Documentation Guidelines

Documentation Guidelines

The ACA House of Delegates ratified the following:

Resolved, that the American Chiropractic Association support the following:

Clinical (Medical) Documentation Recommendations 

Based on these findings and trends, the ACA recommends certain basic requirements be considered as appropriate medical documentation in patient record keeping. A concerted effort by the chiropractic profession to standardize medical documentation will improve the frustration level and reimbursement experience exponentially.

  1. The nationally accepted HCFA billing 1500 form must be completed in detail. This means all required fields must be completed. 
  2. Subjective, Objective, and Treatment, if rendered, components should be incorporated into patient records on each visit. A customized format is not needed but these elements must exist consistently. Any significant changes in the clinical picture (e.g. significant patient improvement or regression) should be noted.
  3. All ICD-10-CM diagnosis codes and CPT treatment and procedure codes must be validated in the patient chart and coordinated as to the diagnoses and treatment code descriptors. 
  4. Uniform chiropractic language should be used within the profession for describing care and treatment. Non-standard abbreviations and indexes should be defined. 
  5. Documentation for the initial (new patient) visit, new injury or exacerbation should consist of the History and Physical and the anticipated Patient Treatment Plan. The initial Treatment Plan except in chronic cases should not project beyond a 30-45 day interval. Subsequent patient visits should include significant patient improvement or regression if demonstrated by the patient on each visit. As the patient progresses, the treatment plan need to be re-evaluated and appropriately modified by the treating doctor of chiropractic (chiropractic physician) until the patient can be released from care, if appropriate.
  6. If the patient is disabled, a statement(s) on the extent of disability and activity restriction is needed at initial and subsequent visits as appropriate over the course of care.
  7. Records can be attached to each billing to pre-empt requests, however, it is not mandatory. Local insurers should be contacted for preferences (i.e., No fault PIP insurers may require records every visit while health insurers may not).
  8. All records must be legible and understandable, released within the authority given by the patients, in a secure confidential manner, and in compliance with existing state (or federal) statutes.
  9. The patient name and initials of the person making the chart notation (especially in multi-practitioner offices) should appear on each page of the medical record.
  10. If the above recommendations have been met then the answers as to why the necessity for continuing treatment is answered.
  11. The insurance industry must improve their claim adjusting procedures by utilizing chiropractic consultants. The ACA can use its resources to assist in this initiative. (Ratified by the House of Delegates, September 2000).
  12. Resolved, that the American Chiropractic Association through the Insurance and Managed Care Committee work with the different third party payors to establish and utilize a uniform set of forms, when additional documentation is required by the third party payor in support of claims submission. (Ratified by the House of Delegates August 2002)