Print This Page

The ACA takes documentation very seriously. As part of our ongoing efforts to ensure that doctors of chiropractic have access to all the information they need on this topic, this webpage is dedicated to the topic of Medicare Documentation.

• Documentation of the Subluxation: The P.A.R.T. System
• Documentation of the Initial and Subsequent Visits
• Conclusion
• Resources

P: PAIN AND TENDERNESS
Identify using one or more of the following:

• Observation: You can document, by personal observation, the pain that the patient exhibits during the course of the examination. Note the location, quality, and severity of the pain.
• Percussion, Palpation, or Provocation: When examining the patient,ask them if pain is reproduced, such as, “Let me know if any of this causes discomfort.”
• Visual Analog Type Scale: The patient is asked to grade the pain on a visual analog type scale from 0-10.
• Audio Confirmation: Like the visual analog scale, the patient is asked to verbally grade their pain from 0-10.
• Pain Questionnaires: Patient questionnaires, such as the McGill pain questionnaire or an in-office patient history form can be used for the patient to describe their pain.

A: ASYMMETRY/MISALIGNMENT
Identify on a sectional or segmental level by using one or more of the following:

• Observation: You can observe patient posture or analyze gait.
• Static and Dynamic Palpation: Describe the spinal misaligned vertebrae, and symmetry.
• Diagnostic Imaging: You can use x-ray, CAT scan and MRI to identify misalignments.

• Observation: You can observe an increase or decrease in the patient’s range of motion.
• Motion Palpation: You can record your palpation findings, including listing(s). Be sure to record the various areas that are involved and related to the regions manipulated.
• Stress Diagnostic Imaging: You can x-ray the patient using bending views.
• Range of Motion Measuring Devices: Devices such as goniometers or inclinometers can be used to record specific measurements.

• Observation: Visible changes such as signs of spasm, inflammation, swelling, rigidity, etc.
• Palpation: Palpated changes in the tissue, such as hypertonicity, hypotonicity, spasm, inflammation, tautness, rigidity, flaccidity, etc. can be found on palpation.
• Use of Instrumentation: Document the instrument used and findings.
• Tests for Length and Strength: Document leg length, scoliosis contracture, and strength of muscles that relate.

The above descriptions must be included in your patient’s record. No specific national policy exists on when you should send your records to your carrier. Individual carriers may specify what they want, and when, but as a matter of rule, only the CMS-1500 form is submitted. Because of this, it is vital that all appropriate boxes on the CMS-1500 are filled in completely and accurately for each billing submitted since the CMS-1500 claims form is considered a necessary part of the documentation requirements. The carrier may request patient records at times, so it is just as important to keep standardized patient chart notes.

CMS states that the following requirements MUST be included in your patient chart notes to describe the presenting complaint. After completing your case history with the patient, you should be able to ask yourself the questions below, and answer them with your documentation:

Initial Visit Requirements

• Relevant History of Patient’s Condition with Detailed Description of the Present Condition
• Evaluation of Musculoskeletal/Nervous System Through Physical Examination
• Diagnosis
• Treatment Plan:
  • Recommended level of care (duration and frequency of visits)
  • Specific treatment goals
  • Objective measures to evaluate treatment effectiveness
• Date of Initial Treatment

Subsequent Visit Requirements

• History:
  • Review of chief complaint
  • Improvement or regression since last visit
  • System review, if relevant
• Physical Examination:
  • Exam of the spine involved in diagnosis
  • Assessment of change in patient condition since last visit
  • Evaluation of treatment effectiveness
• Documentation of Treatment Given on Day of Visit
• Any Changes to the Treatment Plan

Conclusion

As you can see, Medicare’s documentation requirements are very specific, and it is possible to meet the requirement for documenting a subluxation within your daily chart notes. You must use the common sense approach to documentation. What may be appropriate documentation for one visit may not be adequate in another when other factors are taken into consideration such as frequency, duration of condition, severity of condition, past history, other documentation, etc.

Our Medicare sources have indicated that in a records review process, these are some of the questions that will be asked about your records, giving consideration to the combined documentation of the initial and subsequent visit(s):

• Does the record show a significant neuromusculoskeletal condition?
• Is there a precise subluxation(s) documented by physical exam or x-ray?
• Does the exam substantiate the condition and the subluxation?
• Is the complaint consistent with the subluxation level(s)?
• Is there a primary diagnosis of subluxation and a secondary ICD condition caused by the subluxation?
• Is there a treatment plan?
• Is the adjustment clearly recorded in the record as being done each visit?
• Is there a response to the adjustment noted in the records (increased ROM, increased function, decreased pain, etc. that shows quality, character, and intensity that would qualitatively and quantitatively substantiate need and frequency of treatment)?
• Is the adjustment therapeutic or maintenance (maintenance is non-covered by Medicare)?

Sources:
1. CMS Carrier Manual
2. CMS Billing Manual
3. TrailBlazer Chiropractic Services Manual
4. MLN (formerly Medlearn Matters) Article #SE0528
5. MLN (formerly Medlearn Matters) Article #SE0555

Resources

• ACA Chiropractic Coding Solutions Manual
• ACA Clinical Documentation Manual
• ACA TeleSeminars