7.0 Facilities and Ancillary Providers

Transcription

1 7.0 Facilities and Ancillary Providers Note: See Section 8 of this manual for billing guidelines. 7.1 Hospital Admissions A hospital must sign a participation agreement to participate with the Health Plan. The agreement contains provisions governing the hospital s relationship to the Health Plan. For contractual requirements specific to a hospital, refer to the facility s participation agreement. Many health benefit programs require that the member or his/her provider obtain authorization prior to all hospital admissions, excluding maternity and emergency admissions. To obtain prior authorization, providers should call the REFERRAL INTAKE number on the Contact List in Section 2 of this manual. For those health benefit programs that do not require prior authorization for inpatient admission, the Health Plan encourages facilities to notify the Health Plan before admitting a member, or within 48 hours of admitting a member for emergency care. This is to coordinate care and facilitate claims processing. To notify the Health Plan of a hospital admission, facilities must call the REFERRAL INTAKE telephone number listed on the Contact List in Section 2 of this manual. The Health Plan uses concurrent review in assessing inpatient admissions. However, the Health Plan may employ post-service inpatient review, depending upon the subscriber contract. For a description of the Health Plan s utilization review processes, see Section 4 of this manual. When the concurrent review of inpatient care results in an adverse determination that involves member liability, the Health Plan will send a notification of adverse determination to the member, the member s PCP, and the specialist, as applicable. When the concurrent review results in a change in the level of care that does not involve member liability, the Health Plan will send a notice of adverse determination to the attending provider and the inpatient facility. For more information about notices of adverse determinations, see Section 4. The notice of adverse determination will include a description of the grievance and/or appeals processes available to the provider or the member if he/she does not agree with the Health Plan s final determination. See Section 4 for the Utilization Review Grievance and Appeals processes applicable to commercial as well as government sponsored safety net health benefit programs. Fair Hearing for Medicaid members is described in Section 9. See Section 10 for the grievance and appeals processes applicable to Medicare Advantage health benefit programs, including Medicare Blue PPO. January

2 7.0 Facilities and Ancillary Providers Excellus BlueCross BlueShield 7.2 Skilled Nursing Facilities (SNF) General Information A Skilled Nursing Facility (SNF) must sign a participation agreement to participate with the Health Plan. The agreement contains provisions governing the SNF s relationship to the Health Plan. For contractual requirements specific to a SNF, refer to the SNF s Participation Agreement. Note: Most of the Health Plan s health benefit programs do not cover SNF custodial care. Not all member contracts include a benefit for skilled nursing facility care. Many health benefit programs that include a benefit for SNF care require that the member or his/her provider obtain prior authorization before admission to the SNF. To obtain prior authorization, providers should call the REFERRAL INTAKE number on the Contact List in Section 2 of this manual. For those health benefit programs that do not require prior authorization for inpatient admission, the Health Plan encourages facilities to notify the Health Plan before admitting a member for nonemergency care, or within 48 hours of admitting a member for emergency care. This is to coordinate care and facilitate claims processing. To notify the Health Plan of an inpatient admission, facilities must call the REFERRAL INTAKE telephone number listed on the Contact List in Section 2 of this manual. The Health Plan may perform post-service review on SNF claims, whether or not prior authorization was required, as the prior authorization is not specific regarding the level of care needed. See Section 4 of this manual for information regarding post-service review. The Health Plan determines the need for skilled nursing care in accordance with InterQual guidelines. The Health Plan s agreements with SNFs specify that rates are all-inclusive, unless stated otherwise. During the prior authorization process, the SNF must inform the Health Plan of any special needs the member may have that will incur additional expense. Such needs will be subject to Health Plan medical policies and Medical Director review. A SNF is responsible for contacting the Health Plan immediately if a member no longer requires skilled services. Failure to do so may affect payment. 7 2 January 2005

3 Participating Provider Manual 7.0 Facilities and Ancillary Providers Notification of Termination of Services Should the Health Plan determine that a member admitted to a SNF no longer requires certain skilled care services, the Health Plan will notify the member, his/her designated responsible party (if applicable) and the SNF by mail. The letter will identify the reasons for the determination and provide details about the appeal process. For members of Medicare Advantage programs such as Medicare Blue PPO, the Health Plan will send the notification not later than two days before the termination of services. The notification will include a form that the member must sign and return to the Health Plan indicating that the member has received the notification of impending termination of services. Once the Health Plan notifies the SNF that coverage for certain services provided to a Medicare Advantage member will be terminated, the SNF must send the member a Notice of Medicare Non-Coverage (NOMNC). See Section 7.4 for an explanation of this requirement SNF Billing Guidelines Note: For additional billing guidelines, see Section 8 of this manual. Before providing services, a participating SNF must obtain prior authorization from the Health Plan for those health benefit programs that require authorization for the services to be provided. Claims for services provided without required authorization will be denied. Claims may be billed electronically or on paper. Claims for inpatient services should be billed electronically in the 837I institutional HIPAAcompliant format, or on paper on a UB-92. Claims for outpatient services should be billed electronically in the 837P professional HIPAAcompliant format, or on paper on a CMS For inpatient claims, SNFs should use Type of Bill 211 with an appropriate revenue code. The admission date is defined as the first day of the admission for which claim is submitted. Date of discharge will not be paid on final discharge claim. January

4 7.0 Facilities and Ancillary Providers Excellus BlueCross BlueShield 7.3 Home Care Service Providers General Information The purpose of home care services is to provide intermittent, short-term care when outpatient care is not appropriate. Many of the Health Plan s health benefit programs that include coverage for home care also include a limit on the number of visits allowed. Home care services may be subject to prior authorization based on the individual member s contract (see Product Overviews in Section 11 of this manual, or inquire through the Health Plan member eligibility systems, described in Section 2). Participating home care services providers must obtain the appropriate prior authorization before providing services. To obtain authorization for home care services for those health benefit programs requiring it, a provider must call the Referral Intake number included on the Contact List in Section 2 of this manual Notification of Termination of Services Should the Health Plan determine that a member no longer requires home care services, the Health Plan will notify the member, his/her designated responsible party (if applicable) and the home care agency by mail. The letter will identify the reasons for the determination and provide details about the appeal process. For members of Medicare Advantage programs such Medicare Blue PPO, the Health Plan will send the notification not later than two days before the termination of services. The notification will include a form that the member must sign and return to the Health Plan, indicating that the member has received the notification of impending termination of services. Once the Health Plan notifies the home care agency that coverage for certain services provided to the member will be terminated, the home care agency must send the member a Notice of Medicare Non-Coverage. See Section 7.4 for an explanation of this requirement. 7 4 January 2005

5 Participating Provider Manual 7.0 Facilities and Ancillary Providers 7.4 Notice of Medicare Non-Coverage (for SNFs, HHAs and CORFs: Medicare Advantage Only) Overview Based on provisions of a CMS regulation that went into effect January 1, 2004, a Skilled Nursing Facility (SNF), Home Health Agency (HHA) or Comprehensive Outpatient Rehabilitation Facility (CORF) must send a member of a Medicare Advantage health benefit program a Notice of Medicare Non-Coverage (NOMNC) if the organization decides that Medicare services provided to this member should end. A copy of the form is included in Section 7.8. The CMS instructions for completing the form are provided in Section Note: If the member disagrees with the organization s decision, the member may request an immediate review by a Quality Improvement Organization (QIO): See Section 10.8 of this manual. Below is a summary of CMS requirements regarding the Notice of Medicare Non-Coverage (NOMNC): Providers are not required to deliver NOMNC in situations where the member s benefit is exhausted: e.g., 100-day SNF coverage. Rather, the provider must send the member CMS Form NDMC, Notice of Denial of Medical Coverage. Upon request, Univera Healthcare will assist a provider in completing the NDMC form. Providers must deliver the Notice of Medicare Non-Coverage (NOMNC) no later than two days before the termination of services. Providers may not modify the standardized NOMNC form except to: - Add factual information associated with enrollee, for example, the type of services (home care, SNF, CORF), the effective date of termination, and identifying member information (name and member identification number). This information may be added at the open space at the top of the form in addition to the provider s logo, if desired. - On the second page of the form, add information about the rationale for ending of services (optional). CMS has provided detailed information describing valid delivery of the notice and delivery of the notice to authorized representatives when the enrollee is determined to be incompetent (see Section 7.4.2). January

6 7.0 Facilities and Ancillary Providers Excellus BlueCross BlueShield CMS Form Instructions: Notice of Medicare Non-Coverage (NOMNC), The Advance Notice, CMS A Note: See Section 7.8 for a copy of the form. A Medicare Advantage (MA) provider must deliver an advance, completed copy of this notice to enrollees receiving skilled nursing, home health or comprehensive outpatient rehabilitation facility services not later than two days before the termination of services. This notice fulfills the requirement at 42 CFR (b)(2). This is a standard notice. MA providers may not deviate from the content of the form except where indicated. (You may modify the form for mass printing to indicate the kind of service being terminated if only one type of service is provided, i.e., skilled nursing, home health, or comprehensive outpatient rehabilitation.) In situations where the termination decision is not delegated to the provider, the MA plan must provide the termination of services date to the provider not later than two days before the termination of services for timely delivery to occur. The NOMNC should not be used when MA plans determine that an enrollee s services should end based on the exhaustion of Medicare benefits (such as the 100-day SNF limit). Instead, MA plans must issue the Notice of Denial of Medical Coverage. MA plans and providers will note that the notice must be validly delivered. Valid delivery means that the enrollee must be able to understand the purpose and contents of the notice in order to sign for receipt of it. The enrollee must be able to understand that he or she may appeal the termination decision. If the enrollee is not able to comprehend the contents of the notice, it must be delivered to and signed by an authorized representative of the enrollee. Valid delivery does not preclude the use of assistive devices, witnesses, or interpreters for notice delivery. Thus, if an enrollee is able to comprehend the notice, but either is physically unable to sign it, or needs the assistance of an interpreter to translate it or an assistive device to read or sign it, valid delivery may be achieved by documenting the use of such assistance. Furthermore, if the enrollee refuses to sign the notice, the notice is still valid as long as the provider documents that the notice was given, but the enrollee refused to sign. Notice Delivery to Authorized Representatives CMS requires that notification of changes in coverage for an enrollee who is not competent be made to an authorized representative acting on behalf of the enrollee. Notification to the authorized representative may be problematic because he or she may not be available in person to acknowledge receipt of the required notification. MA plans and providers are required to develop procedures to use when the enrollee is incompetent or incapable of receiving the notice, and the provider cannot obtain the signature of the enrollee s representative through direct personal contact. 7 6 January 2005

7 Participating Provider Manual 7.0 Facilities and Ancillary Providers If the provider is unable to personally deliver a notice of noncoverage to a person legally acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee s services are no longer covered. The enrollee s appeal rights must be explained to the representative, and the name and telephone number of the appropriate quality improvement organization (QIO) should be provided. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. Place a dated copy of the notice in the enrollee s medical file and document the telephone contact to include: name of person initiating the contact, name of the representative contacted, date and time of the contact and the telephone number called. When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested. The date that someone at the representative s address signs (or refuses to sign) the receipt is the date of receipt. Place a copy of the notice in the enrollee s medical file and document the attempted telephone contact to include: the name of person initiating the contact, the name of the representative you attempted to contact, the date and time of the attempted contact and the telephone number called. When notices are returned by the post office, with no indication of a refusal date, then the enrollee s liability starts on the second working day after the provider s mailing date. These procedures also may be used where an enrollee has authorized an individual to act on his or her behalf, and the provider cannot obtain the signature of the enrollee s representative through direct personal contact. (continued) January

8 7.0 Facilities and Ancillary Providers Excellus BlueCross BlueShield [Form Heading] Patient Name Patient ID Number CMS Instructions for Completing the NOMNC Form Area on Form THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT {insert type} SERVICES WILL END: {insert effective date} Entry Instructions MA plans and/or providers must be identified in this space. Logos may be used if they include the name of the organization, address and telephone number of the organization responsible for the termination decision above the title of the notice. Insert the patient s full name. YOUR RIGHT TO APPEAL THIS DECISION Bullet # 1 N/A Bullet # 2 N/A Bullet # 3 N/A Bullet # 4 N/A Bullet # 5 N/A Insert a unique patient identifier such as the HIC number or Medical Record number, if applicable. Fill in the type of services ending, {home health, skilled nursing, or comprehensive outpatient rehabilitation services} and the actual date the covered service will end. The date should be in no less than 12-point type. Note that if the effective date for the service termination changes after delivery of the notice, the provider may contact the patient or authorized representative by phone to inform him or her of the new service termination date. Confirm the telephone contact by written notice mailed on that same date. HOW TO ASK FOR AN IMMEDIATE APPEAL Bullet # 1 N/A Bullet # 2 N/A Bullet # 3 N/A Bullet # 4 [The name and telephone numbers (including TTY/TDD) of the applicable QIO has already been included in the copy presented in Section 7.8.] OTHER APPEAL RIGHTS Bullet # 1 N/A Bullet #2 N/A ADDITIONAL INFORMATION (OPTIONAL) Signature line: Date: This space is available, at the option of the plan or relevant provider, to furnish additional relevant information to the enrollee, such as further details about the reason for the service termination, or the timing of any additional liability risk. The use of this space does not replace the requirement to provide the Detailed Notice of Non- Coverage (DENC) to either the enrollee or the QIO when an appeal is filed. The enrollee or the authorized representative must sign this line. The enrollee or the authorized representative must fill in the date that he or she signs the document. (end) 7 8 January 2005

9 Participating Provider Manual 7.0 Facilities and Ancillary Providers 7.5 Rehabilitative Therapy Providers Managed care health benefit programs, as well as some other programs, require prior authorization for therapies, including physical therapy and occupational therapy. Providers should check eligibility and requirements before providing services. To request prior authorization, the referring physician may call the Referral Intake number on the Contact List in Section 2 of this manual. The Health Plan authorizes rehabilitation services based on medical necessity. The authorization is subject to the individual member s contract. HMO members whose health benefit program does not include out-of-network benefits must obtain therapy services from participating therapists. Members in point-of-service plans may use non-participating therapists, but they will have a lower level of benefit (higher out-of-pocket cost) if they do so To Add Visits PT or OT If the physical or occupational therapist feels that more visits are warranted, he or she should request them prior to the last authorized visit, using the PT or OT Update Request Form. A copy of this form is included among the forms and charts in Section 4 of this manual. It is also available on the Health Plan s Web site, or by calling Provider Service. If the Health Plan determines that the request for additional visits does not meet the Health Plan criteria, the Health Plan will ask the physical therapist or occupational therapist to send all case note documentation, including objective, measurable data and an updated physician order. The Health Plan will review patient progress over the previous two-week interval. The case will be presented to a Health Plan Medical Director for review. The Medical Director may authorize additional visits or deny coverage for further services. A Rehabilitation Specialist will call to inform the physical therapist or occupational therapist of the decision. If treatment is denied, the member or his/her representative may initiate an appeal of this decision. See Section 4 of this manual for information about appeals New Course of Treatment in Same Year PT or OT If a physical therapist or occupational therapist requests another authorization while an earlier authorization is still active (due to a different diagnosis or a different practitioner), the Health Plan requires completion of a PT or OT Initial Authorization Form. When the provider calls Referral Intake for the authorization, if the representative finds an authorization still open, he/she will request that the provider complete a PT or OT Initial Authorization Form. A copy of this form is included among the forms and charts in Section 4 of this manual. It is also available on the Health Plan Web site, or by calling Provider Service. January

10 7.0 Facilities and Ancillary Providers Excellus BlueCross BlueShield Reviewers Need Objective Data Both the PT or OT Update Request Form and the PT or OT Initial Authorization Form are designed to capture the specific objective information that our outpatient rehabilitation team requires in order to help determine the appropriate number of visits. Examples of objective data required for a medical physical and/or occupational therapy review include: Range of motion (in degrees) Muscle strength (grade scale 0-5) Pain level Girth Balance status Ambulation status Neurologic status Activities of daily living capabilities Wound size Wound status Subjective data such as feeling better, massage and modalities help, gym is needed for exercise, and can t perform athletics do not support medical necessity. Nor does a list of exercises, with frequency and duration included. These types of data do not provide information about the functional status of the patient. The review team must be able to determine how the patient functions in regard to objective measures at the start of care (initial evaluation) and after subsequent care. 7.6 Chiropractors To help chiropractors provide the type of information the Health Plan needs to appropriately pay claims for chiropractic services, the Health Plan has created some chiropractic documentation standards. The standards are included in Forms and Charts, at the end of this section. Also included are descriptions, and instructions for use, of the clinical outcome tools that are currently a part of the chiropractic documentation standards. Health Plan staff may ask to see charts as part of medical necessity review. Part of this review includes ensuring that the components listed in the documentation standards are included in the patient s chart. The Health Plan requires that all participating chiropractors include the components of the documentation standards in charts for Health Plan members, as well as an appropriate disability measurement tool such as those described. This applies across all lines of business. The Health Plan requires that participating chiropractors use the treatment plan at the end of this section when documenting treatment for Health Plan managed care members. In addition, the Health Plan encourages participating chiropractors to use the treatment plan for all Health Plan members January 2005

11 Participating Provider Manual 7.0 Facilities and Ancillary Providers The Health Plan recommends use of the outcome tools at an appropriate clinical frequency to assess care. Usually this is every two weeks, or on each visit if the interval between visits is greater than two weeks. The referenced tools discussed are available from a variety of sources, including the Internet. Most may be copied for use in an individual chiropractor s practice. The Health Plan recommends The Clinical Application of Outcomes Assessment, Ed: Yeomans, SG. (Stamford, CT), Appleton & Lange. August There are also resources available on the FCER (Foundation for Chiropractic Education and Research) Web site ( 7.7 Imaging Facilities Accreditation Required for MRI Equipment Effective January 1, 2005, the Health Plan requires that all sites operating magnetic resonance imaging (MRI) equipment have, and maintain, accreditation through the American College of Radiology (ACR) for MRI services. This accreditation will be a requirement for continued participation with the Health Plan for the provision of MRI services. Note: This requirement does not yet apply for extremity MRI magnets Preauthorization for Imaging Studies Managed care health benefit programs, as well as most PPO and EPO programs and some traditional indemnity health benefit programs that are customized for specific employer groups, include a requirement that specified imaging studies be preauthorized. Among the charts at the end of the Benefits Management section of this manual (Section 4) is a tip sheet with CPT procedure codes for imaging services that require preauthorization. January

12 7.0 Facilities and Ancillary Providers Excellus BlueCross BlueShield 7.8 Forms and Charts The following forms and charts are presented in this section. Form: Notice of Medicare Non-Coverage (NOMNC) Chart: Chiropractic Medical Record Documentation Standards When and How to Use Chiropractic Outcomes Tools Chiropractic Treatment Plan, Instructions for Use Chiropractic Treatment Plan 7 12 January 2005

13 {Insert logo here} NOTICE OF MEDICARE NON-COVERAGE OMB Approval No Patient Name: Patient ID Number: THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT {insert type} SERVICES WILL END: {insert effective date} Your Medicare Advantage (MA) plan and/or provider have determined that Medicare probably will not pay for your current {insert type} services after the effective date indicated above. You may have to pay for any {insert type} services you receive after the above date. YOUR RIGHT TO APPEAL THIS DECISION You have the right to an immediate, independent medical review (appeal), while your services continue, of the decision to end Medicare coverage of these services. If you choose to appeal, the independent reviewer will ask for your opinion. The reviewer will also look at your medical records and/or other relevant information. You do not have to prepare anything in writing, but you have the right to do so if you wish. If you choose to appeal, you and the independent reviewer will each receive a copy of the detailed explanation about why your coverage for services should not continue. You will receive this detailed notice only after you request an appeal. If you choose to appeal, and the independent reviewer agrees that services should no longer be covered after the effective date indicated above, neither Medicare nor your MA plan will pay for these services after that date. If you stop services no later than the effective date indicated above, you will avoid financial liability. HOW TO ASK FOR AN IMMEDIATE APPEAL You must make your request to your Quality Improvement Organization (also known as a QIO). A QIO is the independent reviewer authorized by Medicare to review the decision to end these services. Your request for an immediate appeal should be made as soon as possible, but no later than noon of the day before the effective date indicated above. The QIO will notify you of its decision as soon as possible, generally by no later than the effective date of this notice. Call your QIO, Island Peer Review Organization, at 1 (888) or TTY/TDD 1 (866) to appeal, or if you have questions. See the back of this notice for more information

14 OTHER APPEAL RIGHTS: If you miss the deadline for requesting an immediate appeal with the QIO, you still may request an expedited appeal from your MA plan. If your request does not meet the criteria for an expedited review, your MA plan will review the decision under its rules for standard appeals. Please see your Evidence of Coverage for more information. Contact your MA plan or MEDICARE ( ), or TTY/TDD: for more information about the MA appeals process. ADDITIONAL INFORMATION (OPTIONAL) Please sign below to indicate that you have received this notice. I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO. Signature of Patient or Authorized Representative Date Form No. CMS Exp. Date 03/31/2007 According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is The time required to prepare and distribute this collection is 15 minutes per notice, including the time to select the preprinted form, complete it and deliver it to the enrollee. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland

15 Participating Provider Manual 7.0 Facilities and Ancillary Providers Chiropractic Medical Record Documentation Standards The following standards are based, in part, on National Committee for Quality Assurance requirements, established documentation standards and the use of medical necessity in establishing the need for continuing care. Each of the following components should be included in the patient s chart. The text in italics provides further explanation of what is expected in each component, and what a reviewer might look for. 1. Patient name or patient ID recorded on every page. Every page of the medical record has patient identification in the form of name or ID number. ID number may be a medical record number or insurance number. 2. Demographics are documented. a) Patient s date of birth (may be kept in separate file or database). b) Patient s current address (may be kept in separate file/database). c) Patient s home and work telephone numbers (A home number should be listed for all patients. There should be a stated method of reaching the patient in case of an emergency.) d) Employer and work phone number, if applicable. e) Marital status. 3. All entries in the medical record are signed or initialed for each visit or episode of care. 4. All entries in the medical record are dated. 5. Visits are documented in the SOAP format. 6. All records are LEGIBLE. Several charts will be reviewed before the reviewer deems them illegible. The medical record review will be scored as unsatisfactory if the charts are deemed illegible. 7. Related Problem List, separate from the progress notes, is present. Problem list should contain all significant illnesses and active medical conditions pertinent to the patient s health care. For those without active problems, the list should indicate no problems. 8. Allergies/adverse reactions are documented. Medication allergies and adverse reactions must be recorded in a prominent location in the chart. If the patient does not have allergies, NKDA or NKA must be recorded in the chart. 9. Relevant past history: Includes serious accidents, operations, physical and psychological illnesses pertinent to the patient s health care. If present, is the history satisfactory? January

16 7.0 Facilities and Ancillary Providers Excellus BlueCross BlueShield Chart needs to include evidence that there was an inquiry about important medical problems (such as heart disease, diabetes, cancer, etc.). 10. Current complaint: a) History of presenting complaint is recorded. Chart needs to list presenting symptom, potential triggering event, and assessment of severity (amount of pain and/or interference with daily activities). History, if present, is satisfactory. Needs to indicate additional details such as what aggravates/relieves symptoms, relation to activity, treatments that have been attempted before chiropractic visit. b) Pain chart is included. Pain drawing is part of the record. Must demonstrate that the patient completed it. c) Examination is documented. 1) Vital Signs At least one visit for the patient needs to include blood pressure and pulse. 2) Neurological exam is documented. Neurological exam should be documented for at least the initial visit. The record should indicate that at least 80 percent of the pertinent examination has been recorded, and the follow-up neurological examinations are performed as clinically indicated. 3) Orthopedic examination is documented. Orthopedic exam should be documented for at least the initial visit. The record should indicate that at least 80 percent of the pertinent examination has been recorded, and the follow-up orthopedic examinations are performed as clinically indicated. 11. Were imaging studies ordered? If studies were/were not ordered, were they appropriate? Were they indicated? Was this based on community standards? If studies were done, is there evidence (signed notation on the report or reference to the study in other notes) that indicates that the physician has reviewed the studies? 12. The differential diagnosis and/or clinical impression are consistent with the findings. The chart indicates, AT LEAST, the most likely diagnosis/condition reflective of patient s symptoms and exam findings. 13. Treatment is appropriate. Does the treatment documented in the chart seem appropriate given the findings and clinical impression? If so, the documentation is adequate and reflective of the clinical impression January 2005

17 Participating Provider Manual 7.0 Facilities and Ancillary Providers Is there sufficient detail in the chart to support and understand the treatments provided? 14. Timing (frequency and interval) of treatment is appropriate. Number of treatments and intervals between visits is reasonable based upon community norms/standards. 15. Date and time frame for follow-up visits are recorded in the chart. 16. Current medications are listed in a discernible manner. May be in the progress notes or on a separate medication record in the chart. Must, at least, indicate the names of the medications. Patient not taking medications should be indicated as no medications. If no medications are listed or there is no statement indicating no medications, then no is recorded. The record should also reflect any nutritional/herbal supplements that the patient is currently taking. 17. There is evidence of continuity of care between chiropractor and primary care provider or other referring specialist. Evidence includes written communication and/or documentation of telephone communications. Evidence of communication of care is satisfactory. Needs to include presenting symptom, likely diagnosis and a treatment plan. January

18 7.0 Facilities and Ancillary Providers Excellus BlueCross BlueShield When and How to Use Chiropractic Outcome Tools Tools discussed include: Low Back and Neck Pain and Disability Questionnaires Pain Rating Scales Headache Disability Index Low Back and Neck Pain and Disability Questionnaires The purpose of these questionnaires is to quantifiably measure a patient s response to care or a change in the patient s condition. The patient should complete the questionnaire. A. When to use 1. Before treatment has begun. It is important to obtain a baseline objective measurement of the patient s functional capabilities. It is best to incorporate the tools as part of the initial documentation. 2. Periodically, during care, when you think a measurable change in the patient s condition has taken place. a. For acute care (defined as symptoms present four weeks or less), the questionnaire should be completed at one-week intervals. b. For other pain complaints, completion of the questionnaire at two-week intervals is appropriate. B. Choice of Questionnaire 1. For patients with neck pain, the Health Plan prefers the Vernon-Mior Neck Pain and Disability Index. 2. For patients with low back pain, the Health Plan prefers either the Oswestry or the Roland- Morris Low Back Pain and Disability Questionnaire. The patient should use the same questionnaire throughout his/her course of treatment. You may decide to use only one questionnaire with all of your back pain patients. This would still be valid and perhaps the least confusing for your staff. However, the Roland-Morris tool is more sensitive in documenting changes with acute and subacute pain (defined as less than six weeks). In other words, you are likely to demonstrate a larger percentage of improvement with chiropractic care with these patients using the Roland-Morris tool. In contrast, the Oswestry is more sensitive in measuring results with chronic pain patients. C. Nuances about the tools 1. Be sure the tools are completed at the appropriate times by the patient January 2005

19 Participating Provider Manual 7.0 Facilities and Ancillary Providers 2. Make sure, with the Vernon-Mior and Oswestry, that all the sections are completed. 3. The tool is not valid if completed after the patient leaves the office. 4. The patient must not be informed of his/her scores after the completion of the tool. D. Scoring Method for Neck Disability Index (NDI) and Oswestry Low Back Pain Disability Questionnaire 1. Each of the 10 sections is scored separately (0 5 points each) and then added for maximum total points of 50. For example: Section 1: Pain Intensity Point Value A. I have no pain at the moment. 0 B. The pain is very mild at the moment. 1 C. The pain is moderate at the moment. 2 D. The pain is fairly severe at the moment. 3 E. The pain is very severe at the moment. 4 F. The pain is the worst imaginable 5 2. If all 10 sections are completed, simply double the patient s score for a percentage of disability. 3. If a section is omitted, simply score the sections completed. Then divide the patient s score by the total number of sections completed times 5 (the maximum number of points). Formula: Patient s score/number of sections completed times 5. Multiply by 100 to obtain a percentage of disability. For example: If nine out of 10 sections are completed, divide the patient s score by 45 (9 x 5). Patient s score = 22. Sections completed = 9, then multiply by the maximum amount of potential points per section (9 x 5) = 45 and... 22/45 = 0.48 x 100 = 48% disability. Interpretation of Disability Scores % = Minimal Disability Patient can cope with most activities of daily living. Usually no treatment is needed apart from advice on lifting, sitting, posture, physical fitness and diet. In this group, some patients have particular difficulty with sitting, and this may be important if their occupations are sedentary (typist, driver, etc.) % = Moderate Disability January

20 7.0 Facilities and Ancillary Providers Excellus BlueCross BlueShield This group experiences more pain and problems with sitting, lifting and standing. Travel and social life are more difficult, and they well may be off work. Personal care, sexual activity and sleeping are not grossly affected, and the condition can usually be managed with conservative means % = Severe Disability In this group of patients, pain remains the main problem. Travel, personal care, social life, sexual activity and sleep are also affected. These patients require detailed investigation % = Totally Functionally Challenged Back pain impinges on all aspects of these patients lives, both at home and at work. Positive interventions are required % These patients are either bed-bound or exaggerating their symptoms. This can be further evaluated by careful evaluation of the patient during the medical examination. E. Scoring Method Roland-Morris Low Back Pain Disability Questionnaire 1. This questionnaire has 24 items of behavior that may be affected by back pain. Simply add up the total points to yield a score that ranges from 1 to 24. A patient places a mark next to each statement or leaves it blank (in effect, a yes or no answer). If the patient writes in the word sometimes, this answer is scored as On subsequent uses of the tool, the Roland-Morris can yield a percentage of improvement in function. For example, if a patient has a score of 22, and two weeks later the score is 11, there is a 50 percent improvement. 11 (points after treatment)/22 (points pretreatment) x 100 = 50% improvement. Pain Rating Scales Neither of the scales below should be used as a stand-alone objective outcome measurement tool. They are best used with either one of the low back pain and disability questionnaires or the neck pain and disability index. 1. Visual Analog Scale (VAS) The patient completes this tool serially to aid in trending his/her perception of his/her pain patterns as he/she progresses through a course of treatment. The VAS is a 100 mm line, with a pain descriptor at either end, set up in the manner as the example below (not to scale). No Pain Excruciating Pain The patient records his/her pain level by making one perpendicular line. You then measure the pain level from the left end of the 100 mm line to the perpendicular line January 2005

21 Participating Provider Manual 7.0 Facilities and Ancillary Providers The second time the patient completes a VAS, you make the same measurement, then compare the scores. Because the line is 100 mm long, the difference between the two scores is a percentage difference. The use of an X or a circle, rather than a perpendicular, makes the scale invalid as an outcome tool. This packet does not contain a VAS ready for patient use. 2. Numerical Rating Scale (NRS) The NRS is equally as valid as the VAS, easier to use and preferred by most patients. The NRS asks the patient to measure pain severity by selecting one of 11 boxes (numbered from 0 through 10), ranging from No Pain to Excruciating Pain. (See example below.) Rate the severity of your pain by checking on box on the following scale. No Pain Excruciating Pain Headache Disability Index Scoring Method for Headache Disability Index (HDI) 2 A headache disability index (HDI) may be used in conjunction with a neck disability index for patients suffering from cervicogenic headaches. It is also useful as a stand-alone instrument for headache sufferers in whom a cervical component is lacking, as in vascular headaches. The Health Plan prefers the headache disability index published several years ago in the journal Neurology. The tool includes 12 emotional and 13 functional questions that make up the subscales, in addition to the total score. Score Values: Yes = 4 points Sometimes = 2 points No = 0 points The 13 emotion-based questions are numbers 1, 3, 5, 6, 8, 9, 10, 11, 12, 14, 20, 22, 23 (maximum 48 points) The 12 function-based questions are numbers 2, 4, 7, 13, 15, 16, 17, 18, 19, 21, 24, 25 (maximum 52 points) Emotion-based score / tool s score total x 100 = Emotion-based percent of patient s total score. Function-based score / tool s score total x 100 = Function-based percent of patient s total score. As with any outcome tool, the trending pattern helps to define the clinical outcomes. January

22 7.0 Facilities and Ancillary Providers Excellus BlueCross BlueShield 1 Data compiled from Fairbanks, J., Davies, J. & O Brien, J. (1980). The Owestry Low-Back Pain Disability Questionnaire. Physiotherapy, 66, Jacobson, G.P., Ramadan, N.M., Aggarwal, S.K., & Newman, C.W. (1994). The Henry Ford Hospital Headache Disability Inventory [HDI]. Neurology, 44, January 2005

23 Participating Provider Manual 7.0 Facilities and Ancillary Providers Chiropractic Treatment Plan, Instructions for Use Providers may make as many copies as needed of the treatment plan form. Consider adding provider name, address, phone and fax numbers prior to copying. 1. Patient Name 2. Patient date of birth 3. Patient ID number (including prefix) 4. Patient Address 5. Patient Phone Number 6. Provider Name 7. Provider Address 8. Provider Phone#/Fax# 9. Referring Physician (full name) NOTE: All of the above items are self-explanatory. The Health Plan has tried to request only the information necessary for a review. 10. Date of initial visit. This refers to the first time the patient was ever seen in your office. 11. Indication whether new patient, new injury, exacerbation of old injury, or updated treatment plan for continued care. 12. Indication whether the treatment plan is for initial, recurrent or chronic complaint. 13. Cause of current complaint. 14. Date of exacerbation/new injury. 15. List the main working diagnoses. 16. Briefly describe the current complaint. For example, right side neck pain with numbness and tingling into the right thumb and right index finger. 17. Please remark about any contributing or relevant factors/history that may affect the outcome of the patient s care, such as obesity, sedentary lifestyle, diabetes, or arthritis. 18. Evaluation findings Use this table to report your findings during an evaluation. It has been designed to allow the provider to use only one treatment plan for multiple requests for care. The Health Plan s goal is for less paperwork and more time available for patient care. Remember to always include the date of the evaluation in the appropriate box in the top row. Include orthopedic, neurologic, diagnostic and outcome study findings in the appropriate column in January

24 7.0 Facilities and Ancillary Providers Excellus BlueCross BlueShield each row. While we prefer to have the diagnostic reports submitted at the time of the request for care, it is not mandatory. If the reports are submitted, however, please enter the word attached in the column so the reviewer knows to look for them. Please submit the actual patient questionnaire/index with all requests for care. Remember that these outcome tools are serial in nature. This means there needs to be more than one (of the same type) in order to trend the patient s response to care. It is, therefore, very important to include a date (as well as the patient s name) on each of these. 19. Status post care. This section is for the provider to make an educated decision on the patient s outcomes and response to care. 20. Treatment goals. BRIEFLY state your outcome goals for the patient based on the course of treatment. 21. Visits Requested. State the number of visits needed. 22. Time Frame for Care. State the time period (from when to when) over which the treatment will occur. 23. Any additional information. Please include any additional information that might be helpful to our utilization management staff. 24. Sign and date the copy of the treatment plan that you mail or fax to the Health Plan January 2005

25 Excellus BlueCross BlueShield Chiropractic Treatment Plan Patient Name: DOB: ID #: Patient Address: Provider Name: Phone #/Fax #: Phone Number: Address: Referring Physician: Date of initial visit: Is this patient: New to office If not new: New injury Exacerbation of old injury Needs continued care Is this: Initial complaint Recurrent complaint Chronic complaint Cause of current complaint: Trauma Insidious Repetitive Injury Post-surgical Date of Exacerbation/New injury: Diagnosis: 1) 2) 3) 4) Current Complaint Description: Contributing Relevant Medical/Surgical and History Factors: Orthopedic Findings/ROM Initial evaluation findings: Date: Reevaluation findings: Date: Reevaluation findings: Date: Neurologic Findings Diagnostic Findings (EMG, MRI, X-rays) - May enclose with treatment plan NDI, Oswestry Outcome Studies - Must enclose with treatment plan Status Post care: No residuals, D/C Residuals, D/C Residuals, PRN/Supportive care Requires cont. care Referred/transferred Treatment Goals: Visits Requested: Time Frame for Care: Any additional information: I certify that this information accurately reflects patient s medical record. Provider Signature: Date: Revised 2003

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