NewsletterJuly 31, 2012
"Audit....Notes of Interest"
"Documentation" requirements for Chiropractic Care following the initial visit, these include:
1. History: Review of chief complaint.
a. Changes since last visit.
b. System review - if relevant.
2. Physical Exam:
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.
NOTE: Documentation cannot be used to substantiate medical necessity retrospectively. In other words, documentation for medical necessity of care must be produced at time of visit. Medicare guidelines require that medical need be established prior to providing the service at issue. The medical record must stand on its own with original records supporting that the billed services is medically necessary and reasonable.
Those of you using our information, be sure to complete the "documentation" at time of visit. If audited, include, with your documentation, the additional requirements listed at the first of this article.