tone (e.g., flaccid, cogwheel, spastic) with notation of any atrophy or abnormal movements 1997 Document Guidelines for Evaluation and Management. (1997) retrieved January 20, 2013 from ACR/Documents/PDF/Economics/1997%20Document%20Guidelines%20for%20Evaluation%20and%20Management.pdf

88 + Exam Minimums Skin 1) Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers) 2) Palpation of the skin and subcutaneous tissue (e.g., induration, subcutaneous nodules, tightening) Neurologic 1) Test cranial nerves with notation of any deficits 2) Examination of DTRs with notation of any pathologic reflexes (e.g., Babinksi) 3) Examination of sensation (e.g., by touch, pin, vibration, proprioception) 1997 Document Guidelines for Evaluation and Management. (1997) retrieved January 20, 2013 from ACR/Documents/PDF/Economics/1997%20Document%20Guidelines%20for%20Evaluation%20and%20Management.pdf

89 + Exam Minimums Psychiatric 1) Description of patient s judgment and insight Brief assessment of mental status which may include 1) orientation to time, place, and person 2) recent and remote memory 3) mood and affect 1997 Document Guidelines for Evaluation and Management. (1997) retrieved January 20, 2013 from ACR/Documents/PDF/Economics/1997%20Document%20Guidelines%20for%20Evaluation%20and%20Management.pdf

90 + Non Covered Services Consent Non-Covered Services Medical Consent Form I,, understand that some services may not be considered eligible benefits (e.g., services and/or supplies may be determined to not be medically necessary, noncovered or investigational) by my health insurance provider. I understand that my health insurance coverage has certain restrictions and limitations, such as authorization requirements and noncovered services. Examples of these non-covered items include, but are not limited to, report writing, conferences and/or meetings and supplies. I agree to be financially responsible for any and all related charges if they are not covered by my health insurance. Common non covered services Filling out forms or writing letters for you at your request (includes work and school absence excuse letters, pre-employment forms, health club medical clearance forms, letters to airlines, family medical leave forms, forms for disability parking stickers, extended care facility applications, etc.) Physician phone consultations and assistance, including calling in prescriptions and prescription refills: when you are traveling out of town; and in management of an urgent health problem, when you are offered an appointment but decline to come to the office Writing, calling in or faxing prescriptions to mail-order pharmacies Writing and refilling prescriptions, when these services are done for you without an appointment Guardian Signature: Date: Prior authorization for medications and tests Writing letters and/or phoning your insurance company on your behalf: To appeal denied claims for services provided by this office or other offices, or for laboratory services or imaging studies To petition for coverage of uncovered drugs, services, diagnostic testing or procedures, and for requests for evaluations by out-of-network physicians outside of Cincinnati Social service and home-care assistance, such as arranging for at-home or in-hospital, private-duty nursing services, arranging for delivery of durable medical equipment, arranging