Document 8 Items for Initial Chiropractic Services

Straighten any kinks in initial subluxation claims with good documentation.
By Marty Kotlar, DC, CHCC, CBCS
Question: I have been treating Medicare patients for the last three years and my office manager recently told me there are specific chiropractic guidelines for a Medicare patient on the initial visit. I did not know that. I just perform my normal history and examination, take X-rays, and do not follow any special system. Should I be doing something different?
Answer: Your office manager is correct: There are specific guidelines Medicare wants doctors of chiropractic to follow. Whether you are meeting those guidelines is hard to tell for sure without knowing what you are documenting presently when you perform your history, exam, and X-ray findings.
A chiropractor is defined in the Social Security Act (section 30.1.) as a physician only for manual manipulation or treatment of subluxation of the spine. The following eight items must be documented in the Medicare patient’s clinical record on the initial visit, whether the required subluxation is demonstrated either by X-ray or physical examination:
1. History – A chief complaint must be documented, including the symptoms present causing the patient to seek chiropractic treatment.
2. Present Illness – This can include any of the following, as appropriate:

• Mechanism of trauma
• Quality and character of problem/symptoms
• Intensity of symptoms
• Frequency of symptoms occurring
• Location and radiation of symptoms
• Onset of symptoms
• Duration of symptom
• Aggravating or relieving factors of symptoms
• Prior interventions, treatments, including medications
• Secondary complaints
• Symptoms causing patient to seek treatment

3. Family History
4. Past Health History – This should include:

• General health statement
• Prior illness(es)
• Surgical history
• Prior injuries or traumas, past hospitalizations (as appropriate)
• Medications

5. Physical Examination – Evaluation of musculoskeletal/nervous system through physical examination to identify:

• P = Pain/tenderness evaluated in terms of location, quality, and intensity;
• A = Asymmetry/misalignment identified on a sectional or segmental level;
• R = Range of motion abnormality (changes in active, passive and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and
• T = Tissue, tone changes in the characteristics of contiguous or associated soft tissues, including skin, fascia, muscle, and ligament.

To demonstrate a subluxation based on physical examination, two of the four criteria mentioned are required, one of which must be asymmetry/misalignment or range of motion abnormality.
Note that a patient’s subluxation/condition is considered chronic when it is not expected to resolve completely, as is the case with an acute condition, but where the continued therapy is expected to result in some functional improvement. If an extensive, prolonged course of treatment is necessary, clearly document it in the clinical record. Coverage will be denied if it is not reasonably expected that continued treatment will result in improvement of the patient’s condition. Continued repetitive treatment without a clearly defined clinical end point is considered maintenance therapy and is not covered.
Complete requirements for chiropractic services under Medicare may be found in the Medicare Benefit Policy Manual, chapter 15, section 240, “Chiropractic Services,” which may be found on the Centers for Medicaid & Medicare Services (CMS) Web site: www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Be sure to read your local Medicare carrier’s guidelines for chiropractic services.
6. Diagnosis – Most Medicare carriers require the primary diagnosis to be subluxation with the neuromusculoskeletal condition causing the treatment to be listed as the secondary diagnosis.
7. Treatment Plan – This should include:

• Therapeutic modalities to effect cure or relief (patient education and exercise training)
• The recommended care level (the duration and frequency of visits)
• Specific goals to be achieved with treatment
• Objective measures that will be used to evaluate the effectiveness of treatment
• Date of initial treatment

8. Signature/initials – This is required to authenticate the records.
For additional information, see also the American Chiropractic Association (ACA) Web site: www.acatoday.org/pdf/part_process.pdf.

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