Insurance News:

Medicare Update: Comprehensive Error Rate Testing Chiropractic Services

by | 9/2/2016 7:35:28 AM

The CERT program’s review of claims for chiropractic services has consistently yielded high improper payment rates. The majority of chiropractic services claims were the result of insufficient documentation, such as:

  • Documentation submitted did not adequately describe the service defined by the billed procedure code or modifier
  • Treatment plan was not submitted  
  • Signature on notes was illegible

Documentation Requirements

For the initial chiropractic visit, the documentation must include the following information:

  • Patient history
  • Description of present illness and evaluation of musculoskeletal/nervous system through physical exam
  • Diagnosis (primary diagnosis must be subluxation)
  • Treatment plan
  • Date of initial treatment

The physical examination must demonstrate at least two of the four following criteria:

  • Pain/tenderness
  • Asymmetry/misalignment
  • Abnormal range of motion
  • Tissue/tone changes

One of these criteria must be either asymmetry/misalignment or abnormal range of motion.

For each subsequent visit, the documentation requirements include:

  • Patient history (lists such items as changes since last service)
  • Physical examination
  • Documentation of treatment provided at each visit
  • Progress or lack thereof, related to treatment goals and plan of care

Documentation of the initial evaluation/periodic re-evaluations at reasonable intervals is essential.

Initial Evaluation

  • Patient’s presenting condition (symptoms, physical signs, and function) must be described in objective, measurable terms along with pertinent subjective information
  • Must provide a clear description of the mechanism of injury and how it negatively impacts baseline function
  • Clear plan of treatment that includes:
    • Recommended level of care (duration and frequency of visits)
    • Specific treatment goals
    • Clinical milestones to be used as measures of progress

Re-evaluations

  • Demonstrate the patients’ progress in objective, rather than conclusory terms
  • The evaluation elements, noted in the initial evaluation need not be documented at each treatment; however, they must be present often enough to show measurable progress, or failure to progress

Updated treatment plan must:

  • Document modifications when needed because of failure to satisfactorily progress in the clinically reasonable and predicted timeframe
  • Demonstrate that the treatments provide more than merely short term symptom control without any associated longer term functional

View the podcast: Improving the Documentation of Chiropractic Services

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