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Documentation
Kathy Mills Chang MCS-P CCPC
in Documentation
By Kathy Mills Chang MCS-P CCPC CCCA

Don’t forget to document your modalities and procedures.

If you did it , but didn't write it down, it didnt happen. Whether performed by the doctor or appropriately delegated to qualified team members, all ancillary services must be recorded in the same way as the primary manipulative treatment. Examples of treatment modalities include electrical stimulation, ultrasound, application of heat or ice, rehab exercise, neuromuscular re-education, manual therapies, and massage.

Usually, the biggest elements missing from chiropractic treatment plans are the ancillary services a doctor intends to use, such as modalities, procedures, and home care. Most doctors incorporate them into the plan—and rightly so—but fail to establish the necessity of using them as a part of the plan.

You may know they are reasonable and necessary and have proven efficacy in most standard treatment plans. However, if they’re not included initially, you might fail to add them to the “plan” section of a daily note, and then wonder why payment denials occur for lack of necessity.

Looking ahead

The initial treatment plan is where the provider’s intentions are established. You may not know exactly what needs to take place every single visit over the upcoming months because you can’t see the future. But establishing your intentions and possible treatment choices in the initial visit launches the plan.

You may predict at first that several types of modalities will be used to address trauma, reduce swelling, and relieve pain during what is known as the “acute phase” of care. Typically, these modalities tend to be passive on the part of the patient.

The most common modalities used for these purposes are electrical stim, the application of heat or ice, traction, and ultrasound. Your initial plan should also outline your prediction as to when you will move to a more active approach by adding active or passive stretching, range of motion exercises, or strengthening exercises.

Documentation of any modality or procedure administered to a patient on a routine basis should be completed by the person who supervises or performs the service. This documentation is in addition to any documentation for which the doctor is responsible.

Even if the CA performs the service under the direction or supervision of the doctor, the doctor—as supervisor—must still initial or “sign off” on the patient record. Part of the documentation requirement is to identify who performed the service and under whose direction it was performed.

Adding modalities

As a patient’s symptoms improve, treatment modalities move toward improving range of motion and overall function. At this point, procedures tend to be more active, requiring participation on the part of the patient. These may include patient education and training, therapeutic exercises, massage therapy, and weight or endurance training.

Some patient modalities and procedures are only supervised while others require constant attendance. In terms of supervised modalities (e.g., heat or ice application, traction), the following guidelines apply:

  • They do not require the constant attendance of the provider
  • The patient record should include what modality was applied and the area of application
  • There is no time factor involved in coding supervised modalities, but you do need to document the time applied
  • Information for the patient record can be stated in words or drawn on a body, such as the location of electrical stimulation pads

Constant attendance by the provider of service is required with constant attendance modalities (e.g., ultrasound, laser, or manual electric stim) and therapeutic procedures (e.g., therapeutic exercises, manual therapy, or neuromuscular reeducation). In these cases, the specific modality or procedure performed, the area of application, and the duration of treatment must be added to the patient record.

For example, if your patient is working with resistance-band training for a shoulder condition, record the type of exercise performed (resistance training), to what body part (shoulder), and the duration in time (9 minutes). When these are initialed by the provider of the service, it’s assumed this is the party who was constantly in attendance.

The minimum requirements

The Centers for Medicare and Medicaid Services (CMS) developed specific documentation guidelines and requirements in March 2006 for therapy services provided by physical therapists under Medicare. However, these same documentation requirements provide an excellent standard for what is considered appropriate documentation to support the medical necessity of services, regardless of the provider.

There are certain minimum requirements that must be adhered to when documenting treatment modalities and procedures. These include the following:

  1. The patient must have a certified plan of care. This can be part of the overall treatment plan. The doctor of chiropractic in charge of the case will write this plan and order the modalities and procedures as part of the initial visit of the episode of care.
  2. Progress reports should be written or updated within 30 treatment days of the initial treatment. This means that you must have a written plan that includes your modality and procedures. You should update it at least monthly or along with your regularly scheduled chiropractic progress exams.
  3. The documentation must include objective evidence or a clinically supportable statement of expectation that:
  • The patient’s condition has the potential to improve or is improving in response to a particular therapy or procedure.
  • The stated functional goal or maximum improvement has yet to be attained.
  • There is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period.
  1. In addition, the content of the patient’s daily routine treatment encounter notes should adhere to the following guidelines:
  2. Documentation is required for every treatment day and therapy service and should clearly state the date of treatment.
  3. The treatment encounter notes must record the name of the treatment, intervention or activity provided, the time spent on services represented by timed codes, the total treatment time, and the identity of the individual providing the intervention.
  4. Frequency and intensity of treatment and other details may be included in the plan of care and do not need to be repeated in the treatment encounter notes unless they are different from the plan.
  5. The signature and professional identification of the qualified professional who furnished or supervised the therapy or procedure and a list containing the identity of each person who contributed to treatment during that encounter must be noted.

Keeping great patient records includes documenting all the services rendered on a given day. While it can be expeditiously completed, it’s important to remember that your notes qualify the care in the eyes of a third-party payer and must not be “skimpy.” Tell your story, explain the need, and show the patient’s response to treatment. Give good reasons why you do what you do, and not only will your notes be excellent, you will have little difficulty proving that they are reasonable, necessary, and deserving of third-party payment.

This article was originally published in the January, 2019 issue of Chiropractic Economics. Click here to review the entire issue.


KATHY MILLS CHANG is a Certified Medical Compliance Specialist (MCS-P). Certified Chiropractic Professional Coder (CCPC), and Certified Clinical Chiropractic Assistant (CCCA). Since 1983, she has been providing chiropractors with reimbursement and compliance training, advice, and tools to improve the financial performance of their practices. Kathy leads a team of 30 at KMC University and is known as one of the profession’s foremost experts on Medicare, documentation and CA development. Contact Kathy or any of her team members at 855-832-6562 or info@KMCuniversity.com.

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