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:
Mechanism of trauma;
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.
Medicare Guideline posts
- Home
- Finding Medicare fee schedule - HOw to Guide
- LCD and procedure to diagnosis lookup - How to Gui...
- Medicare Fee Schedule, Payment and Reimbursement Benefit Guideline,
- Step by step Guide Medicare participation program
- Medicare Fee for Office Visit CPT Codes - CPT Code 99213, 99214, 99203
- Medicare revalidation process - how often provide need to do - FAQ
- Gastroenterology, Colonoscopy, Endoscopy Medicare CPT Code Fee
- Medicare claim address, phone numbers, payor id - revised list
Subscribe to:
Post Comments (Atom)
Top Medicare billing tips
-
Procedure code 77427: Radiation treatment management, 5 treatments Procedure code 98966: Telephone assessment and management service provi...
-
CPT 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a...
-
Procedure code and description 93000 - Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report -average fee... -
This post has Most used J code list and we are constantly updating with example . If you are looking particular J code, use search button. ...
-
Procedure Codes and Definitions 36415 Collection of venous blood by venipuncture - Fee schedule amount $3.10 - Private insurance pay upt... -
Procedure code and description 93224 - External electrocardiographic recording up to 48 hours by continuous rhythm recording and storage;...
-
CPT 99211 Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of...
-
FL 42 - Revenue Code Required. The provider enters the appropriate revenue codes from the following list to identify specific accommodation ...
-
CPT CODES and Description 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitr... -
Procedure code and description 11400- Excision, benign lesion, except skin tag (unless listed elsewhere), trunk, arms or legs; lesion d...
No comments:
Post a Comment