In this case, it is not a ZIP code
99203 IS A CURRENT PROCEDURAL TERMINOLOGY (CPT) CODE used to report a new patient office visit. Health care providers use this code to document and bill for evaluation and management services (E/M). The code is used to describe an office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision-making. When using time for code selection, 30-44 minutes of the total time is spent on the date of the encounter.
Whether you are audited by an insurance company for a “spot check,” an insurance company requests reimbursement or you are doing a preventative in-house “audit,” there are key billing factors to consider in addition to ensuring a thorough examination.
This article discusses required elements of a 99203 examination, which leads to reimbursement as well as sound patient care.
Insurance companies, as you may know, do not pay us to relieve patients’ pain. We are paid to make patients functional. In my opinion, it is difficult to be fully functional if you are in pain. To that end, we must have a solid examination. (All of those classes in chiropractic college were for a purpose.)
As with Medicare, all insurance companies require patients to have a significant health problem in the form of a musculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function. The patient must have a subluxation as demonstrated by X-ray or physical examination. To prove medical necessity, you need the required components. Done right, you get paid.
Key subjective questions
- What is the character of the present complaint?
Aching, annoying, burning, deep, diffuse, dull, heavy, intolerable, pulling, sharp, stiff, shock-like, stabbing, tight, tingling, throbbing, radiating or numb
- How often are the complaints present?
Constant, frequent, intermittent or occasional
- How bad is the pain?
Visual analog or numeric scale of 1 (minimal) to 10 (the worst)
- Since the problem began, is the pain increasing, decreasing or unchanged?
- When did the problem begin?
Gradually over time or following a specific incident
How was the present condition treated?Surgery, spinal injections, physical therapy, back support or other method
Previous treatment by: Chiropractor/MD/PT
- What aggravates the symptoms?
Bathing, bending, caring for family, carrying, changing positions, performing household chores, computer use, concentrating, coughing or sneezing, driving, exercising, lying on the belly, lying on the back, lifting, looking up, looking over your shoulder, looking down, reaching, squatting, sitting, sleeping, training, climbing stairs, standing, twisting, walking, yard work or almost any movement—these are also the key points of function in the Oswestry and neck disability index.
- What relieves the symptoms?
Chiropractic adjustments, ice or heat packs, massage, medication (over-the-counter or prescription), movement or no movement, physical therapy, rest, sitting, standing, stretching, exercise, back support or rest
- What has been most affected in your daily life?
Employment, homemaking, lifting, personal care, sitting, sleeping, social life, standing, driving, traveling or walking
- What difficulty are you having with regard to this complaint?
Bending over, caring for family, climbing stairs, concentrating, driving, exercising, getting into or out of car, getting to sleep, staying asleep, grocery shopping, performing household chores, intimate moments, lifting, looking over shoulder, lying down, reaching overhead, getting out of a chair or bed, personal hygiene, sitting, standing, computer use, walking or yard work
- What are the patient’s therapy goals?
Decreasing stiffness, decreasing swelling, getting out of bed or chair without pain, improving
range of motion without pain, improving flexibility, improving strength, lifting without pain, relieving pain, returning to exercising without limitation, returning to work without limitation, sleeping without interruption, standing without pain or sitting without pain
- List medications and correlate with comorbidities/complicating factors, such as diabetes, hypertension, anxiety, multiple sclerosis (MS) or cancer, etc.
- List any serious injuries in the past 10 years.
- Family histories, including hypertension, diabetes, arthritis, MS, dementia, Alzheimer’s, cancer, etc.
- Social history, including amount and frequency of alcohol, tobacco, coffee, soda, water, sleeping aids and pain relievers
Now, let’s move on to the exam
Remember PART. Two elements should be included, but pain and tenderness alone need to be supported by either asymmetry and/or range of motion. Here are some examples:
(P) Pain, tenderness Sacrum/left, L2, T2
(A) Asymmetry/misalignment high right shoulder, genu valgus, anterior head carriage
(R) Range of motion cervical norms: 90/90 flexion, 55/55 extension, 40/40 left lateral flexion, 40/40 right lateral flexion, 30/30 left rotation, 30/30 right rotation
Lumbo-thoracic norms: 60/60 flexion, 55/55 extension, 35/35 left lateral flexion, 35/35 right lateral flexion. 80/80 left rotation, 80/80 right rotation
(T) Tissue—For example, weak splenius cervicus, tight sternocleidomastoids associated with cervical and thoracic, weak multifidus and gluts, tight hip flexors associated with lumbar and sacral segments, lumbar-sacrum neuro muscle strength L2, L3, L4, L5 and SI
Sensory L2, L3, L4, L5, S1 or demonstrated normal pain perception
Lumbosacral ortho examples include:
- Advancement Bechterew
- Ely test (SI)
- Braggard’s sign (sciatica)
- Lewin Gaenslen test
- Stork Minors test
- Yeoman Femoral Stretch (L3/L4)
- Heel walk (L4/L5)
- Toe walk (l5/S1)
- Nachlas test
- Spinous percussion
- Muscle strength C3, C4, C5, C6, C7, T1
- Sensory C3, C4, C5, C6, C7, C8, T1/B or demonstrated normal pain perception
Cervical ortho examples include cervical compression, foraminal compression, l/r shoulder depression, maximum cervical encroachment, cervical distraction test, Spurling’s (radiculopathy) or Adams (scoliosis).
Another important portion of a cervical examination is taking bilateral blood pressure. If the blood pressure is 20 points different from side to side, this patient may be in a pre-stroke state. Refer out for evaluation.
To qualify as a 99203 examination versus 99202, review of constitution is necessary. Constitutional: enies having had COVID, no loss of taste or smell, no fever, no night sweats, no significant weight gain/weight loss, no exercise intolerance.
Eyes: No irritation, no dry eyes, no vision changes
ENMT: No difficulty hearing, no ear pain
Nose: No frequent nosebleeds, no nose/sinus problems
Mouth/throat: No throat pain, no bleeding gums, no snoring, no dry mouth, no mouth ulcers, no oral abnormalities, no teeth problems
Cardiovascular: No chest pain, no arm pain on exertion, no shortness of breath when walking/climbing stairs or lying down, no palpitations, no known heart murmur
Respiratory: No cough, no wheezing, no coughing up blood, no sleep apnea
GI: No abdominal pain, no vomiting, no abnormal appetite, no diarrhea, no vomiting blood, no dyspepsia, no GERD
GU: No incontinence, no difficulty urinating, no hematuria, no increased frequency Integumentary: No abnormal moles, no jaundice, no rashes, no lacerations
Neuro: No loss of consciousness, no weakness, no numbness, no seizures, no dizziness, no headaches
Psych: No depression, feeling safe in relationship, no alcohol abuse, no restless sleep, no feelings of hurting self or others
Endocrine: No fatigue
Hematologic/lymphatic: No swollen glands, no bruising
Allergic/immunologic: No runny nose, no sinus problems, no itching, no hives, no frequent sneezing
Your assessment should incorporate the neck pain disability index and/or the revised Oswestry disability index or whatever questionnaires you are comfortable with conducting. Assessment gathers the elements of the patient history plus the examination findings as well as functional impairments. This is where the doctor evaluates the clinical information and formulates a treatment plan to cover short-term (two weeks) and long-term care (four weeks).
Medical necessity to provide your treatment plan
Neck pain disability index: Percent of functional impairment: 0-8% (none), 10-28% (mild), 30-48% (moderate), 50-68% (severe) and >70% (crippled)
Revised Oswestry disability index: Percent of functional impairment 0-20% (minimal), 20-40% (moderate), 40-60% (severe), 60-80% (crippled) or 80-100% (bedbound)
Example of treatment plan
The following presents some short-term goals, long-term goals and possible treatment plans.
Short-term goals: Reduce pain from fairly severe to mild/moderate; be able to lift moderate weights from convenient positions; be able to read as much as possible with moderate neck/upper thoracic spine pain (UTSP); reduce headaches to slight and infrequent; be able to concentrate fully with slight difficulty; do as much work as desirable; be able to drive as long as desirable with slight neck pain; be able to sleep moderately disturbed and engage in all recreational activities with some neck pain.
Long-term goals: Eliminate UTSP; be able to lift heavy weights from convenient positions; be able to read as much as desirable with mild neck/UTSP; eliminate headaches; be able to concentrate fully with no difficulty; be able to drive as long as desirable with no neck pain; be able to sleep undisturbed and engage in all recreational activities with no neck pain.
Treatment plan: Recommend the patient be seen two times per week for 1-2 weeks, once per week for 2 weeks, then once every 2 weeks for 4 weeks, then re-exam. If the patient does not respond favorably in a reasonable amount of time, X-rays or MRI will be recommended. Prepare the patient for a home-based exercise program to include floor exercises to target specific erector spinae muscles associated with posture and daily exercises to strengthen core muscles.
The treatment plan should be designed for what the patient needs, not for the financial needs of the doctor or clinic.
Remember to list the segments adjusted along with the technique used. When using modalities list minutes, units and clock time to the specific area treated. Also note the purpose of the modality.
Please get a good history and do a good exam. This takes time, but you have proved medical necessity and you have done due diligence. You deserve to be paid for a job well-done and your patients deserve proper evaluation and proper treatment. A patient just wanting to be “popped” may lead to the doctor missing strategic information.
I am thrilled when patients say I have been more thorough than their medical doctor! I touch (palpate) the spine and find the segments that need to be adjusted, and I adjust them. It is my job. And I love it!
DIANE M. BARTON, DC, MCS-P, CIC, is a graduate of Palmer College of Chiropractic. She received her certifications in medical cmpliance as well as insurance consulting and peer review from Logan College of Chiropractic. She has been in private practice for 35 years in the south suburbs of Chicago.