Q: I have gotten numerous denials on my insurance claims, and the common theme is that I must demonstrate "functional improvement." While I have a basic understanding of what that means, is there any official language and/or specific things I can use to document this and satisfy what the carrier is looking for?
A: Functional improvement has become the buzz term used by the insurance industry to determine the medical necessity of treatment and whether the claim is to be paid.
Specifically, in the chiropractic billing guide it states, "Chronic subluxation: A patient's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered" [emphasis added].
From this statement, a clearer definition of functional improvement becomes apparent: objective clinical improvement, meaning improvement that can be measured, such as ranges of motion, orthopedic testing, strength testing, etc. Each of these generally has an active or functional component that can be used to judge the effectiveness and continued usefulness of care.
Workers' compensation carriers and their administrators also have taken heed to the term functional improvement and also use it as the barometer of treatment effectiveness. Most treatment guidelines for workers' compensation will directly or indirectly define functional improvement. The American College of Occupational and Environmental Medicine (ACOEM) Occupational Medicine Practice Guidelines and other workers' compensation treatment guides define functional improvement as a "clinically significant improvement in activities of daily living or a reduction in work restrictions as measured during the history and physical exam performed and documented as part of the evaluation and management visit; and a reduction in dependency on continued medical treatment." Each of these factors can, of course, easily be documented in some measured fashion.
Note that in each instance, the common theme remains: measured changes. It has been my experience that when dealing with audited claims, some of the best tools for functional improvement are outcome assessments (disability indexes) and functional capacity testing. These instruments and tests can help to further document and correlate the functional improvement of the patient as done as part of the history and exam.
Simply put, insurance carriers are looking to see the patient is "better" not by statement, but by action. It's generally accepted that pain lessened without functional improvement is ineffective, while care that causes functional improvement, but little or no pain reduction, is considered effective.
A very simple six-question outcome assessment tool is the General Pain Index, which measures the effect of pain on daily activities and can be scored for comparative purposes. All providers should, at minimum, use this index, which correlates activities of daily living with overall function. For those of you who would like a copy of this outcome tool, e-mail me at to request the General Pain Index and I will e-mail you a usable copy.
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