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:
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- 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.
Related Content
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- Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 30.5 (Chiropractor’s Services) Section 240 (Chiropractic Services – General)
- CMS IOM Publication 100-04, Medicare Claims Progressing Manual, Chapter 12, Section 220 (Chiropractic Services)
- CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (Signature Requirements)
- MLN Matters® SE1601 Revised: Medicare Coverage for Chiropractic Services – Medical Record Documentation Requirements for Initial and Subsequent Visits
- MLN Matters® SE1603 Revised: Educational Resources to Assist Chiropractors with Medicare Billing
- MLN Educational Tool: Medicare Documentation Job Aid for Doctors of Chiropractic
- Local Coverage Article: Chiropractic Services – Medical Policy Article (A57889)
- YouTube Podcast: Improving the Documentation of Chiropractic Services