Documentation requirements for subsequent visits - Chiropractic billing

The following documentation requirements apply whether the subluxation is demonstrated by X-ray or by physical examination:

1. History

a. Review of chief complaint;

b. Changes since last visit; and

c. Systems review if relevant.

2. Physical examination

a. Examination of area of spine involved in diagnosis;

b. Assessment of change in patient condition since last visit;

c. Evaluation of treatment effectiveness.

3. Documentation of treatment given on day of visit.

 Necessity for treatment of acute and chronic subluxation

The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must
have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.

The patient must have a subluxation of the spine as demonstrated by X-ray or physical examination, as described below.

Most spinal joint problems fall into the following categories:

*** Acute subluxation – a patient’s condition is considered acute when the patient is being treated for a new injury, identified by X-ray or physical examination as specified above. The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression, of the patient’s condition.

*** Chronic subluxation – a patient’s condition is considered chronic when it is not expected tosignificantly improve or be resolved with further treatment as is the case with an acute condition); however, the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.

You must place the HCPCS (healthcare common procedure coding system) modifier AT on a claim when providing active/corrective treatment to treat acute or
chronic subluxation. However, the presence of the HCPCS modifier AT may not  in all instances indicate that the service is reasonable and necessary.

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