apportionment

[Guest guest]

Rod, you know how to have fun! This takes a lot of subjective detailed questioning. I'd have the patient list pre-accident ADLs. Pre both accidents. For example: ask him what he/she did at:

1. gym

2. home activities

3. work activities

4. social activities

Ask if he had pain or problems with any of these activities before BOTH accidents. Have him be as honest as possible. If he woke up with a stiff back before both accidents, list it. how often, how long did it take his back to stop being stiff every morning before both accidents.

Then; compare it to AFTER the first accident and then after the 2nd. Pick the same items to 'grade' over and over as the case progresses. You can subtract a difference between both accident ADL grades, average it and apportion care from that. Call me if you have a ques on how to set that up. It follows the 3+2 type of grading system if you're familiar with that model. I've never had an onset of case complication like this one!

MInga Guerrero DC

In a message dated 12/13/2007 4:10:23 P.M. Pacific Standard Time, rjacksondc@... writes:

Hi all:

New patient, ATV accident one week and an auto accident the week after the ATV wreck. I didn't see patient until after both accidents. Injuries to same areas. Anyone have a good apportionment form they use to differentiate injuries between two accidents? Any good ideas for accurately separating these injuries in the eyes of 2 insurance companies?

Thanks!

Rod , DC

Tillamook Natural Health Center

See AOL's top rated recipes and easy ways to stay in shape for winter.

[Guest guest]

Hi all:

New patient, ATV accident one week and an auto accident the week after the ATV wreck. I didn't see patient until after both accidents. Injuries to same areas. Anyone have a good apportionment form they use to differentiate injuries between two accidents? Any good ideas for accurately separating these injuries in the eyes of 2 insurance companies?

Thanks!

Rod , DC

Tillamook Natural Health Center

[Guest guest]

Hi Rod,

This is where “Evidence Based

Outcome Assessment” self reporting psychometric tools help. If the

second accident exacerbated the same area and worsened his pain, disability,

and possible your objective examination findings eg. Further decreased ROMs I

would bill the second carrier for care relative to that injury and stop billing

the first carrier relative to the ATV accident. Then if and when the

patient returns to their “pre-injury status” that is where their

pain, disability and your exam findings were prior to the second accident then

I would go back to the original carrier and return treating off that insurance

until the patient is at MMI. IF the patient doesn’t return to their

pre-injury status then at MMI you will need to perform an apportionment

relative to permanent impairment. I can fax you a form that helps with

this filled out by the patient’s own hand.

Lastly, run this by the claims

representative of the auto injury and ask if this sounds reasonable and if not

what they recommend…and….be nice!

Vern saboe

From:

[mailto: ] On Behalf Of Rodney G. , DC

Sent: Thursday, December 13, 2007

4:23 PM

Subject:

apportionment

Hi all:

New patient, ATV accident one week and an auto accident the

week after the ATV wreck. I didn't see patient until after both accidents.

Injuries to same areas. Anyone have a good apportionment form they use to

differentiate injuries between two accidents? Any good ideas for accurately

separating these injuries in the eyes of 2 insurance companies?

Thanks!

Rod ,

DC

Tillamook Natural Health

Center

[Guest guest]

You forgot to mention if a green car was involved....

, DC, DABCO

>

> Jay, this is where those " evidence based outcome assessments " come

in as they are very helpful in this regard. Pain drawings, VAS,

numerical pain ratings, Neck Disability Index (if it's her neck)

and/or Revised Oswestry etc...patient driven outcomes combined with

your " provider driven outcomes " your exam findings. How have the

numbers changed on these self-reporting instruments and how have your

exam findings changes 1st MVA vs. 2nd?

>

> " MRI was indicated from disc signs? " What were your clinical

findings which supported this special imaging? Did those change after

the 2nd accident. I believe from your statement that the " two disk

bulges " were found after the 1st and just before the 2nd accident.

Simply put if her symptoms and your findings had not changed after

the second MVA that is to say she was not worsened/exacerbated you

don't have to file a new claim. With that said even if her symptoms

and your clinical findings have not changed I would recommend a

repeat MRI just to rule out a worsening of her " pre-existing

condition " that being the disc bulges and make sure you ask the

radiologist to make that call.... " has there been additional

injury/worsening of the pre-existing bulges. " The liability carriers

love to point the finger at each other at " end-game. "

>

> So...if your patient is symptomatically and clinically worsened via

your exam findings but the 2nd MRI reveals no new findings, no

worsening or additional injury to the pre-existing disc bulges then I

would file a new claim, treat and bill on the new claim only.

However make a clear statement that you believe this to represent a

mild exacerbation of her pre-existing condition and will not result

in a material worsening of her pre-existing condition and that your

treatment goal is to return her to her pre-injury status (not MMI)

which should happen in very short order and give them a approx.

number of visits and length of care. Once the patient is back to

where she was then close the claim noting she has been returned to

her pre-injury status and go back to the 1st claim and continuing

treating off that claim if appropriate.

>

> Alternatively, if your patient has significantly worsened

symptomatically and on exam and may or may not have additional injury

on the 2nd MRI and you anticipate prolonged treatment on the 2nd MVA

and then you don't get her back to her pre-injury status (which btw

means getting her back to the pain and disability levels she was at

prior to the 2nd MVA as well as back to your clinical findings) then

when she no longer shows a progression of care/improvement and again

doesn't return to her pre-injury status you will continue to bill

only on the 2nd claim until that point and then will have to

apportion her permanent injuries at that time.

>

> As you can see I don't go for the % deal of this or that % of

curitive treatment costs going to the 1st vs. 2nd MVA

claim/deal....lastly simply do what I do always....always call the

PIP claims adjuster and tell him or her what you propose to do and

ask for their opinion. Whatever they say or come up with go with

it....then fully document that conversation in your patients file

word for word....time...date....claim rep name....phone # etc.

>

> Unless of course all of this has happened on a Tuesday, wherein

their is a full moon, and a high tide then disregard all the above ha!

>

> Vern Saboe DC, FACO

>

> Apportionment

>

>

>

> I have never done apportionment for two MVA accidents before.

How is this done. I learned it in school just long enough ago to be

inaccessable.

>

> I have a female patinent who got in an MVA 3 months ago and came

to me cause she wasn't getting better. MRI was indicated from disc

signs. While she was leaving the MRI shop, she got rear ended. What

is the process for billing? Do I bill a percentage of a treatment to

one accident, and a portion to the other?

>

> Incidentally, the poor girl does have two disk bulges.

>

> Jay

>

> Lindekugel, DC

> Concordia Chiropractic Center

> 5425 NE 33rd Ave.

> PDX

>

>

> --------------------------------------------------------------------

----------

> Be a better friend, newshound, and know-it-all with

Mobile. Try it now.

>

[Guest guest]

, if not much change from first accident just forget about it and bill original. If significant increase in symptoms in second accident then you must try to figure out what % you feel is due to that accident and bill accordingly.

Good times.

I'd try to go the easy way if possible.

joe

ph Medlin D.C.Spine Tree Chiropracticwww.spinetreepdx.com

Apportionment

I have never done apportionment for two MVA accidents before. How is this done. I learned it in school just long enough ago to be inaccessable.

I have a female patinent who got in an MVA 3 months ago and came to me cause she wasn't getting better. MRI was indicated from disc signs. While she was leaving the MRI shop, she got rear ended. What is the process for billing? Do I bill a percentage of a treatment to one accident, and a portion to the other?

Incidentally, the poor girl does have two disk bulges.

Jay

Lindekugel, DC

Concordia Chiropractic Center

5425 NE 33rd Ave.

PDX

Be a better friend, newshound, and know-it-all with Mobile. Try it now.

[Guest guest]

Thanks Vern! You just give, give, give.

Jay

Apportionment

I have never done apportionment for two MVA accidents before. How is this done. I learned it in school just long enough ago to be inaccessable.

I have a female patinent who got in an MVA 3 months ago and came to me cause she wasn't getting better. MRI was indicated from disc signs. While she was leaving the MRI shop, she got rear ended. What is the process for billing? Do I bill a percentage of a treatment to one accident, and a portion to the other?

Incidentally, the poor girl does have two disk bulges.

Jay

Lindekugel, DC

Concordia Chiropractic Center

5425 NE 33rd Ave.

PDX

Be a better friend, newshound, and know-it-all with Mobile. Try it now.

Be a better friend, newshound, and know-it-all with Mobile. Try it now.

[Guest guest]

Vern –

I appreciate your discussion regarding apportionment that you posted earlier this week. This is a matter of confusion that has come up on this list on a regular basis as well as at Western States Chiropractic College and with the OBCE. Earlier this year I was asked by Dave McTeague to discuss apportionment with the doctors new to Oregon. The request was to discuss the manner of apportionment by percentage, essentially the opposite of your discussion this week. While I do not believe that a specific ruling from the Board is appropriate, I believe the matter should at least be discussed by the Board for guidance. I would request you provide a release to Minga to allow her to share your earlier post outside of the listserv with members of OBCE. I will also grant Minga permission to utilize my posting as well.

I do strongly agree with you about the need to assess and document the case and communicate with the claims representative.

Tom Freedland, DC

Apportionment Discussion:

Apportionment is the separation of the nature of multiple injuries the patient has incurred. Using Vern’s suggestion, treating until the person returns to a pre-accident level, does not address many of the overlapping issues that come up with multiple injuries. In Vern’s scenario, the patient has an injury to the neck, he receives treatment for it, and before he completes treatment, he has another injury affecting the same area causing an increase in symptoms. Under Vern’s plan, the doctor would treat for the second injury claim until that injury has reached a point consistent with the patient’s condition just prior to the second injury. The doctor would then shift to the earlier claim.

What about multiple injuries affecting different parts of the body, or where there is an overlap between different parts of the body?

It is the doctor’s responsibility to treat the patient for the condition, not by the source of reimbursement. The patient should be seen as a whole. It then becomes incumbent upon the doctor to use his clinical expertise to decide which treatment is for which condition and describe it in his clinical assessment and plan of care. It would be inappropriate and cumbersome for the patient if the doctor were to treat each condition on a different day. While it may make bookkeeping easier, it ignores the interrelations of the various conditions.

If we take the case where the individual has a neck injury from a specific accident and then suffers a new injury that involves solely the low back, there is clear delineation between the two injuries. If the doctor is treating the patient as a whole, the patient would come in for a visit reporting his complaints. The doctor in turn would identify and clarify causation of the complaints between the two incidents and render treatment to the patient based on the presenting complaints and the objective findings. He would then describe within his documentation the clinical rationale for each service as it relates to the condition. Some may argue that in this particular case with two distinct areas of injury, the doctor should treat one condition on one visit and the second condition on another visit; however, this ignores potential interrelations that may occur. The documentation should reflect all aspects of the clinical reasoning and separation of the respective injuries and appropriate coding and charges are then submitted for the services rendered.

In this hypothetical case where it involves a more detailed evaluation by the treating doctor and more of his time and clinical expertise, it would be appropriate to reflect the initial evaluation at a level consistent with the complexity caused by the second injury (CPT code 99214 as an example). On subsequent visits, where there is a discussion of separation of services, the manipulation code (CPT code 98940 – 98942), because they are inclusive of the evaluation and management component for the visit, would have attached to it modifier “22†indicating a more detailed or complex service than is normally rendered and allow an appropriate increase in fee to reflect the additional complexity.

In this scenario where there are two distinct regions and two distinct injuries, the separation would be simply at 50 percent. However, there are times where there is an overlap of injured areas. The patient may have one accident causing an injury to the neck and upper back and a second incident causing injury to the shoulder and the upper back. The patient is treated as a whole. He comes in for an evaluation, care is rendered based on complaints and findings, and the doctor makes a determination of what services would be attributed to each of the injuries. Because the patient’s condition is combined and involves an additional region, the doctor’s proposed treatment cannot clearly be delineated between the two injuries and the doctor must make a decision about apportionment, the percentage of that applies to each condition. The doctor should be aware the patient’s condition may not return to a level consistent with their pre-injury status following the second injury. He must also consider the possibility that were it not for the first injury, the magnitude of the second injury might have been less.

Dr. Arthur Croft has a tool for apportionment which may provide some guidance; however, it is based solely on the patient’s subjective report of pain and does not take into account other clinical objective findings that may play a role in the patient’s overall condition and response to care. As such, the Croft document could be described as a tool or adjunct, but does not eliminate the need for the doctor’s clinical expertise.

This discussion has gone on for years. It clearly will not be resolved with our two emails. It is a matter that may be of concern to our Board and it may be appropriate to ask them to provide clarification and guidance.

Tom Freedland, DCWondering what's for Dinner Tonight? Get new twists on family favorites at AOL Food.

[Guest guest]

Hi Tom,

Yes of course Minga and the OBCE can share

my post to the list serve relative to our discussion on “apportionment.”

Vern

From:

[mailto: ] On Behalf Of TFreedland@...

Sent: Saturday, May 03, 2008 11:44

AM

vsaboe@...;

Cc: Dave.MCTEAGUE@...;

AboWoman@...

Subject: Re:

Apportionment

Vern –

I appreciate your discussion regarding

apportionment that you posted earlier this week. This is a matter of

confusion that has come up on this list on a regular basis as well as at Western States Chiropractic

College

and with the OBCE. Earlier this year I was asked by Dave McTeague to

discuss apportionment with the doctors new to Oregon. The

request was to discuss the manner of apportionment by percentage, essentially

the opposite of your discussion this week. While I do not believe that a

specific ruling from the Board is appropriate, I believe the matter should at

least be discussed by the Board for guidance. I would request you provide

a release to Minga to allow her to share your earlier post outside of the

listserv with members of OBCE. I will also grant Minga permission to

utilize my posting as well.

I do strongly agree with you about the

need to assess and document the case and communicate with the claims

representative.

Tom Freedland, DC

Apportionment Discussion:

Apportionment is the separation of the

nature of multiple injuries the patient has incurred. Using Vern’s

suggestion, treating until the person returns to a pre-accident level, does not

address many of the overlapping issues that come up with multiple injuries.

In Vern’s scenario, the patient has an injury to the neck, he receives

treatment for it, and before he completes treatment, he has another injury

affecting the same area causing an increase in symptoms. Under Vern’s

plan, the doctor would treat for the second injury claim until that injury has

reached a point consistent with the patient’s condition just prior to the

second injury. The doctor would then shift to the earlier claim.

What about multiple injuries affecting

different parts of the body, or where there is an overlap between different

parts of the body?

It is the doctor’s responsibility to treat

the patient for the condition, not by the source of reimbursement. The

patient should be seen as a whole. It then becomes incumbent upon the

doctor to use his clinical expertise to decide which treatment is for which

condition and describe it in his clinical assessment and plan of care. It

would be inappropriate and cumbersome for the patient if the doctor were to

treat each condition on a different day. While it may make bookkeeping

easier, it ignores the interrelations of the various conditions.

If we take the case where the individual

has a neck injury from a specific accident and then suffers a new injury that

involves solely the low back, there is clear delineation between the two

injuries. If the doctor is treating the patient as a whole, the patient

would come in for a visit reporting his complaints. The doctor in turn

would identify and clarify causation of the complaints between the two

incidents and render treatment to the patient based on the presenting

complaints and the objective findings. He would then describe within his

documentation the clinical rationale for each service as it relates to the

condition. Some may argue that in this particular case with two distinct

areas of injury, the doctor should treat one condition on one visit and the

second condition on another visit; however, this ignores potential

interrelations that may occur. The documentation should reflect all

aspects of the clinical reasoning and separation of the respective injuries and

appropriate coding and charges are then submitted for the services

rendered.

In this hypothetical case where it

involves a more detailed evaluation by the treating doctor and more of his time

and clinical expertise, it would be appropriate to reflect the initial

evaluation at a level consistent with the complexity caused by the second

injury (CPT code 99214 as an example). On subsequent visits, where there

is a discussion of separation of services, the manipulation code (CPT code

98940 – 98942), because they are inclusive of the evaluation and management

component for the visit, would have attached to it modifier “22” indicating a

more detailed or complex service than is normally rendered and allow an

appropriate increase in fee to reflect the additional complexity.

In this scenario where there are two

distinct regions and two distinct injuries, the separation would be simply at

50 percent. However, there are times where there is an overlap of injured

areas. The patient may have one accident causing an injury to the neck

and upper back and a second incident causing injury to the shoulder and the

upper back. The patient is treated as a whole. He comes in for an

evaluation, care is rendered based on complaints and findings, and the doctor

makes a determination of what services would be attributed to each of the

injuries. Because the patient’s condition is combined and involves an

additional region, the doctor’s proposed treatment cannot clearly be delineated

between the two injuries and the doctor must make a decision about

apportionment, the percentage of that applies to each condition. The

doctor should be aware the patient’s condition may not return to a level consistent

with their pre-injury status following the second injury. He must also

consider the possibility that were it not for the first injury, the magnitude

of the second injury might have been less.

Dr. Arthur Croft has a tool for

apportionment which may provide some guidance; however, it is based solely on

the patient’s subjective report of pain and does not take into account other

clinical objective findings that may play a role in the patient’s overall

condition and response to care. As such, the Croft document could be

described as a tool or adjunct, but does not eliminate the need for the

doctor’s clinical expertise.

This discussion has gone on for

years. It clearly will not be resolved with our two emails. It is a

matter that may be of concern to our Board and it may be appropriate to ask

them to provide clarification and guidance.

Tom Freedland, DC

Wondering what's for Dinner Tonight? Get new

twists on family favorites at AOL Food.

[Guest guest]

Excellent points and agreed Tom.

Obviously I was looking only at what sounded like only the same anatomical area

being injured and treated again by the doctor who wrote in. So Tom about

the 50% are you saying that if I have a patient that is in a MVA and injured

only their neck and that is the only area being treated. Then they get

into a second MVA and suffer an additional injury only to their lower back

hence we are still dealing with “one to two areas” Would you

then only bill 50% of the W/C allowable fee for SMT under “one to two

areas”

On each of the claims 1st PIP

claim vs 2nd PIP claim? And what of the adjunctive modalities

if the same ones are used?

Vern

From:

[mailto: ] On Behalf Of TFreedland@...

Sent: Saturday, May 03, 2008 11:44

AM

vsaboe@...;

Cc: Dave.MCTEAGUE@...;

AboWoman@...

Subject: Re:

Apportionment

Vern –

I appreciate your discussion regarding

apportionment that you posted earlier this week. This is a matter of

confusion that has come up on this list on a regular basis as well as at Western States Chiropractic

College

and with the OBCE. Earlier this year I was asked by Dave McTeague to

discuss apportionment with the doctors new to Oregon. The

request was to discuss the manner of apportionment by percentage, essentially

the opposite of your discussion this week. While I do not believe that a

specific ruling from the Board is appropriate, I believe the matter should at

least be discussed by the Board for guidance. I would request you provide

a release to Minga to allow her to share your earlier post outside of the

listserv with members of OBCE. I will also grant Minga permission to

utilize my posting as well.

I do strongly agree with you about the

need to assess and document the case and communicate with the claims

representative.

Tom Freedland, DC

Apportionment Discussion:

Apportionment is the separation of the

nature of multiple injuries the patient has incurred. Using Vern’s

suggestion, treating until the person returns to a pre-accident level, does not

address many of the overlapping issues that come up with multiple injuries.

In Vern’s scenario, the patient has an injury to the neck, he receives

treatment for it, and before he completes treatment, he has another injury

affecting the same area causing an increase in symptoms. Under

Vern’s plan, the doctor would treat for the second injury claim until

that injury has reached a point consistent with the patient’s condition

just prior to the second injury. The doctor would then shift to the

earlier claim.

What about multiple injuries affecting

different parts of the body, or where there is an overlap between different

parts of the body?

It is the doctor’s responsibility to

treat the patient for the condition, not by the source of reimbursement.

The patient should be seen as a whole. It then becomes incumbent upon the

doctor to use his clinical expertise to decide which treatment is for which

condition and describe it in his clinical assessment and plan of care. It

would be inappropriate and cumbersome for the patient if the doctor were to

treat each condition on a different day. While it may make bookkeeping

easier, it ignores the interrelations of the various conditions.

If we take the case where the individual

has a neck injury from a specific accident and then suffers a new injury that

involves solely the low back, there is clear delineation between the two

injuries. If the doctor is treating the patient as a whole, the patient

would come in for a visit reporting his complaints. The doctor in turn

would identify and clarify causation of the complaints between the two

incidents and render treatment to the patient based on the presenting

complaints and the objective findings. He would then describe within his

documentation the clinical rationale for each service as it relates to the

condition. Some may argue that in this particular case with two distinct

areas of injury, the doctor should treat one condition on one visit and the

second condition on another visit; however, this ignores potential

interrelations that may occur. The documentation should reflect all

aspects of the clinical reasoning and separation of the respective injuries and

appropriate coding and charges are then submitted for the services

rendered.

In this hypothetical case where it

involves a more detailed evaluation by the treating doctor and more of his time

and clinical expertise, it would be appropriate to reflect the initial

evaluation at a level consistent with the complexity caused by the second

injury (CPT code 99214 as an example). On subsequent visits, where there

is a discussion of separation of services, the manipulation code (CPT code

98940 – 98942), because they are inclusive of the evaluation and

management component for the visit, would have attached to it modifier

“22” indicating a more detailed or complex service than is normally

rendered and allow an appropriate increase in fee to reflect the additional

complexity.

In this scenario where there are two

distinct regions and two distinct injuries, the separation would be simply at

50 percent. However, there are times where there is an overlap of injured

areas. The patient may have one accident causing an injury to the neck

and upper back and a second incident causing injury to the shoulder and the

upper back. The patient is treated as a whole. He comes in for an

evaluation, care is rendered based on complaints and findings, and the doctor

makes a determination of what services would be attributed to each of the

injuries. Because the patient’s condition is combined and involves

an additional region, the doctor’s proposed treatment cannot clearly be

delineated between the two injuries and the doctor must make a decision about

apportionment, the percentage of that applies to each condition. The

doctor should be aware the patient’s condition may not return to a level

consistent with their pre-injury status following the second injury. He

must also consider the possibility that were it not for the first injury, the

magnitude of the second injury might have been less.

Dr. Arthur Croft has a tool for

apportionment which may provide some guidance; however, it is based solely on

the patient’s subjective report of pain and does not take into account

other clinical objective findings that may play a role in the patient’s

overall condition and response to care. As such, the Croft document could

be described as a tool or adjunct, but does not eliminate the need for the

doctor’s clinical expertise.

This discussion has gone on for

years. It clearly will not be resolved with our two emails. It is a

matter that may be of concern to our Board and it may be appropriate to ask

them to provide clarification and guidance.

Tom Freedland, DC

Wondering what's for Dinner Tonight? Get new

twists on family favorites at AOL Food.

[Guest guest]

This is not constructive, or directly applicable to the apportionment issue but I need to get it off my chest... THIS IS WHAT IS WRONG WITH THE INSURANCE INDUSTRY!!!! We should have insurance that covers us 24/7, whether we are at work, at play, in a car or whatever. By having multiple policies covering these different activities of life we have a system open to abuse and "he said she said"; the classic, "you didn't hurt yourself on the job", or "you have pre-existing complaints". Again, 24/7 insurance, high deductible, with HSA seems like a better solution. And gives the consumer control over where they spend their health care dollars. Unless of course you have a HSA which dictates who you can go to, which apparently currently exist. Seitz, DC Tuality Physicians 730-D SE Oak St Hillsboro, OR 97123 (503)640-3724

TFreedland@...; CC: Dave.MCTEAGUE@...; AboWoman@...From: vsaboe@...Date: Sat, 3 May 2008 12:01:27 -0700Subject: RE: Apportionment

Excellent points and agreed Tom. Obviously I was looking only at what sounded like only the same anatomical area being injured and treated again by the doctor who wrote in. So Tom about the 50% are you saying that if I have a patient that is in a MVA and injured only their neck and that is the only area being treated. Then they get into a second MVA and suffer an additional injury only to their lower back hence we are still dealing with “one to two areas” Would you then only bill 50% of the W/C allowable fee for SMT under “one to two areas”

On each of the claims 1st PIP claim vs 2nd PIP claim? And what of the adjunctive modalities if the same ones are used?

Vern

From: [mailto: ] On Behalf Of TFreedlandaolSent: Saturday, May 03, 2008 11:44 AMvsaboecomcast (DOT) net; Cc: Dave.MCTEAGUEstate (DOT) or.us; AboWomanaolSubject: Re: Apportionment

Vern –

I appreciate your discussion regarding apportionment that you posted earlier this week. This is a matter of confusion that has come up on this list on a regular basis as well as at Western States Chiropractic College and with the OBCE. Earlier this year I was asked by Dave McTeague to discuss apportionment with the doctors new to Oregon. The request was to discuss the manner of apportionment by percentage, essentially the opposite of your discussion this week. While I do not believe that a specific ruling from the Board is appropriate, I believe the matter should at least be discussed by the Board for guidance. I would request you provide a release to Minga to allow her to share your earlier post outside of the listserv with members of OBCE. I will also grant Minga permission to utilize my posting as well.

I do strongly agree with you about the need to assess and document the case and communicate with the claims representative.

Tom Freedland, DC

Apportionment Discussion:

Apportionment is the separation of the nature of multiple injuries the patient has incurred. Using Vern’s suggestion, treating until the person returns to a pre-accident level, does not address many of the overlapping issues that come up with multiple injuries. In Vern’s scenario, the patient has an injury to the neck, he receives treatment for it, and before he completes treatment, he has another injury affecting the same area causing an increase in symptoms. Under Vern’s plan, the doctor would treat for the second injury claim until that injury has reached a point consistent with the patient’s condition just prior to the second injury. The doctor would then shift to the earlier claim.

What about multiple injuries affecting different parts of the body, or where there is an overlap between different parts of the body?

It is the doctor’s responsibility to treat the patient for the condition, not by the source of reimbursement. The patient should be seen as a whole. It then becomes incumbent upon the doctor to use his clinical expertise to decide which treatment is for which condition and describe it in his clinical assessment and plan of care. It would be inappropriate and cumbersome for the patient if the doctor were to treat each condition on a different day. While it may make bookkeeping easier, it ignores the interrelations of the various conditions.

If we take the case where the individual has a neck injury from a specific accident and then suffers a new injury that involves solely the low back, there is clear delineation between the two injuries. If the doctor is treating the patient as a whole, the patient would come in for a visit reporting his complaints. The doctor in turn would identify and clarify causation of the complaints between the two incidents and render treatment to the patient based on the presenting complaints and the objective findings. He would then describe within his documentation the clinical rationale for each service as it relates to the condition. Some may argue that in this particular case with two distinct areas of injury, the doctor should treat one condition on one visit and the second condition on another visit; however, this ignores potential interrelations that may occur. The documentation should reflect all aspects of the clinical reasoning and separation of the respective injuries and appropriate coding and charges are then submitted for the services rendered.

In this hypothetical case where it involves a more detailed evaluation by the treating doctor and more of his time and clinical expertise, it would be appropriate to reflect the initial evaluation at a level consistent with the complexity caused by the second injury (CPT code 99214 as an example). On subsequent visits, where there is a discussion of separation of services, the manipulation code (CPT code 98940 – 98942), because they are inclusive of the evaluation and management component for the visit, would have attached to it modifier “22” indicating a more detailed or complex service than is normally rendered and allow an appropriate increase in fee to reflect the additional complexity.

In this scenario where there are two distinct regions and two distinct injuries, the separation would be simply at 50 percent. However, there are times where there is an overlap of injured areas. The patient may have one accident causing an injury to the neck and upper back and a second incident causing injury to the shoulder and the upper back. The patient is treated as a whole. He comes in for an evaluation, care is rendered based on complaints and findings, and the doctor makes a determination of what services would be attributed to each of the injuries. Because the patient’s condition is combined and involves an additional region, the doctor’s proposed treatment cannot clearly be delineated between the two injuries and the doctor must make a decision about apportionment, the percentage of that applies to each condition. The doctor should be aware the patient’s condition may not return to a level consistent with their pre-injury status following the second injury. He must also consider the possibility that were it not for the first injury, the magnitude of the second injury might have been less.

Dr. Arthur Croft has a tool for apportionment which may provide some guidance; however, it is based solely on the patient’s subjective report of pain and does not take into account other clinical objective findings that may play a role in the patient’s overall condition and response to care. As such, the Croft document could be described as a tool or adjunct, but does not eliminate the need for the doctor’s clinical expertise.

This discussion has gone on for years. It clearly will not be resolved with our two emails. It is a matter that may be of concern to our Board and it may be appropriate to ask them to provide clarification and guidance.

Tom Freedland, DC

Wondering what's for Dinner Tonight? Get new twists on family favorites at AOL Food.

[Guest guest]

as per HSAs you are preaching to the choir. Freedom of choice coupled with consumer accountability...hence no abuse...

There is no free lunch....

Vern Saboe

RE: Apportionment

Excellent points and agreed Tom. Obviously I was looking only at what sounded like only the same anatomical area being injured and treated again by the doctor who wrote in. So Tom about the 50% are you saying that if I have a patient that is in a MVA and injured only their neck and that is the only area being treated. Then they get into a second MVA and suffer an additional injury only to their lower back hence we are still dealing with “one to two areas” Would you then only bill 50% of the W/C allowable fee for SMT under “one to two areas”

On each of the claims 1st PIP claim vs 2nd PIP claim? And what of the adjunctive modalities if the same ones are used?

Vern

From: [mailto: ] On Behalf Of TFreedlandaolSent: Saturday, May 03, 2008 11:44 AMvsaboecomcast (DOT) net; Cc: Dave.MCTEAGUEstate (DOT) or.us; AboWomanaolSubject: Re: Apportionment

Vern –

I appreciate your discussion regarding apportionment that you posted earlier this week. This is a matter of confusion that has come up on this list on a regular basis as well as at Western States Chiropractic College and with the OBCE. Earlier this year I was asked by Dave McTeague to discuss apportionment with the doctors new to Oregon. The request was to discuss the manner of apportionment by percentage, essentially the opposite of your discussion this week. While I do not believe that a specific ruling from the Board is appropriate, I believe the matter should at least be discussed by the Board for guidance. I would request you provide a release to Minga to allow her to share your earlier post outside of the listserv with members of OBCE. I will also grant Minga permission to utilize my posting as well.

I do strongly agree with you about the need to assess and document the case and communicate with the claims representative.

Tom Freedland, DC

Apportionment Discussion:

Apportionment is the separation of the nature of multiple injuries the patient has incurred. Using Vern’s suggestion, treating until the person returns to a pre-accident level, does not address many of the overlapping issues that come up with multiple injuries. In Vern’s scenario, the patient has an injury to the neck, he receives treatment for it, and before he completes treatment, he has another injury affecting the same area causing an increase in symptoms. Under Vern’s plan, the doctor would treat for the second injury claim until that injury has reached a point consistent with the patient’s condition just prior to the second injury. The doctor would then shift to the earlier claim.

What about multiple injuries affecting different parts of the body, or where there is an overlap between different parts of the body?

It is the doctor’s responsibility to treat the patient for the condition, not by the source of reimbursement. The patient should be seen as a whole. It then becomes incumbent upon the doctor to use his clinical expertise to decide which treatment is for which condition and describe it in his clinical assessment and plan of care. It would be inappropriate and cumbersome for the patient if the doctor were to treat each condition on a different day. While it may make bookkeeping easier, it ignores the interrelations of the various conditions.

If we take the case where the individual has a neck injury from a specific accident and then suffers a new injury that involves solely the low back, there is clear delineation between the two injuries. If the doctor is treating the patient as a whole, the patient would come in for a visit reporting his complaints. The doctor in turn would identify and clarify causation of the complaints between the two incidents and render treatment to the patient based on the presenting complaints and the objective findings. He would then describe within his documentation the clinical rationale for each service as it relates to the condition. Some may argue that in this particular case with two distinct areas of injury, the doctor should treat one condition on one visit and the second condition on another visit; however, this ignores potential interrelations that may occur. The documentation should reflect all aspects of the clinical reasoning and separation of the respective injuries and appropriate coding and charges are then submitted for the services rendered.

In this hypothetical case where it involves a more detailed evaluation by the treating doctor and more of his time and clinical expertise, it would be appropriate to reflect the initial evaluation at a level consistent with the complexity caused by the second injury (CPT code 99214 as an example). On subsequent visits, where there is a discussion of separation of services, the manipulation code (CPT code 98940 – 98942), because they are inclusive of the evaluation and management component for the visit, would have attached to it modifier “22” indicating a more detailed or complex service than is normally rendered and allow an appropriate increase in fee to reflect the additional complexity.

In this scenario where there are two distinct regions and two distinct injuries, the separation would be simply at 50 percent. However, there are times where there is an overlap of injured areas. The patient may have one accident causing an injury to the neck and upper back and a second incident causing injury to the shoulder and the upper back. The patient is treated as a whole. He comes in for an evaluation, care is rendered based on complaints and findings, and the doctor makes a determination of what services would be attributed to each of the injuries. Because the patient’s condition is combined and involves an additional region, the doctor’s proposed treatment cannot clearly be delineated between the two injuries and the doctor must make a decision about apportionment, the percentage of that applies to each condition. The doctor should be aware the patient’s condition may not return to a level consistent with their pre-injury status following the second injury. He must also consider the possibility that were it not for the first injury, the magnitude of the second injury might have been less.

Dr. Arthur Croft has a tool for apportionment which may provide some guidance; however, it is based solely on the patient’s subjective report of pain and does not take into account other clinical objective findings that may play a role in the patient’s overall condition and response to care. As such, the Croft document could be described as a tool or adjunct, but does not eliminate the need for the doctor’s clinical expertise.

This discussion has gone on for years. It clearly will not be resolved with our two emails. It is a matter that may be of concern to our Board and it may be appropriate to ask them to provide clarification and guidance.

Tom Freedland, DC

Wondering what's for Dinner Tonight? Get new twists on family favorites at AOL Food.

[Guest guest]

Vern -

Let's set the parameters for this discussion so there is no confusion (by us or others) as we progress. We have a patient that has been in an accident. For the moment we will limit the thought to an MVA; if we get into work comp overlapping and other problems we will be playing “what if†for the rest of the year.

This patient has presented to you. You perform an evaluation - inclusive of what was medically appropriate - and determine that the patient needs treatment to the neck. You start the treatment and she improves. Treatment includes 98940 (CMT to 1-2 areas) and fifteen minutes of massage (97124)

While still in treatment the patient is involved in a second accident. The second accident results in an injury solely to the low back and does nothing to the neck.

With these parameters, you - the doctor - would perform an evaluation of the patient. Since you have previously seen and treated this patient (within the last three years by CPT definition), this would be an established patient encounter (CPT 99211 - 99215). The level of the CPT code would depend on the complexity in establishing two of the three main components of the CPT code: History, examination, and clinical decision making. “Clinical decision making†would be a potential key part with apportionment.

From the evaluation you concluded that the patient has a cervical strain from the first MVA and a lumbosacral strain from the second MVA (let's keep it basic). You also conclude that the patient's complaints and findings between the two areas are about the same. Your proposed treatment will be chiropractic manipulation to the involved areas and fifteen minutes of massage to each region (cervical and lumbosacral).

With the patient's injuries being comparable between the two incidents, you conclude apportionment would be 50% to each accident.

Now what do you do?

My position is that the re-evaluation would not have occurred had it not been for the second accident. Thus the established patient evaluation code and any related diagnostic procedures (x‑rays, labs) would be apportioned as 100% to the second accident. Other treatment would be apportioned at 50% between to the two accidents.

You, the doctor, are treating the patient for the total condition. You are not treating them based on causation or reimbursement. The issue of who is paying the bills should not enter into the discussion - at least at this point. The patient has a condition; a cervical strain and a lumbosacral strain. The patient hurts and wants to get better. You want to help them to get better; that's why you became a doctor.

Your treatment for this patient involves manipulation to 3-4 areas (98941) and 30 minutes (2 units) of massage separated between the neck and the low back. Your patient encounter is not unique in terms of treatment; here are the complaints. here are the objective findings, and treatment should be this.

Where things would change are outside of the specifics of the patient encounter. What did you do on the first visit following the 2nd MVA? You performed an exam, x-rays, and treatment. Your record of this visit should reflect what happened during the encounter:

, an established patient of this office, came in reporting low back pain. She had been driving her 2004 Toyota Camry through an intersection when it was struck on the right side in a broadside collision. She was wearing her seat belt and shoulder harness, but was thrown sideways, bending across the center console. Her low back felt achy, but she was able to get out of the car – etc.

had been treating at this office for a next injury from another motor vehicle accident that had occurred 3 weeks earlier. She had noticed improved with treatment, and did not notice a significant change in her neck pain following this second collision.

(Discuss what else might be important as to current and past history)

On examination her neck ranges of motion were limit in flexion to 25 degrees, extension 30 degrees, right lateral flexion 30 degrees, left lateral flexion 25 degrees, and right and left rotation 60 degrees. These are slightly improved since her last re-exam, but appear to be stable following this second accident. (Muscle spasms, palpation findings, reflexes, etc.).

Low back ranges of motion (etc. low back findings).

A two view lumbar x-ray was taken and showed slight disk narrowing at L5/S1, with a minimal spurring. No fractures were scene (etc.)

Impression: Cervical sprain as a result of her MVA on April 5, 2008 with no change following her MVA on May 1, 2008. Lumbosacral sprain as a result of the MVA on May 1, 2008.

Plan: (Whatever treatment is clinically appropriate given the findings). Overall apportionment of her condition is 50% to the April 5, 2008 MVA and 50% to the May 1, 2008 MVA.

Prognosis, etc.

Your billing for the office encounter should reflect what was done during the visit. CPT requires that you code for the procedure that accurately reflects the services during the patient encounter:

Established patient evaluation and management 99214-25 $100.00

Lumbar X-rays 72100 100.00

Chiropractic manipulation – 3 to 4 areas 98941 60.00

30 minutes soft tissue massage 97124 (2 units) 80.00

Note: I used dollar amounts that are easily divided. These are for illustration only and are not based on the Workers’ Compensation fee schedule that applies to PIP claims.

Applying your apportionment for this first visit following the second accident:

CPT Code MVA 1 MVA 2

99214-25 $100.00 (100%)

72100 $100.00 (100%)

98941 $30.00 (50%) $30.00 (50%)

97124 $40.00 (50%) $40.00 (50%)

The exam and x-rays would not have been necessary were it not for the second MVA, thus 100%. The treatment would be to both areas that were Injured, neck in the first MVA and low back in the second MVA. The “hassle†of apportionment should be included within the clinical decision making portion of the 99214. If the process is more involved, it may be appropriate to move to the next level of E/M service (99215) or add modifier “22†(99214-25-22) to signify a more involved procedure than is normally encounter for this level of service.

Next is the question of how to bill your services to the two insurances companies (or same company, but different claims). I recommend that you discuss this with the claims representatives involved to determine which of two methods will work best for the companies involved. One method is to bill your full price on the CMS 1500 form, but note the apportionment on the form and in your notes. The second would be to submit the CPT codes, but with a price reflective of the split and still include the information in your notes.

Method #1

99215-25 $100.00 (apportioned at 100% to MVA on May 1, 2008)

72100 $100.00 (apportioned at 100% to MVA on May 1, 2008)

98941 $ 60.00 (apportioned at 50% to MVA on May 1, 2008)

97124 $ 80.00 (apportioned at 50% to MVA on May 1, 2008)

Method #2

99215-25 $50.00

72100 $50.00

98941 $30.00

97124 $40.00

This would then be billed to each of the claims. As long as the issue of apportionment is described in the records, no one will see a concern of double billing or fraud. Apportionment would also counter any claim of an alternate fee schedule.

This may appear quite involved, but it will accurately reflect what services were performed and for which condition. Obviously, this would be more involved with overlapping injuries, different types of claims – such as Workers’ Compensation verse personal injury, and as such it may be appropriate to submit your basic service with a modifier “22†when additional time is encounter (98941-22) and then documented in your record.

As to the case that started this discussion, we do not have enough information to make a decision. We know the patient was injured in a prior accident. An MRI was performed. We do not know the clinical indications for the original MRI. We know the patient had a second MVA immediately after the MRI. We do not know the nature of that collision or what, if any, case in symptoms occurred. Once the treating doctor has reported the clinical findings both before and after the 2nd MVA. We might be able to separate the components. A 2nd MRI may or may not be indicated, depending on the patient's clinical findings and treatment post MVA #2

Tom Freedland

In a message dated 5/3/2008 12:01:46 P.M. Pacific Daylight Time, vsaboe@... writes:

Excellent points and agreed Tom. Obviously I was looking only at what sounded like only the same anatomical area being injured and treated again by the doctor who wrote in. So Tom about the 50% are you saying that if I have a patient that is in a MVA and injured only their neck and that is the only area being treated. Then they get into a second MVA and suffer an additional injury only to their lower back hence we are still dealing with “one to two areas†Would you then only bill 50% of the W/C allowable fee for SMT under “one to two areasâ€

On each of the claims 1st PIP claim vs 2nd PIP claim? And what of the adjunctive modalities if the same ones are used?

Vern

From: [mailto: ] On Behalf Of TFreedlandaolSent: Saturday, May 03, 2008 11:44 AMvsaboecomcast (DOT) net; Cc: Dave.MCTEAGUEstate (DOT) or.us; AboWomanaolSubject: Re: Apportionment

Vern –

I appreciate your discussion regarding apportionment that you posted earlier this week. This is a matter of confusion that has come up on this list on a regular basis as well as at Western States Chiropractic College and with the OBCE. Earlier this year I was asked by Dave McTeague to discuss apportionment with the doctors new to Oregon. The request was to discuss the manner of apportionment by percentage, essentially the opposite of your discussion this week. While I do not believe that a specific ruling from the Board is appropriate, I believe the matter should at least be discussed by the Board for guidance. I would request you provide a release to Minga to allow her to share your earlier post outside of the listserv with members of OBCE. I will also grant Minga permission to utilize my posting as well.

I do strongly agree with you about the need to assess and document the case and communicate with the claims representative.

Tom Freedland, DC

Apportionment Discussion:

Apportionment is the separation of the nature of multiple injuries the patient has incurred. Using Vern’s suggestion, treating until the person returns to a pre-accident level, does not address many of the overlapping issues that come up with multiple injuries. In Vern’s scenario, the patient has an injury to the neck, he receives treatment for it, and before he completes treatment, he has another injury affecting the same area causing an increase in symptoms. Under Vern’s plan, the doctor would treat for the second injury claim until that injury has reached a point consistent with the patient’s condition just prior to the second injury. The doctor would then shift to the earlier claim.

What about multiple injuries affecting different parts of the body, or where there is an overlap between different parts of the body?

It is the doctor’s responsibility to treat the patient for the condition, not by the source of reimbursement. The patient should be seen as a whole. It then becomes incumbent upon the doctor to use his clinical expertise to decide which treatment is for which condition and describe it in his clinical assessment and plan of care. It would be inappropriate and cumbersome for the patient if the doctor were to treat each condition on a different day. While it may make bookkeeping easier, it ignores the interrelations of the various conditions.

If we take the case where the individual has a neck injury from a specific accident and then suffers a new injury that involves solely the low back, there is clear delineation between the two injuries. If the doctor is treating the patient as a whole, the patient would come in for a visit reporting his complaints. The doctor in turn would identify and clarify causation of the complaints between the two incidents and render treatment to the patient based on the presenting complaints and the objective findings. He would then describe within his documentation the clinical rationale for each service as it relates to the condition. Some may argue that in this particular case with two distinct areas of injury, the doctor should treat one condition on one visit and the second condition on another visit; however, this ignores potential interrelations that may occur. The documentation should reflect all aspects of the clinical reasoning and separation of the respective injuries and appropriate coding and charges are then submitted for the services rendered.

In this hypothetical case where it involves a more detailed evaluation by the treating doctor and more of his time and clinical expertise, it would be appropriate to reflect the initial evaluation at a level consistent with the complexity caused by the second injury (CPT code 99214 as an example). On subsequent visits, where there is a discussion of separation of services, the manipulation code (CPT code 98940 – 98942), because they are inclusive of the evaluation and management component for the visit, would have attached to it modifier “22†indicating a more detailed or complex service than is normally rendered and allow an appropriate increase in fee to reflect the additional complexity.

In this scenario where there are two distinct regions and two distinct injuries, the separation would be simply at 50 percent. However, there are times where there is an overlap of injured areas. The patient may have one accident causing an injury to the neck and upper back and a second incident causing injury to the shoulder and the upper back. The patient is treated as a whole. He comes in for an evaluation, care is rendered based on complaints and findings, and the doctor makes a determination of what services would be attributed to each of the injuries. Because the patient’s condition is combined and involves an additional region, the doctor’s proposed treatment cannot clearly be delineated between the two injuries and the doctor must make a decision about apportionment, the percentage of that applies to each condition. The doctor should be aware the patient’s condition may not return to a level consistent with their pre-injury status following the second injury. He must also consider the possibility that were it not for the first injury, the magnitude of the second injury might have been less.

Dr. Arthur Croft has a tool for apportionment which may provide some guidance; however, it is based solely on the patient’s subjective report of pain and does not take into account other clinical objective findings that may play a role in the patient’s overall condition and response to care. As such, the Croft document could be described as a tool or adjunct, but does not eliminate the need for the doctor’s clinical expertise.

This discussion has gone on for years. It clearly will not be resolved with our two emails. It is a matter that may be of concern to our Board and it may be appropriate to ask them to provide clarification and guidance.

Tom Freedland, DC

Wondering what's for Dinner Tonight? Get new twists on family favorites at AOL Food.

Wondering what's for Dinner Tonight? Get new twists on family favorites at AOL Food.

[Guest guest]

I've always said insurance equals leagalize discrimination and

extortion.

, DC, DABCO

>

> as per HSAs you are preaching to the choir. Freedom of

choice coupled with consumer accountability...hence no abuse...

>

> There is no free lunch....

>

> Vern Saboe

> Re: Apportionment

>

>

>

> Vern –

>

>

>

> I appreciate your discussion regarding apportionment that you

posted earlier this week. This is a matter of confusion that has

come up on this list on a regular basis as well as at Western States

Chiropractic College and with the OBCE. Earlier this year I was

asked by Dave McTeague to discuss apportionment with the doctors new

to Oregon. The request was to discuss the manner of apportionment by

percentage, essentially the opposite of your discussion this week.

While I do not believe that a specific ruling from the Board is

appropriate, I believe the matter should at least be discussed by the

Board for guidance. I would request you provide a release to Minga

to allow her to share your earlier post outside of the listserv with

members of OBCE. I will also grant Minga permission to utilize my

posting as well.

>

>

>

> I do strongly agree with you about the need to assess and

document the case and communicate with the claims representative.

>

>

>

> Tom Freedland, DC

>

>

>

>

>

> Apportionment Discussion:

>

>

>

> Apportionment is the separation of the nature of multiple

injuries the patient has incurred. Using Vern's suggestion, treating

until the person returns to a pre-accident level, does not address

many of the overlapping issues that come up with multiple injuries.

In Vern's scenario, the patient has an injury to the neck, he

receives treatment for it, and before he completes treatment, he has

another injury affecting the same area causing an increase in

symptoms. Under Vern's plan, the doctor would treat for the second

injury claim until that injury has reached a point consistent with

the patient's condition just prior to the second injury. The doctor

would then shift to the earlier claim.

>

>

>

> What about multiple injuries affecting different parts of the

body, or where there is an overlap between different parts of the

body?

>

>

>

> It is the doctor's responsibility to treat the patient for the

condition, not by the source of reimbursement. The patient should be

seen as a whole. It then becomes incumbent upon the doctor to use

his clinical expertise to decide which treatment is for which

condition and describe it in his clinical assessment and plan of

care. It would be inappropriate and cumbersome for the patient if

the doctor were to treat each condition on a different day. While it

may make bookkeeping easier, it ignores the interrelations of the

various conditions.

>

>

>

> If we take the case where the individual has a neck injury from

a specific accident and then suffers a new injury that involves

solely the low back, there is clear delineation between the two

injuries. If the doctor is treating the patient as a whole, the

patient would come in for a visit reporting his complaints. The

doctor in turn would identify and clarify causation of the complaints

between the two incidents and render treatment to the patient based

on the presenting complaints and the objective findings. He would

then describe within his documentation the clinical rationale for

each service as it relates to the condition. Some may argue that in

this particular case with two distinct areas of injury, the doctor

should treat one condition on one visit and the second condition on

another visit; however, this ignores potential interrelations that

may occur. The documentation should reflect all aspects of the

clinical reasoning and separation of the respective injuries and

appropriate coding and charges are then submitted for the services

rendered.

>

>

>

> In this hypothetical case where it involves a more detailed

evaluation by the treating doctor and more of his time and clinical

expertise, it would be appropriate to reflect the initial evaluation

at a level consistent with the complexity caused by the second injury

(CPT code 99214 as an example). On subsequent visits, where there is

a discussion of separation of services, the manipulation code (CPT

code 98940 – 98942), because they are inclusive of the evaluation and

management component for the visit, would have attached to it

modifier " 22 " indicating a more detailed or complex service than is

normally rendered and allow an appropriate increase in fee to reflect

the additional complexity.

>

>

>

> In this scenario where there are two distinct regions and two

distinct injuries, the separation would be simply at 50 percent.

However, there are times where there is an overlap of injured areas.

The patient may have one accident causing an injury to the neck and

upper back and a second incident causing injury to the shoulder and

the upper back. The patient is treated as a whole. He comes in for

an evaluation, care is rendered based on complaints and findings, and

the doctor makes a determination of what services would be attributed

to each of the injuries. Because the patient's condition is combined

and involves an additional region, the doctor's proposed treatment

cannot clearly be delineated between the two injuries and the doctor

must make a decision about apportionment, the percentage of that

applies to each condition. The doctor should be aware the patient's

condition may not return to a level consistent with their pre-injury

status following the second injury. He must also consider the

possibility that were it not for the first injury, the magnitude of

the second injury might have been less.

>

>

>

> Dr. Arthur Croft has a tool for apportionment which may provide

some guidance; however, it is based solely on the patient's

subjective report of pain and does not take into account other

clinical objective findings that may play a role in the patient's

overall condition and response to care. As such, the Croft document

could be described as a tool or adjunct, but does not eliminate the

need for the doctor's clinical expertise.

>

>

>

> This discussion has gone on for years. It clearly will not be

resolved with our two emails. It is a matter that may be of concern

to our Board and it may be appropriate to ask them to provide

clarification and guidance.

>

>

>

> Tom Freedland, DC

>

>

>

>

>

>

> --------------------------------------------------------------------

--------

>

> Wondering what's for Dinner Tonight? Get new twists on family

favorites at AOL Food.

>

[Guest guest]



Tom,

Thanks for taking the time on this very important topic. I agree with your points save a couple...

1st on page 2 under your example "Plan: ...Overall apportionment of her condition is 50% the April 5, 2008 MVA and 50% to the May 1, 2008 MVA." I would not use the term "condition" but rather apportionment of treatment.... as per causation since her neck condition "cervical strain" is 100% attributed to the April 5, 2008 MVA and the same as per the lower back condition as per the May 1, MVA. Also this was probably only a brain fart but it should be CMT 1-2 areas of course not 3-4. I to would prefer to bill full price with a note as per the apportionment of treatment.

Vern

Re: Apportionment

Vern -

Let's set the parameters for this discussion so there is no confusion (by us or others) as we progress. We have a patient that has been in an accident. For the moment we will limit the thought to an MVA; if we get into work comp overlapping and other problems we will be playing “what if†for the rest of the year.

This patient has presented to you. You perform an evaluation - inclusive of what was medically appropriate - and determine that the patient needs treatment to the neck. You start the treatment and she improves. Treatment includes 98940 (CMT to 1-2 areas) and fifteen minutes of massage (97124)

While still in treatment the patient is involved in a second accident. The second accident results in an injury solely to the low back and does nothing to the neck.

With these parameters, you - the doctor - would perform an evaluation of the patient. Since you have previously seen and treated this patient (within the last three years by CPT definition), this would be an established patient encounter (CPT 99211 - 99215). The level of the CPT code would depend on the complexity in establishing two of the three main components of the CPT code: History, examination, and clinical decision making. “Clinical decision making†would be a potential key part with apportionment.

From the evaluation you concluded that the patient has a cervical strain from the first MVA and a lumbosacral strain from the second MVA (let's keep it basic). You also conclude that the patient's complaints and findings between the two areas are about the same. Your proposed treatment will be chiropractic manipulation to the involved areas and fifteen minutes of massage to each region (cervical and lumbosacral).

With the patient's injuries being comparable between the two incidents, you conclude apportionment would be 50% to each accident.

Now what do you do?

My position is that the re-evaluation would not have occurred had it not been for the second accident. Thus the established patient evaluation code and any related diagnostic procedures (x‑rays, labs) would be apportioned as 100% to the second accident. Other treatment would be apportioned at 50% between to the two accidents.

You, the doctor, are treating the patient for the total condition. You are not treating them based on causation or reimbursement. The issue of who is paying the bills should not enter into the discussion - at least at this point. The patient has a condition; a cervical strain and a lumbosacral strain. The patient hurts and wants to get better. You want to help them to get better; that's why you became a doctor.

Your treatment for this patient involves manipulation to 3-4 areas (98941) and 30 minutes (2 units) of massage separated between the neck and the low back. Your patient encounter is not unique in terms of treatment; here are the complaints. here are the objective findings, and treatment should be this.

Where things would change are outside of the specifics of the patient encounter. What did you do on the first visit following the 2nd MVA? You performed an exam, x-rays, and treatment. Your record of this visit should reflect what happened during the encounter:

, an established patient of this office, came in reporting low back pain. She had been driving her 2004 Toyota Camry through an intersection when it was struck on the right side in a broadside collision. She was wearing her seat belt and shoulder harness, but was thrown sideways, bending across the center console. Her low back felt achy, but she was able to get out of the car – etc.

had been treating at this office for a next injury from another motor vehicle accident that had occurred 3 weeks earlier. She had noticed improved with treatment, and did not notice a significant change in her neck pain following this second collision.

(Discuss what else might be important as to current and past history)

On examination her neck ranges of motion were limit in flexion to 25 degrees, extension 30 degrees, right lateral flexion 30 degrees, left lateral flexion 25 degrees, and right and left rotation 60 degrees. These are slightly improved since her last re-exam, but appear to be stable following this second accident. (Muscle spasms, palpation findings, reflexes, etc.).

Low back ranges of motion (etc. low back findings).

A two view lumbar x-ray was taken and showed slight disk narrowing at L5/S1, with a minimal spurring. No fractures were scene (etc.)

Impression: Cervical sprain as a result of her MVA on April 5, 2008 with no change following her MVA on May 1, 2008. Lumbosacral sprain as a result of the MVA on May 1, 2008.

Plan: (Whatever treatment is clinically appropriate given the findings). Overall apportionment of her condition is 50% to the April 5, 2008 MVA and 50% to the May 1, 2008 MVA.

Prognosis, etc.

Your billing for the office encounter should reflect what was done during the visit. CPT requires that you code for the procedure that accurately reflects the services during the patient encounter:

Established patient evaluation and management 99214-25 $100.00

Lumbar X-rays 72100 100.00

Chiropractic manipulation – 3 to 4 areas 98941 60.00

30 minutes soft tissue massage 97124 (2 units) 80.00

Note: I used dollar amounts that are easily divided. These are for illustration only and are not based on the Workers’ Compensation fee schedule that applies to PIP claims.

Applying your apportionment for this first visit following the second accident:

CPT Code MVA 1 MVA 2

99214-25 $100.00 (100%)

72100 $100.00 (100%)

98941 $30.00 (50%) $30.00 (50%)

97124 $40.00 (50%) $40.00 (50%)

The exam and x-rays would not have been necessary were it not for the second MVA, thus 100%. The treatment would be to both areas that were Injured, neck in the first MVA and low back in the second MVA. The “hassle†of apportionment should be included within the clinical decision making portion of the 99214. If the process is more involved, it may be appropriate to move to the next level of E/M service (99215) or add modifier “22†(99214-25-22) to signify a more involved procedure than is normally encounter for this level of service.

Next is the question of how to bill your services to the two insurances companies (or same company, but different claims). I recommend that you discuss this with the claims representatives involved to determine which of two methods will work best for the companies involved. One method is to bill your full price on the CMS 1500 form, but note the apportionment on the form and in your notes. The second would be to submit the CPT codes, but with a price reflective of the split and still include the information in your notes.

Method #1

99215-25 $100.00 (apportioned at 100% to MVA on May 1, 2008)

72100 $100.00 (apportioned at 100% to MVA on May 1, 2008)

98941 $ 60.00 (apportioned at 50% to MVA on May 1, 2008)

97124 $ 80.00 (apportioned at 50% to MVA on May 1, 2008)

Method #2

99215-25 $50.00

72100 $50.00

98941 $30.00

97124 $40.00

This would then be billed to each of the claims. As long as the issue of apportionment is described in the records, no one will see a concern of double billing or fraud. Apportionment would also counter any claim of an alternate fee schedule.

This may appear quite involved, but it will accurately reflect what services were performed and for which condition. Obviously, this would be more involved with overlapping injuries, different types of claims – such as Workers’ Compensation verse personal injury, and as such it may be appropriate to submit your basic service with a modifier “22†when additional time is encounter (98941-22) and then documented in your record.

As to the case that started this discussion, we do not have enough information to make a decision. We know the patient was injured in a prior accident. An MRI was performed. We do not know the clinical indications for the original MRI. We know the patient had a second MVA immediately after the MRI. We do not know the nature of that collision or what, if any, case in symptoms occurred. Once the treating doctor has reported the clinical findings both before and after the 2nd MVA. We might be able to separate the components. A 2nd MRI may or may not be indicated, depending on the patient's clinical findings and treatment post MVA #2

Tom Freedland

In a message dated 5/3/2008 12:01:46 P.M. Pacific Daylight Time, vsaboe@... writes:

Excellent points and agreed Tom. Obviously I was looking only at what sounded like only the same anatomical area being injured and treated again by the doctor who wrote in. So Tom about the 50% are you saying that if I have a patient that is in a MVA and injured only their neck and that is the only area being treated. Then they get into a second MVA and suffer an additional injury only to their lower back hence we are still dealing with “one to two areas†Would you then only bill 50% of the W/C allowable fee for SMT under “one to two areasâ€

On each of the claims 1st PIP claim vs 2nd PIP claim? And what of the adjunctive modalities if the same ones are used?

Vern

From: [mailto: ] On Behalf Of TFreedlandaolSent: Saturday, May 03, 2008 11:44 AMvsaboecomcast (DOT) net; Cc: Dave.MCTEAGUEstate (DOT) or.us; AboWomanaolSubject: Re: Apportionment

Vern –

I appreciate your discussion regarding apportionment that you posted earlier this week. This is a matter of confusion that has come up on this list on a regular basis as well as at Western States Chiropractic College and with the OBCE. Earlier this year I was asked by Dave McTeague to discuss apportionment with the doctors new to Oregon. The request was to discuss the manner of apportionment by percentage, essentially the opposite of your discussion this week. While I do not believe that a specific ruling from the Board is appropriate, I believe the matter should at least be discussed by the Board for guidance. I would request you provide a release to Minga to allow her to share your earlier post outside of the listserv with members of OBCE. I will also grant Minga permission to utilize my posting as well.

I do strongly agree with you about the need to assess and document the case and communicate with the claims representative.

Tom Freedland, DC

Apportionment Discussion:

Apportionment is the separation of the nature of multiple injuries the patient has incurred. Using Vern’s suggestion, treating until the person returns to a pre-accident level, does not address many of the overlapping issues that come up with multiple injuries. In Vern’s scenario, the patient has an injury to the neck, he receives treatment for it, and before he completes treatment, he has another injury affecting the same area causing an increase in symptoms. Under Vern’s plan, the doctor would treat for the second injury claim until that injury has reached a point consistent with the patient’s condition just prior to the second injury. The doctor would then shift to the earlier claim.

What about multiple injuries affecting different parts of the body, or where there is an overlap between different parts of the body?

It is the doctor’s responsibility to treat the patient for the condition, not by the source of reimbursement. The patient should be seen as a whole. It then becomes incumbent upon the doctor to use his clinical expertise to decide which treatment is for which condition and describe it in his clinical assessment and plan of care. It would be inappropriate and cumbersome for the patient if the doctor were to treat each condition on a different day. While it may make bookkeeping easier, it ignores the interrelations of the various conditions.

If we take the case where the individual has a neck injury from a specific accident and then suffers a new injury that involves solely the low back, there is clear delineation between the two injuries. If the doctor is treating the patient as a whole, the patient would come in for a visit reporting his complaints. The doctor in turn would identify and clarify causation of the complaints between the two incidents and render treatment to the patient based on the presenting complaints and the objective findings. He would then describe within his documentation the clinical rationale for each service as it relates to the condition. Some may argue that in this particular case with two distinct areas of injury, the doctor should treat one condition on one visit and the second condition on another visit; however, this ignores potential interrelations that may occur. The documentation should reflect all aspects of the clinical reasoning and separation of the respective injuries and appropriate coding and charges are then submitted for the services rendered.

In this hypothetical case where it involves a more detailed evaluation by the treating doctor and more of his time and clinical expertise, it would be appropriate to reflect the initial evaluation at a level consistent with the complexity caused by the second injury (CPT code 99214 as an example). On subsequent visits, where there is a discussion of separation of services, the manipulation code (CPT code 98940 – 98942), because they are inclusive of the evaluation and management component for the visit, would have attached to it modifier “22†indicating a more detailed or complex service than is normally rendered and allow an appropriate increase in fee to reflect the additional complexity.

In this scenario where there are two distinct regions and two distinct injuries, the separation would be simply at 50 percent. However, there are times where there is an overlap of injured areas. The patient may have one accident causing an injury to the neck and upper back and a second incident causing injury to the shoulder and the upper back. The patient is treated as a whole. He comes in for an evaluation, care is rendered based on complaints and findings, and the doctor makes a determination of what services would be attributed to each of the injuries. Because the patient’s condition is combined and involves an additional region, the doctor’s proposed treatment cannot clearly be delineated between the two injuries and the doctor must make a decision about apportionment, the percentage of that applies to each condition. The doctor should be aware the patient’s condition may not return to a level consistent with their pre-injury status following the second injury. He must also consider the possibility that were it not for the first injury, the magnitude of the second injury might have been less.

Dr. Arthur Croft has a tool for apportionment which may provide some guidance; however, it is based solely on the patient’s subjective report of pain and does not take into account other clinical objective findings that may play a role in the patient’s overall condition and response to care. As such, the Croft document could be described as a tool or adjunct, but does not eliminate the need for the doctor’s clinical expertise.

This discussion has gone on for years. It clearly will not be resolved with our two emails. It is a matter that may be of concern to our Board and it may be appropriate to ask them to provide clarification and guidance.

Tom Freedland, DC

Wondering what's for Dinner Tonight? Get new twists on family favorites at AOL Food.

Wondering what's for Dinner Tonight? Get new twists on family favorites at AOL Food.