Chiropractic Documentation Guidelines - Initial Visits vs. Subsequent Visits

Coverage is limited to manual manipulation of the spine to correct a subluxation. CPT Codes 98940, 98941, and 98942 accurately reflect such services. Documentation must clearly reflect the medical necessity for the service billed.

The patient must have significant health problems in the form of a neuro-musculoskeletal condition necessitating treatments and the manual manipulative services rendered must have a direct therapeutic relationship to the patient's condition. Spinal axis aches, strains, sprains, nerve pains and functional mechanical disabilities of the spine are considered medically necessary therapeutic grounds for chiropractic manipulative treatment.

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Initial Visit Documentation Guidelines

The following apply whether the subluxation is demonstrated by x-ray or by physical examination.

  1. History, which includes:
  • Symptoms causing patient to seek treatment; What is the chief complaint that brought the patient in for treatment?; There must be a chief complaint for each level billed;
  • Family history, if relevant;
  • Past health history - What is their general health and has there been prior illness or injury which might impact their treatment? What medications is the patient taking and have they had prior chiropractic treatments?
  1. Description of the present illness including:
  • Mechanism of trauma;
  • Quality and character of symptoms/problem;
  • Onset, duration, intensity, frequency, location, and radiation of symptoms;
  • Aggravating or relieving factors;
  • Prior interventions, treatments, medications, secondary complaints; and
  • Symptoms causing patient to seek treatment.

    These symptoms must bear a direct relationship to the level of subluxation. The symptoms shall refer to the spine (spondyle or vertebral), muscle (myo), bone [sic] (osseo or osteo), rib (costo or costal) and joint (arthro), and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must relate to the spine as such.

    The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited.

    A statement on a claim that there is "pain" is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined.

  1. Evaluation of musculoskeletal/nervous system through physical examination or x-ray. How was it determined there was a subluxation and that it related to the pain that the patient came in with? To determine a subluxation based on physical examination, two of the four criteria of P.A.R.T. are required, one of which must be asymmetry/misalignment or range of motion abnormality.
  • Pain/tenderness evaluated in terms of location, quality and intensity;
  • Asymmetry/misalignment identified on a sectional or segmental level;
  • Range of motion abnormality; and
  • Tissue, tone changes in the characteristics of contiguous or associated soft tissues.
  1. Diagnosis:
  • Primary diagnosis must be subluxation, including level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer either to condition of spinal joint involved or to direction of position assumed by particular bone named
  • Secondary diagnosis required to support condition causing primary diagnosis
  • Notes must support these diagnosis codes for each level of spine adjusted and billed for
  1. Treatment Plan: The treatment plan needs to include the following:
  • Recommended level of care (duration and frequency of visits);
  • Specific treatment goals; and
  • Objective measures to evaluate treatment effectiveness.
  1. Date of the initial treatment

Subsequent Visits Documentation Guidelines

The following apply whether the subluxation is demonstrated by x-ray or by physical examination for subsequent visits.

  1. History
  • Review of chief complaint - why are they returning for chiropractic care?
  • Changes since last visit - just stating increased or decreased pain is not sufficient
  • System review, if relevant
  1. Physical exam
  • Exam of area of spine involved in diagnosis- how provider determined that subluxation was still problematic
  • Assessment of change in patient condition since last visit - how did provider come to conclusion of subluxation and at what level(s)
  • Evaluation of treatment effectiveness
  1. Documentation of treatment given on day of visit

    Inadequate documentation may cause claims to deny. The following outlines the various elements that we identify as lacking in chiropractic documentation and addresses some of the common provider questions.

    Proving medical necessity becomes very difficult with poor documentation. The treating provider is obligated to provide adequate documentation to establish medical necessity and allow for proper reimbursement of services.

    The quality of a beneficiary's medical record impacts current therapy and proper reimbursement of services.

    Documentation is required of all regions adjusted.

    Components which are necessary to prove medical necessity are as follows.

  • History: A review of history must include chief complaint and how it has changed since last visit. This should include current symptoms causing patient to seek skills of a chiropractor. The note must include documentation that reflects location, limitations, severity and frequency of pain. If other significant symptoms were discussed during initial visit, a pertinent system review must be indicated
  • Physical exam: Just stating that patient is having "pain" and stating pain scale is not sufficient to support medical necessity for treatments. Documentation of exam must include examination of those areas of spine that are involved in diagnosis. Objective findings may include provocative orthopedic tests, ranges of motion and physical limitations, but should reflect more findings than only tenderness and tightness. Notes shall also reflect location, test (and how test relates to subjective complaint) and severity of disorder
  • Assessment shall reflect how patient's condition has changed since prior treatment. Progression of care must be evident. This can be shown in decrease frequency of visits, decrease in pain and increase in functional capabilities of patient. Plan and claim history should therefore reflect decreased number of visits required
  • Exact spinal segment manipulated on day of visit must be documented in patient's record. Simply stating region is not sufficient
  • Documentation generated after visit date for purposes of supplying information to Medicare when requested is considered a supplemental report and is not considered actual daily chart notes
  • Daily notes must be encounter specific for each day of service with both functional and measureable elements evident for subjective and objective portions of documentation. It should be clear from documentation why service was necessary that day and why it required skills of a chiropractor. What is appropriate for one date on a specific patient might not be enough or not be required on a different patient or different visit when factors such as age, severity of condition, past response to treatment, frequency of treatment, complicating factors, etc were taken into consideration. Documentation that appears to be same from one day to next and from one beneficiary to next is not appropriate and will be denied
  • Software Generated Documentation: On subject of computerized documentation, CMS states, "Documentation should detail the specific elements of the chiropractic service for this particular patient on this day of service. It should be clear from the documentation why the service was necessary that day. Services supported by repetitive entries lacking encounter specific information will be denied."
  • Documentation must demonstrate vertebrae affected, to what degree and if particular vertebra is capable of producing pain that patient came in with. If billing for more than one level, all levels must reflect this.
    • Item 21 on CMS-1500 claim form or its electronic equivalent allows space for four (4) diagnoses for each claim; however, each treatment region requires two diagnoses, a primary and a secondary
    • When billing for two treated regions, enter the two most clinically significant primary and corresponding secondary diagnoses on claim form
    • If billing for three to five regions of subluxation, documentation must support both primary and secondary codes for each region individually. When billing for three to five regions, the two most clinically pertinent diagnosis pairs are placed in Item 21 on CMS-1500 claim form and remaining three to five primary and secondary code pairs must be present in documentation

The primary and secondary diagnosis codes for each level billed must be reflected in the documentation. Medical review checks diagnosis codes for correlation in the documentation.

  • Under Medicare program, Chiropractic maintenance therapy is not considered to be medically reasonable or necessary, and is therefore not payable
  • Maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health and prolong and enhance quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and  chiropractic treatment becomes supportive rather than corrective in nature, treatment is then considered maintenance therapy. Noridian does not argue benefit of supportive care to beneficiaries; it simply is not payable under current Medicare regulations
  • Chiropractor should be afforded the opportunity to effect improvement or arrest or retard deterioration in such condition within a reasonable and generally predictable period of time. Acute subluxation (e.g., strains or sprains) problems may require as many as three months of treatment but some require very little treatment. In first several days, treatment may be quite frequent but decreasing in frequency with time or as improvement is obtained.
  • For Medicare purposes, a chiropractor MUST append an AT modifier on a claim when providing active/corrective therapy to treat acute or chronic subluxation. However, the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary
  • Claims without AT modifier will be considered maintenance therapy and will be denied. Chiropractors who give or receive from beneficiaries an Advance Beneficiary Notice of Noncoverage (ABN)
  • Use of AT modifier and GA modifier together on a claim is never appropriate
  • All claims submitted for payment to Noridian are subject to pre or post pay medical review
  • It is providers responsibility to determine if treatment or part of treatment for that day of service is maintenance or not and to bill accordingly with GA modifier after having received a valid ABN

Documentation Tips

  • Provide complete and legible documentation
  • Clearly identify medical necessity
  • Use standard abbreviations
  • Include plan of treatment
  • Computerized documentation may not provide individualized information
    • Detail specific date of service elements
    • Clarify which services necessary
    • Documentation must support each level billed
  • Be careful with software generated documentation as some include identical entries for different patients/ different dates of service
  • Be careful with check-off sheets: they can be difficult to read, lack findings, be too generic, and lack enough space to list specific required information
  • Be careful including non-encounter specific repetitive entries that do not contain policy required components, denied upon review
  • Whichever documentation style is used, it must include required elements to support medical necessity for service(s) rendered
  • Physicians/NPPs should not add late signatures to medical records, other than a short delay that occurs during transcription process. Use signature authentication process. Retroactive orders are not acceptable

Resources

 

Last Updated Feb 19, 2019