Lawyers PI Program


From the Desk of:
Evaluation Report vs. Final Narrative


After reviewing 1000’s of narrative and evaluation reports, I can say with certainty a common mistake doctors make is interchanging evaluation reports and final narratives. An evaluation report is designed to certify the necessity for care with an insurance company, and a final narrative report is meant to report what condition has persisted after a reasonable course of care.

 An evaluation and re-evaluation report should be thorough in meeting the requirements and requisite number of elements in the level of E&M code that you are using. If you choose a 99203 or a 99214, then you must fulfill either the time requirements or the number of items needed for each. Medicode, a company that is utilized by the carriers and the Federal Government, has clearly outlined the parameters of each along with your local Medicare carrier. I urge you to get a CPT book, or go online and learn those parameters. 

In your initial evaluation, there is no need to talk about clinically correlating causality to bodily injury and persistent functional loss, as you cannot have anything persistent without concluding a reasonable course of care. Furthermore, your primary role in the report is to determine causality and potential bodily injury. How can you make an accurate assessment of persistent loss without any testing? At the very least, you need x-rays to see structural deviations. 

You should also include, as per your licensure standards along with the coding requirements, current history (including causality), past medical history, family and social history, review of systems and either a focused, detailed or comprehensive evaluation with appropriate recommendations. There should be an original signature on the document as well. 

Never use a signature stamp, ever. If you have any in your office, throw them away after destroying them. I made that mistake only to find my staff using it at their discretion and not mine. In addition, the insurance carrier can legally delay the payment of your claim for verification purposes by not having an original signature.  

There needs to be a legible report that should also be sent in with the claim to ensure you get paid for verification purposes. This will also reduce your chances of being audited, as the insurer will have your records up front without having to guess how you arrived at your clinical decisions and treatment plan.

If you state in you re-evaluation that your treatment plan is to care for the patient for 12 visits or 1 month and then re-evaluate your patient, make sure you perform that re-evaluation. This is one area in which the insurance industry is going after doctors for fraudulent activity. It’s called unnecessary and excessive treatment. You are treating a patient with no clinical information, signs or symptoms, and insurance companies are prevailing in cases they take against those doctors. If you order 12 visits or 1 month and that time period has expired, what is the basis for your ongoing care if you have no additional orders? You actually are the cause of the problem with your own report. A timely re-evaluation is critical.   

This brings up another very, no HUGE, issue. How complete is your paperwork? I spent a significant amount of time with a doctor this past week listening to him tell me that his goal is to keep his evaluation to 1-2 pages…no more. I actually got ill listening to him and wished he practiced closer to Long Island so I could visit him and smack him on the back of his head!!! 

It’s not about the length of the report; it’s about the completeness of the report. In fact, I welcome you to e-mail me, or fax me a copy of your evaluation template and I will let you know if it meets the basic standard of your license. I am also a very big proponent of having the evaluation typed, just like every other specialist in the medical community. This will allow you to send a professionally prepared report to lawyers and/or primary care doctors of your patients. This is a very good referral practice, as every specialist in the medical community sends reports to primary care doctors. Should your report be deficient in content, the other doctor will know and you will look the fool. Worse, you will never get the referral!

I have previously recommended a dictation company (Medscribers 516-620-4494 – discount arranged if you mention you are a CMCS client), as that is the most efficient and least expensive avenue to generate reports. Another efficient avenue is a report-writing program, as long as it doesn’t look “canned,” as unfortunately, most do. Many of those programs discuss, in the history, the patient’s “First Stated Symptom, the Second State Symptom,” and so forth. The courts are starting to throw these reports out, as they are not unique to your patient because they appear “Canned.” Other doctors, such as primary care physicians, who you would send a report, also frown on those, as no one in the real world articulates problems in those words. Keep it simple and keep it real!

I have talked at length about the narrative in previous consultations. The narrative is to certify what has persisted after a reasonable course of care, yet doctors are still including treatment plans and what modalities have been done. The modalities and treatment plan have absolutely nothing to do with what is wrong with the patient. To render a record of care, simply list the number of visits and attach your LEGIBLE SOAP Notes.

Many of you are also including the findings of your first, second, third, etc. findings of your evaluations and re-evaluations. This is also not relevant. All that matters is what has persisted over a reasonable course of care. (Have I said that enough?) Therefore, only include your last evaluation findings. In the “Treatment” section of your narrative, also list the dates of your evaluation and re-evaluation and attach those to the back of the report, as well. This also underscores the necessity of having a typed evaluation report. All specialists in the medical community have typed reports and you are considered a specialist by the lawyer.

DO NOT SEND A NARRATIVE TO THE INSURANCE COMPANY. Narratives are not part of the care process. Only the evaluations and re-evaluations are. A narrative should be done 6-8-10 weeks post care, as a final evaluation, as described in consultation #14 (perhaps the most important one). The final evaluation report, if billed to the carrier, should be sent with the claim as described above, but the final narrative is a separate document that is designed for the lawyer, only upon request. It outlines all of the permanent and persistent findings and should only be released to the carrier upon their request.

In representing the best interest of your patient, the patient’s legal representative should have the advantage of the report prior to the carrier having a copy. Again, you are not withholding anything from the carrier, as that would be unethical and perhaps illegal, but based upon the timeline of creating the report, the lawyer requests a report and then the carrier requests copies. The carrier usually gets a copy from the lawyer, as they have to exchange reports during the discovery process.

If a lawyer does not ask for a narrative, here is where you contact the lawyer and share with them that you have “significant information that could positively impact the outcome of their case,” and request a meeting with them over breakfast to discuss the results you have determined for their client. Once you have a relationship with the lawyer, based upon your narrative and credentials, they will, as a matter of business, always request your reports. Most, if not all, lawyers will meet with you because in their mind, you are making them money by talking their language. If they want you to just send the report, press a bit to meet with them. If they absolutely refuse, then just send it. However, in my experience, that rarely happens if articulated correctly.

When you meet with the lawyer, have an educational binder prepared with your CV. Make sure you have the correct credentials on your CV. If not, take the PI Bootcamp, as the feedback from doctors nationally, is lawyers are extremely impressed with those citations on the CV. They can now utilize your credentials in settling cases and it also makes it possible for them to use you as an expert. Credentials count…BIG!

Have the patients report in a separate binder; make it a formal presentation. Style counts for those who follow the 6 P’s; Proper Planning Prevent Piss Poor Performance. As a side note, I know this is going to sound silly to some, but wear a suit for the first meeting. 1 doctor told me since it was breakfast, they wore jeans, a tee shirt and sandals to keep it collegial and not be stuffy. I only have 1 word to say…For those of you who saw the movie Borat...”NOT.” You get the picture.

Also…Have you heard of the joke, “What do you call 500 lawyers who died in a airplane crash?...A Good start.” This type of “dark humor” is also not suggested. I know this sounds like common sense to some, but others, like me, have a very sick sense of humor and think everyone else does. They don’t. Keep your initial meetings very conservative and professional. Should a relationship develop, then feel free to make a fool out of yourself.

Evaluations, re-evaluations and narratives all have very specific purposes. Make sure you utilize them correctly and you will win.