Perhaps your patient is nearly recovered, or recently released, from a low back strain suffered in a motor vehicle accident. Your office gets a call. While taking out the garbage, your patient experienced sharp, shooting low back pain. Is this a new injury or an exacerbation of the original injury?

The PIP carrier, the liability insurance company of the person at fault (if any) and their lawyers are interpreting this as a new injury. This is understandable. It gives them a reason not to pay any resulting medical bills. But is this interpretation medically correct? This conclusion may be drawn by these self-interested entities even if it is not the opinion of the treating physician.

In such cases, the history of such incidents in your chart notes should state specifically that the activity causing the flare-up of pain was an exacerbation of the injury you had been treating - if that is what you believe to be the case.

Otherwise, the bills may not be paid by the PIP carrier. Also, any treatment needed subsequently may not be recognized as part of the original injury claim, if any, against the liability insurance company.

Your stating specifically that the accident injury was exacerbated may also affect the level of payment your office will receive for your services. Since PIP carriers have no direct agreement with medical providers regarding the level of reimbursement, they are governed by the standard of "reasonable" charges. Therefore, in most cases, they will pay the full billed amount.

So, even if health insurance (or other "secondary" insurance) is available as a back-up, payment by the PIP carrier is preferable, if the charges really are related to the original accident injury. Therefore, it would be a shame to be denied full payment for your services solely on the basis of how your chart note was written!

For example, suppose the patient who experienced the sharp pain in her low back while taking out the garbage had, in the weeks before, experienced gradual improvement through physical therapy sessions, which were down to one a week. She took out the garbage Sunday night, after you had released her on Thursday to return to work Monday. If your chart note reads, "Patient says she hurt her back again" or "patient re-injured her back" with an assessment of "low back strain," without connecting it to the MVA injury, then it would be difficult for the patient (or her lawyer) to oppose the PIP insurance company's conclusion that this was a new, unrelated and, therefore, not covered injury. This would be especially true if the physical therapist noted the following week: "Patient reports stabbing pain after taking out garbage; additional therapy needed" - even if both you and the therapist believed that this was in fact an exacerbation of the MVA injury!

Such misunderstandings are less likely when doctors refer to the latter incident as an aggravation, exacerbation or flare-up of the MVA injury. This will not guarantee that the PIP carrier won't refuse to pay the medical bill, but at least it will maximize your patient's chances of success in getting your bill paid.