Question: A patient completes a new Oswestry questionnaire. The doctor notes that the patient has selected the same level on the same functional limitations for the third consecutive time. The doctor declares the condition chronic, and does not document further plans to address the ongoing functional restriction. Which G code should I apply to this case scenario?
Delaware Subscriber
Answer: Your answer would be G8543 (Documentation of a positive functional outcome assessment using a standardized tool; care plan not documented, reason not given). At times, the provider gathers the information but does not get the plan documented. Sometimes, the provider does not see the need for a plan. This code is made to cater to such instances.