Medicare Documentation FAQs: 4 Questions Chiropractors Are Asking

Have questions about Medicare documentation? Here’s a closer look at four common topics chiropractors encounter, including initial visit requirements, imaging, treatment plans, and care timeframes.

1) Do you have to document the mechanism of trauma for Medicare?

Yes, the mechanism of trauma is one of the components of documentation requirements for the initial visit. If there was no trauma, for example, the condition was due to repetitive stress, just include this in the notes. Here are the remaining requirements:

• Chief complaint including the symptoms causing patient to seek treatment
• Family history if relevant
• Past medical history (general health, prior illness, injuries, hospitalizations, medications; surgical history)
• 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
• Symptoms causing patient to seek treatment

2) Can I use an MRI instead of an x-ray to document a subluxation?

Yes, an MRI or CT scan is acceptable evidence if a subluxation of the spine can be demonstrated. Please be aware of the imaging requirements established by CMS as it relates to timeliness.

The date of the imaging must be reasonably close to (within 12 months prior or 3 months following) the beginning of treatment. In certain cases of chronic subluxation (for example, scoliosis, DDD), an older x-ray/CT/MRI may be accepted if 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.

3) What would constitute a good treatment plan?

There are many variations of a treatment plan, some more detailed than others but at a minimum, I would suggest the following:

• The frequency and duration of visits over a short period of time (for example, you establish a care plan with multiple stages, Stage 1-Acute care; Stage 2-Corrective or Active care; Stage 3- Rehabilitative or strengthening) or you can do it over the entire Care plan (for example, 3 months of active care). List the expected number of visits and duration for each.
• Have specific treatment goals and they should be objectively measurable. For example, instead of saying the goal is to reduce lumbar pain, be slightly more specific and maybe state the goal is to reduce the pain by 40% over the first 4 weeks, another 20% over the next 4 weeks and lastly an additional 20% over the last weeks, totaling an 80% improvement. Or if you were just using one phase/stage of care, just communicate you expect an 80% improvement over 3 months. This makes it easier for an auditor or a reviewer to track patient progress without having to ask you for additional documentation.
• It may be helpful to establish patient goals based on why they are in your office to begin with. Pain is certainly a major motivator, but it is not the only one. Think of that patient that states they have difficulty in turning their neck when they back out of the driveway to see if there is any oncoming traffic. That patient may be in your office because of a lack of mobility more than pain.
• It is also helpful to establish goals that are tied to Activities of Daily Living. Think of the patient that tells you they can only sleep 2 hours before waking up in pain. Maybe your long-term goal would be to get that patient to sleep 8 hours per night. Again, it is easy to document progress just by asking the patient how many hours of sleep they got last night. This can be documented periodically in the daily SOAP notes. Goals related to outcome assessments may hold more weight.

Bottom line is if you document frequency, duration, specific goals and objective measures to monitor progress, you would be meeting the documentation requirements established by Medicare for treatment plans.

4) Does Medicare discuss treatment timeframes for acute and chronic subluxations/conditions?

Yes, Medicare discusses treatment parameters for acute and chronic conditions in the Medicare Benefit Policy Manual, Chapter 15, Section 240.1.5. With respect for the timeframe, this is what Medicare states, “The chiropractor should be afforded the opportunity to effect improvement or arrest or retard deterioration in such condition within a reasonable and generally predictable period of time. Acute subluxation (e.g., strains or sprains) problems may require as many as three months of treatment, but some require very little treatment. In the first several days, treatment may be quite frequent but decreasing in frequency with time or as improvement is obtained. Chronic spinal joint condition implies, of course, the condition has existed for a longer period of time and that, in all probability, the involved joints have already “set” and fibrotic tissue has developed. This condition may require a longer treatment time, but not with higher frequency.”