www.njchiropractors.com I 15 Medicare Q&A Q  Do the P.A.R.T. requirements need to be documented for each subluxation diagnosed and treated in the medical record for that date of service? A  The P.A.R.T. requirements should be documented for each level of subluxation treated on each subsequent visit. This documentation should be consistent with the level of CMT reported for that date of service.  In the case of a record review or audit, you may refer to the initial examination findings on each daily progress note as long as you submit the initial examination findings with each billed subsequent visit when responding to a medical record request. Q  Can you discuss the elements of a good treatment plan? And how specific do the goals have to be? A  The treatment plan consists of three basic elements: 1) Frequency and duration of care 2) Specific treatment goals  3)  Objective measures to evaluate treatment effectiveness  The goals of treatment should be as specific as possible. For example, rather that stating the goal of treatment is to reduce pain; stating the goal is to decrease pain from 7/10 to 3/10 as measured by the Visual Analog Scale would be much stronger documentation. Q   For the subsequent visits, the section on “assessment of change in patient’s condition AND the “evaluation of treatment effectiveness” – is it enough to say “patient is progressing towards goals,” or is more specific information required? A  The Novitas article, “Chiropractic Services Frequently Asked Questions” states, “The documentation must indicate an evaluation of the effectiveness of the treatment provided for each billed date of service.” This evaluation should be based on the treatment goals established on the initial visit for that episode of care. Providing examples like, “pain frequency reduced from constant to intermittent” or “ROM improved in lumbar flexion” or “patient is now able to walk without use of a cane,” all help to establish a reasonable expectation of improvement towards the goals. Q   I was told that the specific levels of the subluxation ex. (C5-6, T7-8, L4-5) must be documented in both the exam portion and treatment portion of the medical record. Is this true? A  The precise level of the subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine.  There are two ways in which the level of the subluxation may be specified in patient’s record: 1) The exact bones may be listed, for example: C 5, 6; 2)  The area may suffice if it implies only certain bones such as: occipito-atlantal (occiput and Cl (atlas)), lumbo-sacral (L5 and Sacrum) sacro-iliac (sacrum and ilium).   The specific levels of the subluxation diagnosed and treated should be documented in the record.  For example, you may have diagnosed subluxations at C5-6, L5-S1 and right SI joint. However, let’s say the patient was exhibiting severe spasms in the cervical spine and you decided it would be more appropriate to do soft tissue treatment in that area on that particular day.  This would change the level of the CMT code from a potential 98941 code (3 levels of subluxations diagnosed) to a 98940 code (only 2 levels of subluxation treated).   Therefore, specific levels need to be documented in the exam and treatment sections of the note. Richard C. Healy, DC, CCSP, is the treasurer and Medicare consultant for the ANJC. A New Jersey Medicare Carrier Advisory Committee delegate and a Certified Chiropractic Insurance Consultant, Dr. Healy is a graduate of New York Chiropractic College and has been in private practice in Dumont for more than 35 years. By Dr. Richard C. Healy ANJC Medicare Consultant