Medicare Review Tips

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.

Please 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. Our 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 subsequent visit(s):

  • 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)?
  • Is there a primary diagnosis of subluxation and a secondary ICD diagnosis that bears a direct relationship to the primary level of subluxation?
  • Is there a treatment plan?
  • Is the adjustment clearly recorded in the record as being done each visit with the specific vertebral segment(s) identified?
  • In 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?
  • Do 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 complaintImprovement 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 your documentation:


Requirement Ask Yourself
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?



NOTE: 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 such.

Most of 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