Many doctors of
chiropractic have probably received a request for records on one or
more Medicare patients from CAHABA, the contractor/payor for Medicare in
Georgia. It is vitally important to all of us that you comply with this
request and that your records meet the required standards to properly
document the medical necessity of your treatment. These reviews are
mandated by CMS to all local carriers to assure claims are properly
paid. If your records do not substantiate your care, the claim may be
denied, or if already paid, you may be required to refund the money.
click here to review the record requirements for chiropractic care under
Medicare. Please take time to read them and make sure your records meet
the standard of care. Also please remember that it is unwise and
illegal to change or alter your patient records, but you can make an
addendum to your records at any time if so properly noted.
Medicare sources have indicated that in a records-review process, these
are some of the questions they will be asking about your records, giving
consideration to the combined documentation of the initial and
- Does the record show a significant neuromusculoskeletal condition?
- Is there a precise subluxation(s) documented by physical exam or X-ray?
- Does the exam substantiate the condition and the subluxation?
- Is the complaint consistent with the subluxation level(s)?
there a primary diagnosis of subluxation and a secondary ICD
diagnosis that bears a direct relationship to the primary level of
- Is there a treatment plan?
the adjustment clearly recorded in the record as being done each
visit with the specific vertebral segment(s) identified?
order to substantiate the need and frequency of ongoing care, does
your documentation note a response to treatment, i.e., increased
range of motion, increased function, decreased pain, etc?
the subjective complaints and objective findings reflect
qualitative and quantitative factors when describing onset,
duration, intensity, frequency and location?
- Is the adjustment therapeutic or maintenance (maintenance is non-covered by Medicare)?
Initial Visit Requirements
- Relevant history of patient’s condition with detailed description of the present condition(s)
- Evaluation of musculoskeletal/nervous system through physical examination (evidence of subluxations through P.A.R.T.)
- Diagnosis (must contain a subluxation level and corresponding symptom diagnosis)
- Treatment plan
- Recommended level of care (duration and frequency of visits)
- Specific treatment goals
- Objective measures to evaluate treatment effectiveness
- Date of initial treatment
Subsequent Visit Requirements
- HistoryReview of chief complaintImprovement or regression since last visit
- System review, if relevant
- Physical examination
CMS states that the following requirements should
be included in your patient chart notes to describe the presenting
complaint. After completing your case history with the patient, you
should be able to ask yourself the questions below and answer them with
|Symptoms causing patient to seek treatment||Why is patient seeking care?|
|Mechanism of onset||How did the condition/injury happen?|
Was it gradual or sudden?
|Quality & character of symptoms/problem||Onset, duration, intensity, frequency location and radiation of symptoms?|
Do my notes paint a picture of the patient's symptoms, including specific, descriptive remarks that would allow a third-party reader to fully understand this complaint?
|Aggravating or relieving factors||What causes the condition to improve or worsen?|
|Prior interventions, treatments, medications, complicating factors||What has been tried in the past, and are there secondary |
|Family history, if relevant||Are there any factors in the family history that related to this|
|Past health history (general health, prior illness, injuries, hospitalizations, medication, surgeries)||What aspects of the patient's health history factor into this current condition?|
These symptoms must bear a direct relationship to the level of
subluxation. The symptoms should refer to the spine, muscle, bone, rib
and joint and be reported as pain, inflammation 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
the reviews we know of involve a patient that was treated for several
months, possibly completed treatment and returned with a new episode or a
new condition. It is important that your care plan be updated when this
occurs to meet the record keeping requirements. Medicare looks at goals
and treatment plans seriously. They must be in your records. One big
issue is knowing when to release a patient to Maintenance Care, and when
to consider care Active Therapeutic Care(AT). Bear this in mind and
take an objective look at the claim being reviewed.
Members may contact the GCA office at
770-723-1100 for access to the members-only Insurance Hotline for
specific review questions.
Dr. Mark Cotney, GCA Medicare Subcommittee Chair