Chiropractic Coding & Compliance Alert

Question: A patient comes to the clinic a few weeks after his scheduled visit with the similar complaint of low back pain that he last presented with. The DC briefly evaluates and treats his condition, but he fails to ask the patient to quantify his pain with a number. Do we have a G code to report such an occurrence? 

Colorado Subscriber

Answer:  In this situation, the provider did not assess or document the pain using a pain scale. Although these events sometimes do happen because of sheer forgetfulness or work stress, there is no escape from the consequences. This will ultimately count as an unsuccessful performance and the encounter would not count toward your 50 percent threshold. The G code for quality reporting in this case would be G8732 (No documentation of pain assessment, reason not given). This code is available for those situations where the provider forgets or simply fails to comply. 

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