Medicare’s CERT (Comprehensive Error Rate Testing) Program Initiated August 1 Will Certainly Generate Medicare Audits - Are Your Records Ready for an Audit?

As of August 1, 2010, Medicare will begin aggressively auditing offices as part of their CERT (Comprehensive Error Rate Testing) program.  It is an attempt by the Medicare to recoup monies paid to providers when the services rendered did not meet Medicare's guidelines.  They will be auditing all types of providers including medical doctors, chiropractors, durable medical equipment providers and any other Medicare practitioner.  For the most part, it is believed that they will audit services rendered in 2007 and 2008.  Unlike most Medicare audits where you are given 60 to 90 days to produce the records, the records requested under the CERT program will have to be produced in 30 days.  Medicare is pursuing an aggressive timeline for this program.

There are two important parts of the Medicare audit:  1. Proving that your billing was completed correctly.  2. Providing documentation for the services rendered that meets the Medicare guidelines.   This article addresses the billing aspect of the Medicare audit… making sure that you are billing correctly for the services provided.  The second article in this series will address the very specific documentation requirements to pass a Medicare audit.

Take This Short Billing Quiz

We have prepared a short Medicare quiz.  If you get all questions right, do not bother to read this article -- you don't need it.  If you miss some of the questions, it is definitely to your benefit to wade through this article even though some of the material is fairly dry in nature - okay, very dry.  Knowing the facts can save you a lot of money in a Medicare audit.  Since many private insurance companies use the Medicare guidelines as their standards, it would give you a heads-up as to the expectations of any of the private insurers also.

1.  The modifier AT, when added to the procedure code 98941, means Acute Treatment.

2.  A diagnosis of pain is sufficient to justify medical necessity for Medicare.

3.  Subluxations can be substantiated either by x-ray or by a PART examination.

4.  A neuro-musculo-skeletal diagnosis of muscle spasm substantiates a long-term treatment plan.

5.  If you are using the PART exam to substantiate subluxation, you must have a diagnosis of pain.

6.  Range of motion abnormalities can be substantiated by observation or range of motion measurements.

7.  Long-term treatment plans are usually associated with sprain/strain injuries.

8.  Medicare pays for maintenance care with the appropriate modifier.

9.  Medicare requires the use of the 739.xx diagnosis codes for your primary diagnosis; these codes describe regions of the spine, not specific vertebrae.

10. A diagnosis of postpolio syndrome would substantiate a long-term treatment plan.

*Answers:  1. False  2. False  3. True  4. False  5. False  6. True  7. False   8. False  9. True  10. False

*A complete explanation of the test answers occurs at the end of this article.

Talk about a challenge... trying to grab your attention when talking about dull, boring material.  It is hard not to fall asleep while writing it.  The reality is this: in order to pass a Medicare audit, you have to know what they are looking for.  Because they have published guidelines, they have announced their expectations.  While some of the guidelines are up for interpretation, the majority of the guidelines are very explicit.  If you follow the guidelines, you don't get hurt.  If you do not follow the guidelines, you can end up paying Medicare back thousands of dollars.  So, back to the boring material, here are their guidelines as published on the WPS website. 

Documentation of Subluxation

A subluxation may be demonstrated by an x-ray or by physical examination, as described below.

a. Demonstrated by X-Ray.

- Effective for claims with dates of service on or after January 1, 2000, an x-ray is not required to demonstrate the subluxation.

- An x-ray may be used to document subluxation. The x-ray 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 3 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 that the condition is permanent. A previous CT scan or MRI is considered acceptable evidence if a subluxation of the spine is demonstrated.

b. Demonstrated by Physical Examination Evaluation of musculoskeletal/ nervous system to identify (PART = Pain, Asymmetry Range of motion and tissue tone changes):

P.A.R.T. Information:

- Pain/tenderness evaluated in terms of location, quality, and intensity

Pain – Most primary neuromusculoskeletal disorders manifest primarily by a painful response. Pain and tenderness findings may be identified through one or more of the following: observation, percussion, palpation, provocation, etc. Furthermore pain intensity may be assessed using one or more of the following: visual analog scales, algometers, pain questionnaires, etc.

- Asymmetry/misalignment identified on a sectional or segmental level; P.A.R.T. Information

Asymmetry/misalignment – Asymmetry/misalignment may be identified on a sectional or segmental level through one or more of the following:

Observation (posture and gait analysis), static palpation for misalignment of vertebral segments, diagnostic imaging, etc. of motion abnormality.

- Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and

Range of motion abnormality – Range of motion abnormalities may be identified through one or more of the following: motion, palpation, observation, stress diagnostic imaging, range of motion measurements, etc.

- Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament.

Tissue/Tone texture may be identified through one or more of the following procedures: observation, palpation, use of instruments, tests for length and strength etc.

To demonstrate a subluxation based on physical examination, two of the four criteria mentioned under the above physical examination list are required, one of which must be asymmetry/misalignment or range of motion abnormality.

As you skim through the fine print above, notice that Medicare has been quite specific about the type of documentation required if you use the PART examination to substantiate subluxation.  If you are assessing pain, you can use observation, percussion, palpation or provocation.  You are also allowed to use visual analog scales, algometers or pain questionnaires.  If the patient winces or screams during the examination, you have certainly met the criteria -- as long as you document the response.  If you have the patient fill out a pain questionnaire or elicit that information during an interview, you have met the criteria.  For each of the four portions of the PART exam, the criterion that meets their standards is specific.

Although it is not in bold in their guidelines, we have deliberately bolded the final sentence.  In order to qualify under the PART guidelines, two of the four criteria are required AND one must be asymmetry/misalignment or range of motion abnormality.  Medicare requires at least two of the four criteria and further specifies that one of them must be misalignment or abnormal range of motion.  As you document your findings, keep in mind the four criteria of the PART exam.

Relationship of Symptoms to Level of Subluxation

These symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo or osteo), rib (costo or costal) and joint (arthro) and 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.

In this part of the guidelines, Medicare has stated their position.  For the most part, pain in the head, neck, shoulder and hands emanate from a cervical subluxation from Medicare's standpoint.  If you can prove that a patient's arm pain is related to a lumbar subluxation, Medicare might allow it.  However, in that situation, the burden of proof would be on your documentation and your examination.  Medicare expects that symptoms or conditions correlate rather closely to areas of the spine.

Diagnosis, Primary and Secondary

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.

When you are submitting claims, you must use the 739.x series of codes to describe the misalignment or asymmetry.  In your actual documentation, you can be more specific and name the actual vertebra.  Once you indicate the 739 code such as 739.1 indicating a cervical misalignment, the neuromusculoskeletal condition associated with that misalignment becomes the secondary diagnosis.  Here's the part that many doctors do not understand: Medicare dictates the neuromusculoskeletal (NMS) diagnosis codes that they will pay for.  If the diagnosis code not on the list, they may choose to deny it and most often will.  In addition, the NMS diagnosis code determines the type of treatment plan that Medicare is expecting: short-term, moderate-term or long-term.    

Printed below are the acceptable codes separated into three categories of treatment:

Short-Term Treatment  (These conditions generally require short-term treatments.)

ICD-9 CM Symptom/Condition Codes  (Secondary Diagnosis)

307.81  Tension Headache

346.00  Classical migraine, without mention of intractable migraine

346.01  Classical migraine, with intractable migraine, so stated

346.10  Common migraine, without mention of intractable migraine

346.11  Common migraine, with intractable migraine, so stated

346.20  Variants of migraine, without mention of intractable migraine

346.21  Variants of migraine, with intractable migraine, so stated

346.80  Other forms of migraine, without mention of intractable migraine

346.81  Other forms of migraine, with intractable migraine, so stated

346.90  Migraine, unspecified, without mention of intractable migraine

346.91  Migraine, nspecified, with intractable migraine, so stated

355.1    Meralgia Paresthetica

721.0    Cervical Spondylosis without myelopathy

721.2    Thoracic Spondylosis without myelopathy

721.3    Lumbosacral spondylosis without myelopathy

721.90  Spondylosis of unspecified site without myelopathy

723.1    Cervicalgia

724.1    Pain in the thoracic spine

724.2    Lumbago

724.5    Backache, unspecified

728.85  Muscle spasm

784.0    Headache


Moderate-Term Treatment

353.0  Brachial plexus lesions

353.1  Lumbosacral plexus lesions

353.2  Cervical root lesions

353.3  Thoracic root lesions

353.4  Lumbosacral root lesions

353.8  Other nerve root and plexus disorders

355.0  Lesion of the sciatic nerve

355.2  Other lesions of femoral nerve

355.8   Mononeuritis of lower limb, unspecified

719.01-719.09 Effusion of joint

719.11-719.19 Hemarthrosis

719.21-719.29 Villonodular synovitis

719.31-719.39 Palindromic rheumatism

719.41-719.49 Pain in joint

719.51-719.59 Stiffness of joint, not elsewhere classified

719.61-719.69 Other symptoms referable to joint

719.7 Difficulty Walking

719.81-719.89 Other specified disorders of joint

720.1   Spinal enthesopathy

722.91 Other and unspecified disc disorder, cervical region

722.92 Other and unspecified disc disorder, thoracic region

722.93 Other and unspecified disc disorder, lumbar region

723.2   Cervicocranial syndrome

723.3   Cervicobrachial syndrome

723.4   Brachial neuritis or radiculitis

723.5   Torticollis, unspecified

724.4   Thoracic or lumbosacral neuritis or radiculitis

724.6   Disorders of sacrum, ankylosis

724.79 Coccygodynia (disorder of coccyx)

724.8   Other symptoms referable to back, facet syndrome

729.1   Myalgia and myositis, unspecified

729.4   Fascitis, unspecified

738.4   Acquired spondylolisthesis

756.11 Spondylosis, lumbosacral region

846.0   Sprains and strains of lumbosacral (joint) (ligament)

846.1   Sprains and strains of sacroiliac ligament

846.2   Sprains and strains of sacrospinatus (ligament)

846.3   Sprains and strains of sacrotuberus (ligament)

846.8   Sprains and strains of sacroiliac region, other specified sites of sacroiliac region

847.0   Sprains and strains of neck

847.1   Sprains and strains of thoracic

847.2   Sprains and strains of lumbar

847.3   Sprains and strains of sacrum

847.4   Sprains and strains of coccyx


Long-Term Treatment

721.7    Traumatic Spondylopathy

722.0    Displaceent of cervical intervertebral disc without myelopathy

722.10  Displacement of lumbar intervertebral disc without myelopathy

722.11  Displacement of thoracic intervertebral disc without myelopathy

722.4    Degeneration of cervical intervertebral disc

722.51  Degeneration of thoracolumbar intervertebral disc

722.52  Degeneration of lumbosacral intervertebral disc

722.81  Postlaminectomy syndrome, cervical region

722.82  Postlaminectomy syndrome, thoracic region

722.83  Postlaminectomy syndrome, lumbar region

723.0    Spinal stenosis in cervical region

724.01  Spinal stenosis, thoracic region

724.02  Spinal stenosis, lumbar region

724.3    Sciatica

756.12  Spondylolisthesis

As you look through the lists above, you'll notice that the short-term treatment plans mostly consist of headaches and pain symptoms.  The moderate plans often deal with sprains and strains.  The long-term treatment is really aimed at degenerative conditions.  Remember, these codes are the only ones that will get paid and the use of the code determines the type of treatment plan that Medicare is expecting.

Treatment Parameters

The chiropractor should be afforded the opportunity to effect improvement or arrest or retard deterioration of subluxation within a reasonable and generally predictable period of time. Acute subluxation (e.g., strains or sprains) problems may require as many as 3 months of treatment but some require very little treatment. In the first several days treatment may be quite frequent but decreasing in frequency with time or as improvement is obtained.

Chronic spinal joint condition (e.g., loss of joint mobility or other joint problems) implies, of joints have already "set" and fibrotic tissue has developed. This condition may require a longer treatment time, but not with higher frequency.  The mere statement or diagnosis of "pain" is not sufficient to support medical necessity for the treatments.  The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined.


The problem/complaint addressed and precise level of each subluxation treated must be specified in the medical record. The need for an extensive, prolonged course of treatment should be consistent with the reported diagnosis and must be clearly documented in the medical record.

From their guidelines, they expect a short-term problem to be corrected within three months or shortly thereafter.  They expect a long-term problem will take longer to correct or reach the maximum level of correction.  In this case, the length of the treatment is not explicitly stated and is more dependent upon your documentation of progress in meeting stated treatment goals.   Once a condition has stabilized, Medicare regards continuing care as maintenance care.

Modifier Billing Guidelines

AT modifier:  redefined from  Acute Treatment to Active Treatment

GA modifier:  If the provider uses the AT Modifier and believes a service is likely to be denied by Medicare as not being medically necessary, the beneficiary must sign an Advance Beneficiary Notification (ABN) and the GA modifier must be used.

The AT modifier must not be placed on the claim when maintenance therapy has been provided. Claims without the AT modifier will be considered as maintenance therapy and denied.

Not only does Medicare specify the treatment parameters, they also specify the use of modifiers.  If the patient is in the active treatment phase of care, you must use an AT modifier; if the patient is being seen for maintenance care, you must get an ABN (Advanced Beneficiary Notice) signed and use the GA modifier.  When you use the GA modifier, you are telling Medicare that you have informed the patent to the use of the ABN that the care will likely be rejected by Medicare and that the patient has agreed to pay for the care.

Audit Triggers - Who Is Likely to Be Audited Through the CERT Program?

Given their stated guidelines, what are the situations that are triggering Medicare audits right now and what will determine the offices that the CERT program will likely go after?  Some of the audit triggers are obvious based on the guidelines; some of these audits can be avoided.  Other audit triggers are occurring because Medicare is able to keep better statistics with advanced technology.  They are able to compare your office to other chiropractors in your area and in the state.  While computerization has decreased your payment time, it is also increased the amount of information and data available to the insurance carriers.

1. Treating more Medicare patients than normal within a certain timeframe (usually six months.)  This is a relatively new audit trigger that will affect any high volume practice.  For example, if Medicare statistics show that an average chiropractor has 25 Medicare patients active at any time and your office has 56, you are more likely to be audited.  This statistic was not used until recently as grounds for a Medicare audit.  In this case, there is nothing that you can do to avoid this audit if you are a high-volume Medicare practice.   

2. Excessive use of the AT modifier.  Based on the NMS diagnosis code used, Medicare expects a certain number of visits before a patient is released to maintenance care.  If your active care phase is much longer than normal chiropractor, this will trigger an audit.  Unfortunately, many chiropractors continue to bill using the AT modifier even when the patient has been under care for two or three years.  Here is an example: The initial treatment date was listed as 10/1/2006.  Every visit from that point until the current time has been billed with an AT modifier.  If the diagnosis has not changed and the patient has not experienced a new condition, Medicare will consider this excessive use of the active treatment phase.    

3. A mismatch between the subluxation code and the NMS code.  It is realistic that you will sometimes make a billing error.  However, if you are consistently billing a 739.3 lumbar region subluxation with an 847.0 cervical sprain/strain, the diagnosis mismatch will throw up red flags.  Make sure that your subluxation diagnosis codes match your NMS secondary diagnosis codes.

4. Excessive use of the 98942 procedure code.  Because the 98942 requires five regions of the spine to be diagnosed and treated, Medicare expects that this procedure code will be used infrequently.  If you use this procedure code on more than half of your patients, this would be considered another red flag.

5. A visit frequency or visit count higher than normal. Medicare compiles statistics and determines the average number of visits before a patient is released from care or switched to maintenance care. They also track how many times per week (visit frequency) is considered normal. If your individual statistics fall higher than normal, this may trigger an audit. 

6. Failure to release patients to maintenance care.  Once a condition has been corrected or a degenerative condition has stabilized, Medicare expects that the patient is released to maintenance care.  They use the "duck" method of determining the maintenance care.  If it looks like a duck, walks like a duck and quacks like a duck, it must be a duck.  If the patient is being seen only once or twice a month, it will look like maintenance care statistically therefore, it is maintenance care.  The only way to prove otherwise would be to document the fact that the patient is continuing to make progress toward the treatment goals that you have specified.  In the next article, we will discuss the need for very specific treatment goals.

Understanding the Guidelines

Wading through the Medicare guidelines can be a tedious task not to be undertaken by the fainthearted.  On the other hand, once you understand their guidelines, it is easier to extrapolate the documentation that will meet Medicare standards should you ever get audited.    Medicare guidelines are very specific about what they require for documentation.  In the next article, the documentation requirements will be explained in depth and referenced back to the guidelines in this article.  In addition to explaining the specific documentation required for the initial visit and for subsequent visits based on Medicare's written material, we'll discuss the interpretations currently being applied by WPS Medicare in recent audit situations.  As a software company providing documentation notes through electronic medical records, we have had the opportunity to work closely with offices undergoing audits at the present time.  We have had the opportunity to observe failed audits with the use of travel cards as well as those offices that have passed at 100% with the appropriate documentation.  Yes, it is possible to give Medicare exactly what they want!

*Medicare Quiz Explanations

If you missed the right answers to the Medicare quiz at the beginning of the article, here is the explanation for each of the answers.

1. False  The AT modifier has been redefined.  It used to mean "Acute Treatment."  It now means "Active Treatment."

2. False  Medicare is very explicit in saying the diagnosis of pain is not sufficient documentation to substantiate care.  In addition, you must have two of the four criteria of the PART exam, not just one.

3. True   This is true - refer to the documentation of subluxation.

4. False  If you look through the list of NMS codes, a muscle spasm appears in the short term treatment list.

5. False  Pain can be used as one of the four criteria but it is not required.  It is required that misalignment or range of motion abnormality be one of the four criteria.

6. True   Medicare guidelines allow range of motion abnormalities to be documented using these techniques.

7. False  Long term treatment plans are usually associated with degenerative conditions.  Sprains and strains usually fall within the moderate treatment plan range. 

8. False  Medicare does not pay for maintenance care under any circumstances or with any modifiers.

9. True   Unlike the 839.xx series of codes where cervical vertebrae can be specified, the 739.x only address regions of the spine.

10. False  While postpolio syndrome is usually degenerative and can cause other spinal problems, postpolio syndrome as diagnosis itself is not listed in the long term treatment approved codes.

Passing a Medicare Audit – There Is No Reason to Be Scared If You Have the Documentation Required

Passing a Medicare audit is a matter of knowing the Medicare chiropractic guidelines and following the rules about documentation.  If you have the appropriate documentation, passing the audit will be tedious but not impossible.  Let's examine the Medicare chiropractic guidelines as they have been written.  On the initial visit, the following information should be recorded in the patient’s record as part of the patient history.  This is subjective - as told to you by the patient.

Patient history:

1.     Symptoms causing patient to seek treatment.  There should be a portion of your case history form that asks the patient why he/she is seeking treatment.  This information should be recorded in the patient's own words.

2.     Family history if relevant.  For many chiropractic patients, the family medical history may not be significant.  In an allopathic office, family medical history is important because certain conditions such as cancer or heart problems have a tendency to run in families.  For spinal problems, family history information can be gathered but may not have an impact on treatment.

3.     Past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history).  There are many personal health records that will solicit this information in a very organized fashion as part of the patient history.  ICER-2-GO offers an online personal health record that gathers and reports all of the past history information listed above.

4.     Mechanism of trauma.   Mechanism of trauma is the area of documentation that is the most contentious at this point in time.  Prior to recent developments, chiropractors were recording mechanism of trauma only when there was a specific accident or injury that precipitated the care.  Otherwise, if the patient woke up one day with a sore back, there was no documentation on mechanism of trauma.  Many of the current Medicare audits have received failing marks because the mechanism of trauma was not recorded in the documentation.  It needs to be recorded for every patient.  In addition, WPS auditors were requiring that the mechanism of trauma not be related to an activity of daily living.  This would leave only a slip and fall or an injury caused by an external force to meet the mechanism of trauma guidelines.  More recently, WPS auditors have backed off of the requirement that the mechanism of trauma not be related to activities of daily living (ADL).

 For your documentation, it is best to record a mechanism of trauma for every new patient.  If possible, ask leading questions of your patient to elicit a specific incident that precipitated the pain that the patient is experiencing.  “Prior to experiencing your low back pain, did you slip or fall?  Were you doing any unusual activity?  When did you first experience the pain?  Can you recall anything unusual that happened prior to experiencing the pain?”  Record any incident that the patient can relate that ties to the pain that brought them into your office.

5.     Quality and character of symptoms/problem.   In this scenario, you are trying to elicit information about the type of pain that is being experienced – dull, sharp, tingling, stabbing, ache, burning, numbness.  In addition, you might want to ask whether the pain is constant, intermittent or random.

6.     Onset, duration, intensity, frequency, location and radiation of symptoms.  If you have recorded mechanism of trauma above, it should have included a date of onset.  The intensity and frequency are also addressed in the quality and character of the symptoms or problems.  If the patient has a neck pain radiating into the right arm, the radiation must be indicated.

7.     Aggravating or relieving factors; and prior interventions, treatments, medications, secondary complaints.  As part of your documentation of chief complaint, there should be an indication whether certain activities exacerbate the problem.  For example, if the patient presents with neck pain, does sitting, lying down, standing or bending over aggravate or relieve the pain?  In addition, where has the patient sought treatment… from their medical doctor?  From a physical therapist?  Remember, this section of documentation is the patient history, the subjective part of the documentation requirements.

PART exam:  After recording the patient history, the objective portion of the examination begins.  You can either use x-rays or an orthopedic/neurological examination to justify the need for care.  If the patient is presenting with a neck problem, Medicare expects to see a physical examination of the cervical area.  If the patient presents with low back pain, Medicare expects to see a physical examination of the lumbar area.  Even though neck pain can be related to a misalignment of the lumbar or pelvic area, Medicare does not comprehend or substantiate a problem unless an examination of that problem area occurs.

Thankfully, Medicare stopped short of requiring specific physical examinations in their documentation.  The examinations performed are left to the discretion of the chiropractor.  In addition to recording positive findings, be sure to also record negative findings.  Remember, there are four sections of the PART exam: pain, asymmetry, range of motion and tissue/tone changes.  To use the PART exam to justify care, you must have positive findings in either asymmetry or range of motion.

Treatment plan:  in addition to mechanism to trauma documentation, the treatment plan documentation has received the most attention from Medicare auditors.  The documentation must include the recommended level of care which is defined as duration and frequency of visits.  Again, remember that Medicare determines short, intermediate, and long-range treatment plans based on the neuromusculoskeletal diagnosis codes so your treatment plan should specify the primary and secondary diagnosis codes.

The most critical part of required documentation seems to be the treatment plan - and the part that is gaining the closest scrutiny from Medicare - is specific treatment goals.  For example, if the patient's current cervical right rotation is 50, a specific treatment goal might be to increase the range of motion to 75.  Given that most Medicare patients are older and have some degree of spinal degeneration, the treatment goal must be cognizant of the patient's current condition.  A 90-year-old patient will probably not be able to achieve normal cervical right rotation unless they are in exceptional physical condition.  If you have not recorded degrees of range of motion, perhaps you have used a scale such as zero to four to indicate restriction.  If the patient is currently experiencing a 4, severe restriction, the treatment goal might be to increase the range of motion to a 2, mild restriction.  If you are using a rating scale, it is necessary to explain to Medicare the gradients on that scale.

For asymmetry or misalignment, it is much more difficult to establish specific treatment goals.  How do you quantify the degree of misalignment?  If you have found a good way of quantifying misalignment or subluxation, include specific treatment goals related to correcting the misalignment or asymmetry.

If you choose to establish treatment goals related to pain, we suggest that you use the Analog Pain Scale.  Using this pain scale, the patients will rate their pain on a scale from zero to 10 with 10 being almost intolerable.  If the patient presents with the pain scale of seven, you can establish a goal of reducing the pain 3 or 4.  In addition, you can also reference their dependence on prescription painkillers and the possibility of eliminating drugs entirely.

With regard to tissue or tone changes, you can substantiate and quantify the severity of muscle spasms.  In most cases, doctors are using a rating scale from zero to four.

Adjustments performed:  as the final part of your initial assessment, Medicare requires an indication whether adjustments were performed on the initial visit, what segments were adjusted and how.

Functional assessment: in addition to establishing treatment goals related to range of motion or asymmetry, you can also establish ancillary treatment goals related to functional assessment and/or limitations.  If you use a functional assessment tool that rates the degree of difficulty in performing a task correlated with the level of pain involved in the performance, you can establish very specific treatment goals related to returning the individual to as much a normal functional abilities as possible.  In this case, you would have a list of functional activities that can be graded according to difficulty and associated with level of pain.

Subsequent visits:  once you have collected all of the data on the initial visit, Medicare looks at your specific treatment plan and goals to see if you have achieved optimal level of correction during subsequent visits.  When it is appropriate, you should review the history and the progress toward resolving the chief complaint.  At the time of re-examination, you should focus on all of those areas that were positive it during your initial examination to determine whether changes have occurred.  Each treatment should indicate the treatment performed, the visit number (as part of the visit plan), the date of the initial visit and a treatment plan update if appropriate.  Periodically throughout the treatment plan, you should indicate your evaluation of the treatment effectiveness.  When you perform a re-examination, you should summarize the progress made toward resolving the treatment goals.

During the course of treatment:  every chiropractor realizes that the body is not a static organism but a living, breathing and constantly changing collection of cells.  If the patient experiences one of these three scenarios during the course of treatment, it should be highly documented and perhaps initiate a new treatment phase:

  1. New injury - a new injury especially to a different area of the spine should be thoroughly documented.  In most cases, especially if you have a new diagnosis, you would change the “date first consulted” or date of initial treatment since this is a new problem that has surfaced.  You would have a different treatment plan and different treatment goals.
  2. New condition - if the patient originally presented with headaches and is now experiencing low back pain, this is another indication for a complete examination and perhaps a new treatment phase with new diagnosis.
  3. Exacerbation/aggravation of existing condition - suppose that you have been treating the patient for three months and they have been making steady but slow progress.  As a result of a new daily activity, the patient experiences a return of their symptoms.  In this case, the exacerbation should be thoroughly documented in the patient's words and through your physical exam prior to adjustment.

Playing by Medicare's Rules:   When you accept Medicare patients in your office, it forces you to buy into the rules and guidelines established by Medicare.    That is just a fact of life.   There is no doubt that the documentation requirements are stringent.  Of course, having written guidelines makes it easier to ”play by the rules.”  There should be no surprises.   With the appropriate documentation and attention to detail, it is possible to pass a Medicare audit at 100%.  For more information or to discuss your audit needs, the author of this article welcomes your calls.

About the Author

This article was written by Marilyn K Gard, MBA, CEO of ClinicPro chiropractic software and ICER-2-GO LLC.  Marilyn has been involved with the chiropractic profession for 30 years, conducting chiropractic insurance seminars, writing professional articles and running a software development company.  ClinicPro software currently offers an electronic health record program in addition to chiropractic practice management software.   As part of EMR development and working with offices using software to meet documentation requirements, Marilyn has studied the Medicare chiropractic guidelines intensively and talked personally with Medicare auditors to obtain additional insight into the interpretation of the guidelines.  Marilyn can be reached at or 928-203-0854.

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