Documentation requirements for the initial visit - X RAY and Date of Initial treatment

The following documentation requirements apply for initial visits whether the subluxation is demonstrated by x-ray or by physical examination:

1. History: The history recorded in the patient record should include the following:

*** Chief complaint including the symptoms causing patient to seek treatment;

*** Family history if relevant; and

*** Past medical history (general health, prior illness, injuries, or hospitalizations; medications; surgical history).

2. Present illness: 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.

Note: Symptoms must be related to the level of the subluxation that is cited. A statement on a claim that there is “pain” is insufficient. The location of the pain must be described and whether the particular vertebra listed is capable of producing pain in that area.

3. Physical exam: Evaluation of musculoskeletal/ nervous system through physical examination. To demonstrate a subluxation based on physical examination, two of the following four criteria (one of which must be asymmetry/misalignment or range of motion abnormality) are required and should be documented:

*** P - pain/tenderness: The perception of pain and tenderness is evaluated in terms of location, quality, and intensity. Most primary neuromusculoskeletal disorders manifest primarily by a painful response. Pain and tenderness findings may be identified through one or more of the following: observation, percussion, palpation,
provocation, etc. Furthermore, pain intensity may be assessed using one or more of the following; visual analog scales, algometers, pain questionnaires, and so forth.

*** A - asymmetry/misalignment: Asymmetry/ misalignment may be identified on a sectional or segmental level through one or more of the following: observation (such as,  osture and heat analysis), static palpation for misalignment of vertebral segments, diagnostic imaging.

*** R - range of motion abnormality: Changes in active, passive, and accessory joint movements may result in an increase or a decrease of sectional or segmental mobility. Range of motion abnormalities may be identified through one or more of the following: motion palpation, observation, stress diagnostic imaging, range of motion, measurement(s).

*** T -tissue tone, texture, and temperature abnormality: Changes in the characteristics of contiguous and associated soft tissue including skin, fascia, muscle, and ligament may be identified through one or more of the following  procedures: observation, palpation, use of  instrumentation, test of length and strength.

Note: The P.A.R.T. (pain/tenderness; asymmetry/  misalignment; range of motion abnormality; and tissue tone, texture, and temperature abnormality) evaluation
process is recommended as the examination alternative to the previously mandated demonstration of subluxation by X-ray/MRI/CT for services beginning January 1, 2000. The acronym P.A.R.T. identifies diagnostic criteria for spinal dysfunction (subluxation).

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. The precise level of the subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine. This designation is made in relation to the part of the spine in which the subluxation is identified as shown in the following table:

Area of spine     Names of vertebrae    Number of  vertebrae      Short form  or other  name   Subluxation ICD-10 code

Neck Occiput     Cervical  Atlas Axis      7         Occ,  CO  C1-C7   C1  2         M99.00  M99.01

Back         Dorsal or  Thoracic  Costovertebral    12          D1-  D12  T1-T12  R1-  R12  R1-  R12     M99.02
Low back      Lumbar          5             L1-L5                M99.03

Pelvis              Ilii, R and L (I, Si)        I, Si                    M99.05

Sacral            Sacrum,  coccyx            S, SC             M99.04

In addition to the vertebrae and pelvic bones listed, the Ilii (R and L) are included with the sacrum as an area where a condition may occur which would be appropriate for chiropractic manipulative treatment. There are two ways in which the level of the subluxation may be specified in patient’s record.

*** The exact bones may be listed, for example: C 5, 6;

*** 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

Following are some common examples of acceptable descriptive terms for the nature of the abnormalities:

*** Off-centered;

*** Misalignment;

*** Malpositioning;

*** Spacing - abnormal, altered, decreased, increased;

*** Incomplete dislocation;

*** Rotation;

*** Listhesis - antero, postero, retro, lateral, spondylo; and

*** Motion - limited, lost, restricted, flexion, extension, hypermobility, hypomotility, aberrant.

Other terms may be used. If they are understood clearly to  refer to bone or joint space or position (or motion) changes of vertebral elements, they are acceptable.
X-rays As of January 1, 2000, an X-ray is not required by  Medicare to demonstrate the subluxation. However, an x-ray may be used for this purpose if you so choose.
The x-ray must have been taken reasonably close to (within 12 months prior or three months following) the beginning of treatment. In certain cases of chronic
subluxation (for example, scoliosis), an older X-ray 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.

A previous CT scan and/or MRI are acceptable evidence if a subluxation of the spine is demonstrated.

5. Treatment plan: The treatment plan should always include the following:

*** Recommended level of care (duration and frequency of visits);

*** Specific treatment goals; and

*** Objective measures to evaluate treatment effectiveness.

Date of the initial treatment

The patient’s medical record.

*** Validate all of the information on the face of the claim, including the patient’s reported diagnosis(s), physician work (CPT® code), and modifiers.

*** Verify that all Medicare benefit and medical necessity requirements were met.

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