(MLN1232664-Medicare-Documentation-Job-Aid-for-Chiropractic-Doctors)

Educational ToolMLN1232664 March 2022Page 1 of 3Medicare Documentation Job Aid for Chiropractic DoctorsWhats Changed?No substantive content updates. Did you get a request from a Medicare contractor for chiropractic documentation? This tool will help you respond to documentation requests.Documentation Basics Chiropractic documentation should include: Patient Information Include the patients name and date of service on all documentation Subluxation Documentation Requirements  Include documentation of subluxation shown by x-ray or physical exam:  Include a CT scan and or MRI showing subluxation of spine  Include documentation of your review of the x-ray, MRI, or CT, noting level of subluxation  Include x-rays taken within 12 months before or 3 months following the beginning of treatment  In some cases of chronic subluxation (for example, scoliosis), Medicare may accept an older x-ray if the patients health record shows the condition existed longer than 12 months and its reasonable to conclude the condition is permanent Or   Include documentation of subluxation shown by physical examination. Documentation must show at least 2 elements of:  Pain  Asymmetry/misalignment  Range of motion abnormality  Tissue tone changes (P.A.R.T.), including 1 that falls under asymmetry/misalignment or range of motion abnormality  Include dated documentation of the first evaluation  Include primary diagnosis of subluxation (including level of subluxation)   Include any documentation supporting medical necessity MLN Educational Tool Medicare Documentation Job Aid for Chiropractic DoctorsMLN1232664 March 2022 Page 2 of 3Initial Evaluation History Date of initial treatment.  Description of current illness.  Symptoms related to level of subluxation causing patient to seek treatment.  Family history (recommended).  Past health history (recommended).  Mechanism of trauma (recommended).  Quality and character of symptoms or problem (recommended).  Onset, duration, intensity, frequency, location, and radiation of symptoms (recommended). Aggravating or relieving issues (recommended).  Past interventions, treatments, medication, and secondary complaints (recommended).  Contraindications (for example, risk of injury to patient from dynamic thrust or discussion of risk with patient) (recommended).  Physical examination (P.A.R.T.).  Evaluation of musculoskeletal and nervous system through physical examination.  Treatment given on day of visit (if relevant).  Include specific areas and levels of the spine that you manipulated.  Medicare may cover treatment using hand-held devices. But Medicare doesnt offer more payment or recognize an extra charge for use of the device. Treatment Plan Frequency and duration of visits (recommended)  Specific treatment goals (recommended)  Objective measures to evaluate treatment effectiveness (recommended) Subsequent Visits History Review of chief complaint  Changes since last visit  System review, if relevant Physical examination (P.A.R.T.)  Assessment of change in patients condition since last visit Evaluation of treatment effectiveness Treatment given on day of visit (include specific areas and levels of spine that you manipulated) MLN Educational Tool Medicare Documentation Job Aid for Chiropractic DoctorsMLN1232664 March 2022 Page 3 of 3General Guidelines Make sure medical records show that the service is a corrective treatment, not a maintenance treatment.  For Medicare purposes, place an AT modifier on a claim when you give active or corrective treatment for acute or chronic subluxation.  Dont use an AT modifier for maintenance therapy.  Only use an AT modifier when chiropractic manipulation is reasonable and necessary as defined by national and local policy.  Note: An AT modifier doesnt prove the service is reasonable and necessary . As always, contractors can deny a claim after medical review. Make sure you know these policies, along with any local coverage determination in your area, to better understand how active or corrective chiropractic services are covered.  Include records for all dates of service on a claim.  Make sure documentation is legible and complete, including signatures.  Include legible signatures and credentials of professionals providing services.  If signatures are missing or illegible, include a completed signature attestation statement.  For illegible signatures, include a signature log.  For electronic health records, include a copy of electronic signature policy and procedures describing  how notes and orders are signed and dated. Validating electronic signatures depends on getting this information.  Include abbreviation key (if relevant).  Include any other documentation to support medical necessity of services billed, as well as documentation specifically asked for in an additional   documentation request (ADR) letter .  Include a copy of the Advance Beneficiary Notice of Noncoverage (if relevant). Resources Medicare Benefit Policy Manual, Chapter 15, Sections 30.5 and 240 Medicare Claims Processing Manual, Chapter 12, Section 220 MLN Matters SE1601 Medicare Coverage for Chiropractic Services  Medical Record Documentation Requirements for Initial and Subsequent Visits MLN Matters SE1603 Educational Resources to Assist Chiropractors with Medicare BillingMedicare Learning Network Content Disclaimer, Product Disclaimer, and Department of Health & Human Services DisclosureThe Medicare Learning Network, MLN Connects, and MLN Matters are registered trademarks of the U.S. Department of Health & Human Services (HHS).