Chiropractic Coding & Compliance Alert

You Be the Coder:

G Code When a Patient Does Not Fill Out the Form

Published on Fri Jun 12, 2015

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Question: A patient presents for re-evaluation. He is asked to complete an updated Oswestry questionnaire. He refuses because he is in a hurry. Which G code should the provider report?

Illinois Subscriber

Answer: The precise G code for this situation is G8540 (Functional outcome assessment not documented as being performed, documentation the patient is not eligible for a functional outcome assessment using a standardized tool). A patient is ineligible for a functional outcome assessment on a visit when one of the following applies:

The patient refuses to participate

The patient is unable to complete the form.

Note: Any number of scenarios could meet the ineligibility requirements for this code. More often, patients will simply bristle at the completion of additional paperwork. Once the obtaining of information becomes more routine, patients will acknowledge it as standard procedure. Some refusals are more a factor of anxiety over how to best complete the form. A little reassurance goes a long way in those instances. Further, if a patient is physically unable to complete the form, there is no reason to press the issue. Simply try again when they are able, and note within the record if you believe the scoring is likely improved because of the wait from the most acute presentation.