Chiropractic Documentation Guidelines - Initial Visits vs. Subsequent Visits

Document the patient's condition, the level of subluxation treated, the services provided, and the medical necessity of treatment in the medical record. Documentation should support the diagnosis reported, the spinal segment manipulated, and the clinical rationale for care. Medicare coverage is limited to manual manipulation of the spine to correct a subluxation, which is typically reported using CPT codes 98940, 98941, and 98942. Complete and accurate documentation helps demonstrate medical necessity and supports the services billed.

The medical record must demonstrate that the patient has a significant neuro-musculoskeletal condition requiring treatment and that the chiropractic manipulative treatment has a direct therapeutic relationship to that condition. Documentation should clearly describe the patient's symptoms, functional deficits, clinical findings, diagnosis, treatment plan, and response to care to support medical necessity. Conditions such as spinal aches, strains, sprains, nerve pain, and functional mechanical disabilities of the spine may support the need for chiropractic manipulative treatment when appropriately documented.

At a Glance: Initial and Subsequent Visit Documentation

Initial Visit Subsequent Visit
Establish the patient's condition and reason for treatment Document changes since the previous visit
Identify the subluxation and related symptoms Confirm the continued presence and clinical significance of the subluxation
Establish baseline examination findings Document current subjective and objective findings
Report the applicable diagnoses Assess the patient's response to treatment
Develop the treatment plan Demonstrate progress toward treatment goals
Identify measurable goals and evaluation methods Document the specific treat

Initial Visit Documentation

History and Present Illness

Whether a subluxation is identified through x-ray or physical examination, providers must document a comprehensive patient history and description of the present illness. Documentation should clearly identify the symptoms that prompted the patient to seek chiropractic care and include a chief complaint for each level of subluxation billed. Include the following information when applicable:

  • Relevant family history
  • Patient's general health status
  • Prior illnesses or injuries that may affect treatment
  • Current medications
  • Previous chiropractic treatment

These elements help establish medical necessity and support the services reported on the claim.

Providers should also document:

  • Mechanism of trauma or onset of the condition
  • Quality, duration, intensity, and frequency of symptoms
  • Location and radiation of symptoms
  • Aggravating or relieving factors
  • Relevant prior treatments, medications, or interventions
  • Secondary complaints that affect the course of care

Complete documentation helps demonstrate the patient's clinical condition and supports the need for chiropractic treatment.

The symptoms documented in the medical record must be directly related to the level of subluxation being treated. Symptoms should involve the spine (spondyle or vertebral), muscles (myo), bones (osseo or osteo), ribs (costo or costal), or joints (arthro), and may be reported as pain (algia), inflammation (itis), swelling, spasticity, or other clinical findings. Vertebral pinching of spinal nerves may cause headaches, as well as pain, numbness, or other symptoms involving the arms, shoulders, hands, legs, or feet. Rib and chest pain are also recognized symptoms. In general, symptoms must be related to the spine and the documented subluxation.

The documented subluxation must be the cause of the patient's symptoms and correspond to the level of subluxation identified in the medical record. When documenting pain, providers should identify the specific location of the pain rather than simply stating that pain is present. Documentation should support that the identified vertebra can produce the reported symptoms. This information helps establish the relationship between the patient's condition, the documented subluxation, and the treatment provided.

Evaluation of the Musculoskeletal and Nervous System

Providers must document how the subluxation was identified and demonstrate the relationship between the documented subluxation and the patient's symptoms. This may be established through physical examination or x-ray findings. Documentation should clearly support the presence of a subluxation and explain how it relates to the condition for which the patient is seeking treatment.

P.A.R.T. Examination Requirements

When using a physical examination to identify the subluxation, document at least two of the four P.A.R.T. criteria. One of the documented criteria must be either asymmetry/misalignment or range-of-motion abnormality. These findings help establish the presence of a subluxation and support the medical necessity of chiropractic manipulative treatment.

  • Pain or tenderness: Evaluated in terms of location, quality and intensity
  • Asymmetry or misalignment: Identified on a sectional or segmental level
  • Range-of-motion abnormality
  • Tissue or tone changes: Changes in the characteristics of contiguous or associated soft tissues

The record should identify the tests performed, the location examined, the severity of the findings, and their relationship to the patient's symptoms.

Diagnosis Documentation

Document a primary diagnosis identifying the subluxation and the specific level being treated. The subluxation may be explicitly stated or described using terminology that identifies the condition of the spinal joint or the direction of displacement of the affected vertebra. Accurate diagnosis reporting helps support the medical necessity of the chiropractic manipulative treatment provided. Also document a secondary diagnosis that describes the underlying clinical condition associated with the subluxation.

The medical record must support:

  • Every diagnosis code reported on the claim
  • Each level of the spine adjusted and billed
  • The relationship between the patient's symptoms and the documented subluxation
  • The services performed during the encounter

Treatment Plan

Develop a treatment plan that establishes the expected course of care and provides a measurable framework for assessing the patient's progress. The treatment plan must include:

  • Recommended duration and frequency of treatment
  • Specific treatment goals based on the patient's condition.
  • Objective measures that will be used to evaluate treatment effectiveness
  • Date of the initial treatment

Subsequent Visits Documentation

The following requirements apply whether the subluxation is demonstrated by x-ray or physical examination during a subsequent visit.

Updated History

For subsequent visits, providers must document the patient's current condition and demonstrate the continued medical necessity of chiropractic treatment. Documentation should include a review of the chief complaint, explaining why the patient is returning for care, and describe any changes since the previous visit. The medical record should identify the location, severity, frequency, and functional impact of symptoms, as well as the patient's response to prior treatment. Simply stating that pain has increased or decreased is not sufficient. When clinically relevant, providers should also document a pertinent review of systems.

Physical Examination

Providers must perform and document an examination of the area of the spine associated with the diagnosis. Documentation should support the continued presence of the subluxation, identify the level or levels involved, and explain how the provider determined that the condition remains clinically significant and requires ongoing treatment. The physical examination must support both the diagnosis and the medical necessity of treatment. Objective findings may include orthopedic testing, range-of-motion measurements, physical limitations, and other clinically relevant observations. Documentation should clearly identify the location examined, tests performed, relationship of findings to the patient's symptoms, and severity of the condition.

Assessment of Progress

The assessment should describe how the patient's condition has changed since the previous visit and demonstrate progression of care. Improvement may be reflected through reduced pain, increased functional abilities, improved clinical findings, or a decrease in treatment frequency. The assessment, treatment plan, and claim history should collectively support the patient's progress and continued need for chiropractic treatment.

Treatment Provided

Complete and accurate documentation is essential to support medical necessity and proper reimbursement of chiropractic services. Inadequate documentation may result in claim denials. Providers are responsible for maintaining medical records that clearly support the services rendered, the patient's condition, and the need for continued treatment. Documentation is required for all spinal regions adjusted and billed, and each encounter should contain sufficient detail to support the care provided.

Treatment Documentation

Providers must document the exact spinal segment manipulated on the date of service. Documentation of only a spinal region is insufficient. The medical record should support the level of subluxation treated and demonstrate that the identified vertebrae can produce the patient's reported symptoms. When multiple levels of subluxation are billed, each level must be supported by the medical record.

Daily Notes

Daily notes must be specific to the date of service and include functional, measurable findings within both the subjective and objective portions of the record. Documentation should clearly explain why the service was medically necessary on that date and why it required the skills of a chiropractor. Records that appear repetitive from one visit to another or from one beneficiary to another may not adequately support medical necessity and may result in claim denial.

Software Generated Documentation

CMS states that documentation should describe the specific services provided to the individual patient on that specific date of service. The medical record should clearly demonstrate why the service was necessary on that date. Documentation containing repetitive or non-encounter-specific entries may not support medical necessity and may be denied upon review.

Billing and Claims Requirements

Diagnosis Reporting Requirements

Providers must ensure that diagnosis reporting is fully supported by the medical record. Each treatment region requires both a primary diagnosis and a secondary diagnosis. The primary diagnosis should identify the subluxation being treated, while the secondary diagnosis should support the underlying condition related to the subluxation.

Item 21 of the CMS-1500 claim form, or its electronic equivalent, allows space for up to four diagnosis codes per claim. Because each treatment region requires both a primary and secondary diagnosis, providers should report the most clinically significant diagnosis pairs on the claim form when multiple treatment regions are billed.

When billing for two treated regions, providers should report the two most clinically significant primary diagnoses and their corresponding secondary diagnoses in Item 21 of the CMS-1500 claim form. When billing for three to five regions of subluxation, documentation must support both a primary and secondary diagnosis for each region treated. Report the two most clinically pertinent diagnosis pairs in Item 21 and maintain documentation supporting the remaining diagnosis pairs within the medical record.

The primary and secondary diagnosis codes reported for each level billed must be supported by the medical record. During medical review, diagnosis codes are compared against the documentation to verify that they accurately reflect the patient's condition, the level of subluxation treated, and the services provided. Complete and accurate documentation helps support medical necessity and ensures consistency between the claim and the medical record.

Modifier Requirements

Providers must append the AT modifier when furnishing active or corrective treatment for acute or chronic subluxation. However, the presence of the AT modifier alone does not establish that a service is medically reasonable and necessary. Documentation must support the patient's condition, the medical necessity of treatment, and the continued need for care. Claims submitted without an AT modifier are considered maintenance therapy and are denied.

It is the provider's responsibility to determine whether all or part of the treatment provided on a particular date of service constitutes maintenance therapy. When maintenance therapy is furnished and a valid Advance Beneficiary Notice of Noncoverage (ABN) has been obtained, the claim should be billed with the appropriate modifier. Providers should not report the AT modifier and GA modifier together on the same claim.

Documentation and Coverage Requirements

Maintenance Therapy

Under the Medicare program, chiropractic maintenance therapy is not considered medically reasonable and necessary and is therefore not covered. Maintenance therapy includes treatment intended to prevent disease, promote health, enhance quality of life, or maintain or prevent deterioration of a chronic condition when further clinical improvement is no longer expected.

Providers should document treatment goals and the patient's progress to demonstrate that care remains corrective rather than supportive in nature. When ongoing treatment is no longer expected to improve the patient's condition and serves only to maintain the current level of function, the services are considered maintenance therapy. While chiropractors should be afforded a reasonable opportunity to improve the patient's condition or arrest or slow deterioration, treatment frequency should generally decrease as improvement occurs. Some acute subluxation conditions, such as strains and sprains, may require an extended course of treatment, although the duration of care will vary based on the individual patient's condition and response to treatment.

Medical Review

All claims submitted to Noridian are subject to prepayment or post payment medical review. Providers should ensure that medical records accurately support the billed services, the diagnoses reported, and the medical necessity of treatment. Complete, encounter-specific documentation helps facilitate the review process and supports appropriate reimbursement.

Documentation Tips

Maintaining complete, accurate, and encounter-specific documentation helps support medical necessity, facilitate claim review, and reduce the risk of claim denials. Providers should ensure that documentation clearly reflects the patient's condition, the services performed, and the clinical rationale for treatment. Regardless of the documentation method used, medical records must contain sufficient detail to support the services billed and the diagnoses reported.

Providers can help support medical necessity and reduce documentation-related denials by following these best practices:

  • Provide complete, legible, and timely documentation
  • Clearly document the medical necessity of the services provided
  • Use standard and widely recognized abbreviations
  • Include a treatment plan that supports the patient's care
  • Ensure documentation supports each level of subluxation adjusted and billed
  • Document the specific services performed on each date of service and explain why those services were medically necessary
  • Verify that diagnosis codes, treatment provided, and supporting documentation are consistent throughout the medical record

When using computerized or software-generated documentation, providers should ensure that records are individualized for each patient and each encounter. Documentation should contain patient-specific findings and avoid repetitive language that does not accurately reflect the services provided on a particular date of service.

Providers should also exercise caution when using check-off forms and templates. These formats may be difficult to read, may not capture sufficient clinical findings, and often do not provide enough space to document the information necessary to support medical necessity. Similarly, repetitive entries that are not specific to the individual encounter may not satisfy documentation requirements and may result in denial during medical review.

Regardless of the format used, documentation must include all required elements necessary to support the services rendered. Physicians and non-physician practitioners should not add retroactive signatures or orders to medical records. If a signature is delayed due to transcription or administrative processing, providers should follow the appropriate signature authentication process. Retroactive orders are not acceptable.

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Last Updated Oct 07 , 2026