Meeting Medicare’s Documentation Requirements
By Susan McClelland, BS, CCA
Documentation continues to be the chiropractic profession’s greatest weakness when it comes to Medicare reimbursement. A major focus of the Chiropractic Summit meetings has been to advance efforts for improving Medicare documentation.
For a service to be reimbursable through Medicare, the documentation must show clinical necessity for the patient’s care. There are several essential elements for required Medicare documentation, including demonstrating a subluxation and thoroughly documenting both the initial visit and each subsequent visit.
Demonstrating a Subluxation
A subluxation may be demonstrated by either an X-ray or by physical examination using the PART criteria (see below). If an X-ray is used to document the subluxation, it must have been taken at a time reasonably proximate to the initiation of a course of treatment. Unless more specific X-ray evidence is warranted, an X-ray is considered reasonably proximate if it was taken no more than 12 months prior to, or three months following, the initiation of the course of chiropractic treatment.
To demonstrate a subluxation based on the physical examination, two of the four PART criteria (pain/tenderness, asymmetry/misalignment, range-of-motion abnormality and tissue, tone changes) are required, one of which must be either asymmetry/misalignment or range-of-motion abnormality.
- Pain and tenderness must be documented in terms of location, quality and intensity. Examples of ways pain may be identified include noting antalgic gait or pain-avoidance postures; noting if pain is reproduced while examining the patient – “Let me know if this causes discomfort”; having the patient mark their pain on a scale from 0-10; asking the patient to verbally grade their pain from 0-10; and using questionnaires such as the McGill pain questionnaire.
- Asymmetry/misalignmentmay be identified on a sectional or segmental level. Examples of ways asymmetry/misalignment can be identified include observing the patient’s posture or analyzing gait, static palpation and diagnostic imaging.
- Range-of-motion abnormality represents changes in active, passive and accessory joint movements, resulting in an increase or decrease of sectional or segmental mobility. Abnormalities can be identified via several methods: observing an increase or decrease in the patient’s ROM; motion palpation to identify “fixed” segments; X-raying the patient using bending views; and utilizing goniometers or inclinometers.
- Tissue tone changes represent alterations in the characteristics of contiguous and associated soft tissues including skin, fascia, muscle and ligament. Tissue changes can be identified by observing tissue tone, texture and temperature for spasm, inflammation, swelling and/or rigidity; palpating hypertonicity, hypotonicity, spasm, tautness, rigidity, and/or flaccidity; and testing for scoliosis contracture and/or muscle strength.
Remember, identifying a subluxation by using the PART criteria requires identifying at least two of the four PART components through physical examination. In addition, one of those two must be “A” (asymmetry/misalignment) or “R” (range-of-motion abnormality).
Initial and Subsequent Visits
The following elements should be documented at initial and subsequent office visits in order to meet Medicare documentation requirements:
The Initial Visit
- Date of first visit
- History: statement of general health (including vital signs); family history, if relevant; past health history (prior injuries/traumas, prior surgeries, prior hospitalizations and current medications); contraindications; description of present illness (symptoms causing patient to seek treatment – must bear a direct causal relationship to the level of subluxation); mechanism of trauma; quality and character; onset, duration, intensity, frequency, location and referral/radiation; aggravating and relieving factors; and prior interventions, treatments, and medications); and secondary complaints
- Physical evaluation
- Diagnosis: primary (required to be subluxation for Medicare reimbursement) and secondary (must be a neuromusculoskeletal condition with a direct causal relationship to the primary diagnosis)
- Treatment plan: recommended level of care (duration and frequency of visits), specific treatment goals and objective measures to evaluate treatment effectiveness
- Signature/initials (legal requirement to authenticate records)
Subsequent Visits
Date of subsequent visit
History: review of chief complaint, changes since last visit, system review if relevant
Physical exam: examination of area of spine involved in diagnosis; assessment of change in patient condition since last visit
Evaluation: Assessment of treatment effectiveness
Treatment given on day of visit
Signature/initials (legal requirement to authenticate records)
For additional information on improving Medicare documentation, members of the profession are urged to access the Summit Steering Committee-endorsed “Proper Medicare Documentation” Webinar, available free of charge at www.acatoday.org/online.
The Chiropractic Summit is an ongoing collaborative process through which participants seek common solutions and formulate collective action steps to address several challenges facing the chiropractic profession, including Medicare and the upcoming national debate on system-wide health reform. Thus far, there have been five summit meeting, the latest of which involved representatives from 35 chiropractic organizations, including membership organizations, educational institutions, and research and public education foundations, who gathered in Washington, D.C., in May 2009. Meetings and related activities take place under the auspices of a broad-based steering committee comprised of representatives of the four major participating organizations: Dr. Carl Cleveland III, past president, Association of Chiropractic Colleges (ACC); Dr. Lewis Bazakos, former board chair, American Chiropractic Association (ACA); Dr. John Maltby, president, International Chiropractors Association (ICA); and Dr. Jerry DeGrado, president, Congress of Chiropractic State Associations (COCSA).
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