Medicare Update: Comprehensive Error Rate Testing Chiropractic Services

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Category: Insurance News
Sep
02

The CERT program’s review of claims for chiropractic services has consistently yielded high improper payment rates. The majority of chiropractic services claims were the result of insufficient documentation, such as:

  • Documentation submitted did not adequately describe the service defined by the billed procedure code or modifier
  • Treatment plan was not submitted  
  • Signature on notes was illegible

Documentation Requirements

For the initial chiropractic visit, the documentation must include the following information:

  • Patient history
  • Description of present illness and evaluation of musculoskeletal/nervous system through physical exam
  • Diagnosis (primary diagnosis must be subluxation)
  • Treatment plan
  • Date of initial treatment

The physical examination must demonstrate at least two of the four following criteria:

  • Pain/tenderness
  • Asymmetry/misalignment
  • Abnormal range of motion
  • Tissue/tone changes

One of these criteria must be either asymmetry/misalignment or abnormal range of motion.

For each subsequent visit, the documentation requirements include:

  • Patient history (lists such items as changes since last service)
  • Physical examination
  • Documentation of treatment provided at each visit
  • Progress or lack thereof, related to treatment goals and plan of care

Documentation of the initial evaluation/periodic re-evaluations at reasonable intervals is essential.

Initial Evaluation

  • Patient’s presenting condition (symptoms, physical signs, and function) must be described in objective, measurable terms along with pertinent subjective information
  • Must provide a clear description of the mechanism of injury and how it negatively impacts baseline function
  • Clear plan of treatment that includes:
    • Recommended level of care (duration and frequency of visits)
    • Specific treatment goals
    • Clinical milestones to be used as measures of progress

Re-evaluations

  • Demonstrate the patients’ progress in objective, rather than conclusory terms
  • The evaluation elements, noted in the initial evaluation need not be documented at each treatment; however, they must be present often enough to show measurable progress, or failure to progress

Updated treatment plan must:

  • Document modifications when needed because of failure to satisfactorily progress in the clinically reasonable and predicted timeframe
  • Demonstrate that the treatments provide more than merely short term symptom control without any associated longer term functional

View the podcast: Improving the Documentation of Chiropractic Services

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