Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 550
Narratives 40 N

From the Desk of Dr. Mark Studin
Academy of Chiropractic
Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time.

“Reporting Positive and Negative Examination Findings”

According to the Department of Health and Human Services in a bulletin posted on November 2014, ALL EXAMINATION FINDINGS must be documented regardless if they were positive or negative and this holds true for every evaluation and management service performed, inclusive of 99202-99205 and 99212-99215. There are no exceptions and this also holds true for every financial class inclusing cash patients.
I often get asked about including negative findings in personal injury narratives and that document has a different set of rules. Because you are only reporting persistent sequella to bodily injuries it is accpetable to report in the heading “Positive Examination Findings” and then enter only those tests that are positive to focus the legal community to what is injured and the verification. It is also acceptable to report all tests, both positive and negative. However, I like to minimize the size of my “already long” report to the lawyers and it is more user friendly.


Adjunct Associate Professor of Chiropractic, University of Bridgeport, College of Chiropractic
Adjunct Professor of Clinical Sciences, Texas Chiropractic College
Educational Presenter, Accreditation Council for Continuing Medical Education Joint Partnership with the State University of New York at Buffalo, School of Medicine and Biomedical Sciences
Academy of Chiropractic
US Chiropractic Directory
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