When treating a patient for one condition, such as neck pain, who later returns with a new physician order for a different issue like shoulder pain, your next steps depend on clinical judgment. If the therapist determines the shoulder condition is related to the neck, a reevaluation may be appropriate. However, if the shoulder issue is completely unrelated, a new evaluation should be performed. Keep in mind that whether a second evaluation is reimbursable depends on the specific insurance carrier. For Medicare beneficiaries, your plan of care will vary based on the referring physician(s). If the same physician referred the patient for both issues, you can create an updated plan of care that includes both conditions and obtain a dated signature from that physician. If two different doctors are involved one for the neck and one for the shoulder—you have two options: either one physician agrees to assume responsibility for both conditions and signs a combined plan of care, or you must maintain two separate plans of care, each with the appropriate physician’s certification and recertification. In such cases, it may be helpful to document separate treatment notes if both conditions are addressed during the same visit. Furthermore, if the neck treatment is billed to Insurance A and the shoulder treatment to Insurance B, the shoulder should be considered a separate episode, requiring a new evaluation and separate medical records for each condition. Proper documentation and compliance with insurance policies are essential to ensure accurate billing and optimal patient care.
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