Documentation Requirements:
The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD (see Coverage Indications, Limitations and/or Medical Necessity). This documentation includes but is not limited to relevant medical history, physical examination and results of pertinent diagnostic tests or procedures. Chiropractic care is focused on the treatment goals outlined in the plan of care (POC).
A POC should be individualized for each patient and should include the following:
- Recommended level of care (duration and frequency of visits)
- Specific treatment goals (with documentation of progress or lack thereof within the clinical records)
- Objective measures to evaluate treatment effectiveness (with qualitative and/or quantitative measures)
The use of objective measures at the beginning of treatment, during and/or after treatment is recommended to quantify progress and support justifications for continued treatment. Therefore, treatment effectiveness must be assessed at appropriate intervals during subsequent visits (measurable goals).
Specific recommendations (e.g., ‘home program’, life style modifications, etc.) for ongoing amelioration of musculoskeletal complaints should be provided as early in the course of treatment as possible and should be reinforced at each visit and documented in the medical record.
For patients who have not achieved the goals documented in the POC, the practitioner should conclude the episode of chiropractic care in the last visit by documenting the clinical factors that contributed to the inability to meet the stated goals in the treatment plan.
The precise level of subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine.
The level of spinal subluxation must bear a direct causal relationship to the patient's symptoms and the symptoms must be directly related to the level of the subluxation that has been diagnosed.
Dynamic thrust is the therapeutic force or maneuver delivered by the physician during manipulation in the anatomic region of involvement. A relative contraindication is a condition that adds significant risk of injury to the patient from dynamic thrust but does not rule out the use of dynamic thrust. The doctor must discuss this risk with the patient and record this in the chart.
The need for a prolonged course of treatment must be clearly documented in the medical record. Treatment should result in improvement or arrest of deterioration of subluxation within a reasonable and generally predictable period of time.
The word “correction” may be used in lieu of “treatment.” Also, a number of different terms composed of the following words may be used to describe manual manipulation:
- Spine or spinal adjustment by manual means
- Spine or spinal manipulation
- Vertebral manipulation or adjustment
Documentation Requirements: History
The history recorded in the patient record should include the following:
- Symptoms causing patient to seek treatment,
- Family history if relevant,
- Past health history (general health, prior illness, injuries or hospitalizations,
medications, surgical history),
- Quality and character of symptoms/problem,
- Onset, duration, intensity, frequency, location and radiation of symptoms;
Aggravating or relieving factors, and
- Prior interventions, treatments, medications, secondary complaints.
Documentation Requirements: Initial Visit
The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:
1. History as stated above
2. Description of the present illness including:
- Quality and character of symptoms/problem,
- Onset, duration, intensity, frequency, location, and radiation of symptoms,
- Aggravating or relieving factors,
- Prior interventions, treatments, medications, secondary complaints and symptoms causing patient to seek treatment.
These symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo or osteo), rib (costo or costal) and joint (arthro) and be reported as pain (algia), inflammation (itis) 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. The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited. A statement on a claim that there is “pain” is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined.
3. Evaluation of musculoskeletal/nervous system through physical examination.
4. Diagnosis: The primary diagnosis must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named.
5. Treatment Plan: The treatment plan should include the following:
- Recommended level of care (duration and frequency of visits),
- Specific treatment goals, and
- Objective measures to evaluate treatment effectiveness.
6. Date of the initial treatment.
Documentation Requirements: Subsequent Visits
The following documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination:
1. History (an interval history sufficient to support continuing need; document substantive changes):
- Review of chief complaint
- Changes since last visit
- System review if relevant
2. Physical exam (interval, document subsequent changes). A full repeat pain, asymmetries, range of motion (ROM) abnormalities, tissue changes (P.A.R.T.) assessment is not expected.
- Exam of area of spine involved in diagnosis
- Assessment of change in patient condition since last visit
- Evaluation of treatment effectiveness
3. Documentation of treatment given on day of visit.
4. Documentation of how the day’s treatment fits within the POC (e.g., “visit 4 of planned 7 treatments”) and any way the treatment plan is being changed.
Documentation: X-Ray/Computed Tomography (CT)/Magnetic Resonance Imaging (MRI)
An x-ray may be used to document subluxation. The x-ray 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 3 months following the initiation of a course of chiropractic treatment.
In certain cases of chronic subluxation (e.g., scoliosis), an older x-ray may be accepted provided the beneficiary’s health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent.
A previous CT scan and/or MRI is acceptable evidence if a subluxation of the spine is demonstrated.
If the diagnostic studies have been taken in a hospital or outpatient facility, a written report, including interpretation and diagnosis by a physician, must be present in the patient's medical record. Documentation of the chiropractor's review of the x-ray (MRI/CT) noting the level of subluxation must be maintained in the medical record.
Documentation: Demonstrated by Physical Examination (aka “P.A.R.T. Evaluation Process”)
The P.A.R.T. evaluation process is recommended as the examination alternative to the previously mandated demonstration of subluxation by x-ray/MRI/CT for services beginning January 1, 2000. The acronym P.A.R.T. identifies diagnostic criteria for spinal dysfunction (subluxation).
P - Pain/tenderness evaluated in terms of location, quality and intensity: The perception of pain and tenderness is assessed. Most primary neuromusculoskeletal disorders manifest primarily by a painful response. Pain and tenderness findings may be identified through 1 or more of the following: observation, percussion, palpation, provocation, etc. Furthermore, pain intensity may be assessed using 1 or more of the following: visual analog scales, algometers, pain questionnaires, etc.
A - Asymmetry/misalignment identified on a sectional or segmental level: observation (posture and heat analysis), static palpation for misalignment of vertebral segments, diagnostic imaging, etc.
R - ROM abnormality (changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility. ROM abnormalities may be identified through 1 or more of the following: motion palpation, observation, stress diagnostic imaging, ROM, measurement(s), etc.
T - Tissue, tone changes in the characteristics of contiguous or associated soft tissues including skin, fascia, muscle and ligament. Abnormalities in tone, texture and/or temperature may be identified through 1 or more of the following procedures: observation, palpation, use of instrumentation, test of length and strength, etc.
To demonstrate a subluxation based on physical examination, 2 of the 4 (P.A.R.T.) criteria are required, 1 of which must be asymmetry/misalignment or ROM abnormality.
Documentation of changes in the patient’s examination, status and progression must be recorded at each visit.
The evaluation process must be ongoing. Signs and certain symptoms must be rechecked during the course of treatment to determine the extent of the patient progress. Standardized measurement scales (e.g., Visual Analog Scale (VAS), Oswestry Disability Questionnaire and the Quebec Back Pain Disability Scale) may be used to measure improvement or lack thereof. This ongoing evaluation and assessment forming the basis for treatment modification is a key factor in total patient management. The initial examination, no matter how thorough, cannot be expected to provide all the answers. A treatment trial should be instituted with its effects assessed to determine whether it should be continued or a different plan devised. Moreover, it is the examination that forms the foundation for treatment, guiding the doctor in selecting appropriate treatment techniques, frequency and course of treatment.
On receipt of a request for documentation, at a minimum, the practitioner must submit the initial visit’s treatment plan, the concluding/discharge visit and subsequent visits that demonstrate any change in the history, physical exam or treatment plan.
Utilization Guidelines:
The frequency and duration of chiropractic treatment must be medically necessary and based on the individual patient’s condition and response to treatment. Prolonged or repeated courses of treatment are more likely to undergo medical review.
