Chiropractic Services: Subsequent Visits and Treatment Plans

Published 05/29/2020

Upon determination of a subluxation, the physician is required to develop an individualized treatment plan that includes the following:
  • Recommended level of care (duration and frequency of visits)
  • Specific treatment goals
  • Objective measures to evaluate treatment effectiveness
Treatment effectiveness must be assessed during every subsequent visit (objective measurable goals). In addition to the treatment effectiveness, subsequent visits require the following documentation in the patient's medical record:
  • History
    • Review of chief complaint
    • Changes since last visit
    • System review, if relevant
  • Physical Exam (P.A.R.T.)
    • Exam of area of the spine involved in diagnosis
    • Assessment of change in the patient's condition since the last visit
  • Treatment
    • Documentation of treatment given on the day of the visit

Reminder: Subsequent visits are synonymous with any face-to-face encounter following the initial visit.

* Objective measures consist of standardized patient assessment instruments, outcome measurements tools or measurable assessments of functional outcome. Use of objective measures at the beginning of treatment, during and/or after treatment is recommended to quantify progress and support justifications for continued treatment. Therefore, treatment effectiveness must be assessed during every subsequent visit (objective measurable goals). 

Some providers use forms (Oswestry, etc.) to measure treatment effectiveness. If this is the case, then a patient would need to complete the form on every visit.

Reminder: Some forms, including the Oswestry, may not contain answers/responses that are objective (actual measures/values). The Chiropractor or patient may need to add additional information. For example, the form may use the term "severe" for the evaluation of pain. "Severe" is not an objective measure. The pain would need an actual value.

Examples of objective measures to evaluate goals include:

  • Pain
    • Baseline: "9" on a scale of "1–10"
    • Goal: Decrease pain to "1"
  • Standing: 
    • Baseline: Only able to stand for 20 minutes
    • Goal: Able to stand for more than 1 hour 
  • Range of Motion (ROM):
    • Baseline: Lumbar spine flexion of 53 degrees and extension 11 degrees
    • Goal: Increase lumbar flexion to 80 and extension to 25

Signature Requirements
Medicare requires the individual who ordered/provided services be clearly identified in the medical records. The signature for each entry must be legible and should include the practitioner’s first and last name and applicable credentials, e.g., P.A., D.O. or M.D. For more information about signatures, please refer to the article titled "Medicare Part B Medical Records: Signature Requirements, Acceptable and Unacceptable Practices."


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