A request for documentation from a Medicare contractor does not have to be daunting to doctors of chiropractic and their billing staff. This checklist breaks down what medical data you need to include to properly respond to a request for chiropractic medical records.

The documentation should include, but is not limited to:

Patient Information

• Name of patient and date of service on all documentation

Subluxation

• Subluxation demonstrated by X-ray, include the date of X-ray
  • Note: CT scan and/or MRI is acceptable if demonstrate subluxation of the spine
  • Documentation of chiropractor’s review of the X-ray/MRI/CT, noting the level of subluxation
  • The X-ray must have been taken reasonably close to (within 12 months prior or 3 months following) the beginning of treatment
    • In certain cases of chronic subluxation (for example, scoliosis), an older X-ray may be accepted if the patient’s health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent.
• Subluxation demonstrated by physical examination (Pain, Asymmetry/misalignment, Range of motion abnormality, Tissue tone changes [P.A.R.T.]; at least 2 elements, 1 of which must be A. or R.)
  • Include dated documentation of initial evaluation
  • Primary diagnosis of subluxation (including the level of subluxation)
• Documentation of presence or absence of subluxation must be included for every visit
• Any documentation supporting medical necessity

Initial Evaluation

• History
  • Date of initial treatment
  • Description of present illness
  • Symptoms causing the patient to seek treatment (must bear a direct relationship to the level of subluxation )
  • Past medical history; relevant family history
  • Mechanism of trauma
  • Quality and character of symptoms/problem
  • Onset, duration, intensity, frequency, location, and radiation of symptoms
  • Aggravating or relieving factors
  • Prior interventions, treatments, medication, and secondary complaints

• Physical examination (P.A.R.T.)
  • Evaluation of musculoskeletal/nervous system through physical examination
• Documentation of presence or absence of subluxation (include for every visit)
• Contraindications (e.g., risk of injury to the patient from dynamic thrust, discussion of risk with the patient)
• Treatment given on the day of the visit (if applicable)
  • Include specific areas/levels of the spine where the provider performed manipulation
  • Manual devices that are hand-held with the thrust of the force of the device being controlled manually may be covered (no additional payments or extra charges are allowed for use of the device)

Treatment Plan

• Frequency and duration of visits
• Specific treatment goals
• Objective measures to evaluate treatment effectiveness

Subsequent Visit

• History
  • Review of chief complaint
  • Changes since the last visit
  • System (if relevant)
• Physical examination (P.A.R.T.)
  • Assessment of change in patient condition since last visit
  • Evaluation of treatment effectiveness (address objective measures included in the treatment plan)
• Documentation of presence or absence of subluxation (must include for every visit)
• Treatment given on the day of visit (include specific areas/levels of the spine where manipulation was performed)

Request for Chiropractic Records: General Guidelines

• Ensure medical records submitted support the service is “corrective treatment,” rather than maintenance
  • For Medicare purposes, you must place an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation
    • Only use modifier AT when chiropractic manipulation is “reasonable and necessary” as defined by national and local policy
• Submit records for all dates of service on the claim
• Documentation must be legible and complete (including signatures)
•  The signatures/credentials of professionals providing services must be legible
  • If signatures are missing or illegible, include a completed signature attestation statement
  • For illegible signatures, include a signature log
  • For electronic health records, include a copy of the electronic signature policy and procedures describing how notes and orders are signed and dated.
• Include an abbreviation key and a copy of the Advance Beneficiary Notice of Noncoverage (if applicable)
• Incorporate any other documentation the provider deems necessary to support the medical necessity of services billed, as well as documentation specifically requested in the additional documentation request (ADR) letter