Documentation Requirements

Medicare’s Standard

Medicare has published a standard for documentation that is easily followed for all of your documentation. Sometimes, a state chiropractic board has also set minimum requirements for documentation. Be sure you check with your state board for any requirements you’re subject to, and consider using Medicare’s standard below as your guideline for excellent documentation.

Medicare’s Documentation Requirements: Initial Visit

The following is the standard of documentation required by Medicare and published in most Chiropractic Local Coverage Documents (LCDs) in order to establish medical necessity for care for the initial visit note, for any episode for which a patient presents for care.

History

• symptoms causing the patient to seek treatment
• family history
• past health history
• mechanism of injury
• quality and character of symptoms/problem
• onset, duration, intensity, frequency, location, and radiation of symptoms
• aggravating or relieving factors
• prior interventions/treatments/medications and any secondary complaints

Description of the present illness

Evaluation of Musculoskeletal/nervous system through physical exam

Diagnosis

Primary diagnosis must be subluxation- including level either so stated or identified by a term descriptive of subluxation for Medicare. Such terms may refer to either the condition of the spinal joint involved or to the direction or position assumed by the particular bone named. Other third party reimbursement does not require the subluxation diagnosis codes.

Treatment plan

• Including recommended level of care (duration and frequency of visits)
• Specific treatment goals
• Objective measures to evaluate treatment effectiveness
• Date of initial treatment

Medicare’s Documentation Requirements: Subsequent Visits

The following should be documented in order to establish medical necessity for care for all subsequent visit notes for any episode for which a patient presents for care.

• History

• Review of chief complaint

• Changes since last visit

• System review if relevant

Physical Exam

• Examine area of the spine involved in diagnosis
• Assessment of change in patient condition since last visit
• Evaluation of treatment effectiveness
• Documentation of the presence or absence of a subluxation must be present at every visit
• Documentation of treatment given on day of visit
• Progress (or lack thereof) related to treatment goals and plan of care