Chiropractic Medical Recordsand Documentation: Comprehensive Error Rate Testing (CERT) Program Requests

As a Medicare provider, you may receive a request from the CERT Documentation Contractor (CDC), AdvanceMed, for medical records. There are special requirements for chiropractors when responding to requests from the CDC.

Chiropractic Medical Records and Documentation
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."

When the CDC requests documentation from Doctors of Chiropractic Medicine, the request letter will contain specific instructions to provide records/documentation for the preceding six months prior to the date of service for the sampled claim(s), if the services in those six months are associated with the same condition(s). When you submit documentation to the CDC in response to their request, it is imperative that you include the treatment plan to support chiropractic services planned and rendered for the course of treatment.

The treatment plan must contain the following elements:

  • Therapeutic modalities to effect a cure or relief (patient education and exercise training)
  • The level of care that is recommended (the duration and frequency of visits)
  • Specific goals that are to be achieved with treatment
  • The objective measures that will be used to evaluate the effectiveness of treatment

Initial Visit
The following documentation requirements apply whether the subluxation is demonstrated by X-ray or by physical examination and must be documented in the patient's record:

1. The history recorded in the patient record should include the following:

  • Symptoms causing patient to seek treatment
  • Family history, if relevant
  • Past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history)
  • Mechanism of trauma
  • Quality and character of symptoms/problems
  • Onset, duration, intensity, frequency, location and radiation of symptoms
  • Aggravating or relieving factors
  • Prior interventions, treatments, medications and 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 and secondary complaints
  • Symptoms causing patient to seek treatment
3. Evaluation of musculoskeletal/nervous system through physical examination:
  • 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 of sectional or segmental mobility)
  • Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle and ligament

The precise level of the subluxation must be specifically identified by the chiropractor and documented in the medical record to substantiate a claim for manual manipulation of the spine.

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

4. Diagnosis: The primary diagnosis must be subluxation, including the precise 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)
  • Specific treatment goals
  • Objective measures to evaluate treatment effectiveness
6. Date of initial treatment

Subsequent Visits
The following documentation requirements apply whether the subluxation is demonstrated by X-ray or by physical examination and must be documented in the patient's record:

1. History
  • Review of chief complaint
  • Changes since last visit
  • System review if relevant
2. Physical Exam
  • Exam of area of spine involved in diagnosis
  • Assessment of change in patient condition since last visit
  • Evaluation of treatment effectiveness
3. Documentation of treatment given on day of visit
  • The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient's condition and provide reasonable expectation of recovery or improvement of function
  • The patient must have a subluxation of the spine demonstrated by X-ray or physical exam as described above
Failure to meet the required documentation for chiropractic spinal manipulation may result in denial of claim(s). Documentation must be legible and made available to Medicare upon request. Acronyms used must be universal or accompanied by a legend.

Medical record documentation is a key element in payment. Chiropractors often receive refund requests due to CERT requests, because the medical records received by CDC are missing:
  • Plan of treatment
  • Chief Complaint is not clearly documented
  • Area being treated is not clearly documented
To avoid refund requests, follow the documentation guidelines previously stated. All of the requested documentation must be submitted to the CERT Documentation Contractor by the deadline given in the letter. If it is not, Palmetto GBA is required to recoup any payment(s) that may have been made on the claim(s).

Important Note: Late documentation will be received and reviewed by the CERT program. If the review result is favorable, the original CERT decision will be reversed. Appeals for claims reviewed by CERT are to be made to Palmetto GBA and not the CERT contractor.

Background
  • The Comprehensive Error Rate Testing (CERT) Program, established by the Centers for Medicare & Medicaid Services (CMS), calculates error rates that measure both the extent to which providers are correctly submitting claims to Medicare and the extent to which contractors (including Palmetto GBA) are correctly paying claims
  • Every month, the CERT contractor selects a random sample of both paid and denied claims processed by Palmetto GBA. The CERT Documentation Contractor (CDC) sends letters to the providers who submitted those claims, requesting medical records and any additional documentation that will support the service(s) that were provided.
References

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