Medical documentation requirement for initial visit

DOCUMENTATION REQUIREMENTS

A subluxation may be demonstrated by an X-ray or by physical examination. (If the X-ray is used to demonstrate the subluxation, it is required on the claim form. Refer to the “Claim Requirements” section of this manual.) If the X-ray is to be used to document the subluxation, it must have been taken at a time reasonably proximate to the initiation of a course of treatment. Unless more specific X-ray evidence is warranted, an X-ray is considered reasonably proximate if it was taken no more than 12 months prior to or three months following the initiation of a course of chiropractic treatment. In certain cases of chronic subluxation (e.g., scoliosis), an older X-ray may be accepted provided the beneficiary’s health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding the condition is permanent.

A previous Computed Tomography (CT) scan and/or MRI are acceptable evidence if a subluxation of the spine is demonstrated.

INITIAL VISIT
The following documentation requirements apply whether the subluxation is demonstrated by X-ray or physical examination:

1. History:
* Family history if relevant.
* Past health history (general health, prior illness, injuries or hospitalizations, medications, surgical history).
* Chief complaint including the symptoms present that caused the patient to seek chiropractic treatment.
* 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, medications, secondary complaints.

2. Description of the present illness including:
*  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, medications, secondary complaints.
* Symptoms causing patient to seek treatment.

These symptoms must bear a direct relationship to the level of subluxation. The symptoms refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo or osteo), rib (costo or costal) and joint (arthro) and would be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder and hand problems as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must relate to the spine as such. The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited. A statement on a claim that there is “pain” is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined.

3. Evaluation of musculoskeletal nervous system through physical examination (PART exam) is required to identify:
* Pain/tenderness evaluated in terms of location, quality and intensity.
* Asymmetry/misalignment identified on a sectional or segmental level.
* Range of motion abnormality (changes in active, passive and accessory joint movements resulting in an increase or a decrease in sectional or segmental mobility).
* Tissue tone changes in the characteristics of contiguous or associated soft tissues, including skin, fascia, muscle and ligament.

To demonstrate a subluxation based on the physical examination, two of the four described criteria (pain/tenderness, asymmetry/misalignment, range of motion abnormality and tissue tone changes) are required, one of which must be asymmetry/misalignment or range of motion abnormality.

4. Diagnosis:
The primary diagnosis must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named.

5. Treatment plan:
* The treatment plan should include the following:
* Recommended level of care (duration and frequency of visits).
o Specific treatment goals.
o Objective measures to evaluate treatment effectiveness.

6. Date of the initial treatment.

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