Chiropractic documentation gap analysis

Recognize what’s missing to master your reimbursement and collections!

This Documentation Gap Analysis allows us to evaluate the significant components of your current Documentation program. It should take less than 5 minutes to complete.

Take The Billing GAP Analysis

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This course explains the significant role chiropractic care can play in the sports industry and how a DC can succeed as a Sports Chiropractor. Start your steps to success here!

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Don’t Forget to Do Your PART for Medicare

Don’t Forget to Do Your PART for Medicare

For any claim that requires proof of medical necessity, the primary diagnosis has to be subluxation. Applying the PART process, in the absence of an x-ray, can help you determine whether the diagnosis is truly Subluxation. PART is an acronym for Pain, Asymmetry, Range, and Tissue; each is described below:


Pain and Tenderness

Identify using one or more of the following:

Observation Observe the pain the patient exhibits during the course of the examination. Document the location, quality, and severity of the pain.
Percussion, Palpation, or Provocation During the exam, ask the patient if pain is reproduced (e.g., “Let me know if any of this causes discomfort.”).
Visual Analog Scale Ask the patient to grade the pain from 0-10 on a visual analog scale.
Audio Confirmation Ask the patient to verbally grade the pain from 0-10.
Pain Questionnaires Use patient questionnaires, such as the McGill pain questionnaire or an in-office patient history form, for the patient to describe his/her pain.




Identify on a sectional or segmental level by using one or more of the following:

Observation Observe patient posture and/or analyze gait.
Motion Palpation Describe the misaligned spinal vertebrae and asymmetry.
Diagnostic Imaging Use X-ray, CAT scan, and MRI to identify misalignments.



Range of Motion Abnormality

Identify an increase or decrease in segmental mobility using one or more of the following:

Observation Observe an increase or decrease in the patient’s range of motion.
Percussion, Palpation, or Provocation Record palpation findings—include listing(s). Be sure to record the various areas involved and related to the regions manipulated.
Stress Diagnostic Imaging 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.



Tissue, Tone Changes

Identify using one or more of the following:

Observation Observe visible changes (e.g., 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.


If PART is demonstrated, and the patient has a documented loss of function, there is usually medical necessity. But what if you find that your patient has entered a maintenance stage of care? Help them understand that Medicare expects them to cover the cost of that care. Check out the “Proper Scripting for the Medicare Maintenance Patient.

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If you are looking to invest in your practice in the best possible way with the best possible people, KMC University is the way to go. They are thorough, extremely knowledgeable, and truly go above and beyond to provide technical and emotional support through what can be an exceptionally tedious process with reimbursement, documentation and compliance. Whether you need to brush up on your HIPAA guidelines and policies, or you are completely starting from scratch, they will give you the tools and show you how to use them.

Neomi Hunt, M.S.