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Comprehensive Error Rate Testing

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Chiropractic Services

Insufficient Documentation Causes Most Improper Payments. Insufficient documentation means that something was missing from the medical records. Below is a list of the most common reasons CERT determined there was insufficient documentation that caused improper payments for chiropractic services:

    • Missing initial evaluation
    • Missing treatment plan
    • Missing details of treatment given on day of visit
    • Missing electronic signature or legible signature

Missing initial evaluation: Includes patient history, diagnosis, description of present illness and evaluation of musculoskeletal/nervous system through physical exam.

Missing treatment plan: Includes frequency and duration of visits, specific treatment goals and objective measures to evaluate treatment.

Missing treatment given on day of visit: Includes specific areas/level of spine where manipulation was performed.

Missing electronic signature or legible signature: An electronic signature or legible signature is required on medical records.

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