Chiropractic Services: Documentation of Treatment Effectiveness for Subsequent Visits

Published 02/08/2018

There are three areas that are required to be documented for subsequent chiropractic visits. They are History, Physical Exam (including evaluation of treatment effectiveness) and documentation of treatment given on day of visit. We have found that providers are often not documenting their evaluation of treatment effectiveness during these visits. Documentation of effectiveness is often not specific and/or measureable. While we have found some documentation of treatment effectiveness to be specific and measureable, it does not relate back to the treatment plan initiated by the provider. Documentation of this element is key to meeting Medicare guidelines for reimbursement.

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