Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 51
"Evaluation Requirements & Certifying the Subluxation"
In my research to support doctors who have had issues fighting insurance companies, I found a Medicare article that is “on-point” in helping you understand what documentation is required in both examinations and supporting subluxation. I strongly urge you to read it slowly. If you meet this standard on every evaluation, you will be on very firm ground for any audit. Although this is Medicare, the rule of thumb in compliance is, "If you make the Feds happy, you can make anyone happy." The reason, the federal standard is higher than everyone else.
Identifying the subluxation:
Subluxation must be demonstrated by x-ray or by PART in all of your initial and subsequent notes. Technically, this is not true. If you utilize x-ray, the films must be reasonably proximate (within 12 months prior to, or three months after, the initiation of care). Exceptions may be made if the condition is chronic/permanent. A CT/MRI may be accepted. If you utilize the PART method, you must demonstrate a subluxation based on physical examination. Two of the four criteria are required, and one of them must be asymmetry/misalignment or range of motion abnormality.
Pain/tenderness Include location, quality, intensity. (Findings can be identified via: observation, percussion, palpation, provation, pain scales, alogmeters, pain questionnaires, etc.)
Asymmetry/misalignment Sectional or segmental level. (Findings can be identified via: observation of posture/gait, static palpation, imaging, etc.)
Range of motion abnormality Changes in active, passive, and accessory joint movements resulting in an increase or decrease of sectional or segmental mobility. (ROM findings can be identified via: motion palpation, observation, stress diagnostic imaging, ROM measurements, etc.)
Tissue/tone changes Changes in the soft tissues including skin, fascia, muscle, and ligament. (Findings may be identified via: observation, palpation, use of instrumentation, tests for length and strength, etc.)
Always back up findings with objective data and remember that no one will complain if you utilize both x-ray and PART to demonstrate your case!
Initial Visit Must-Have’s:
The initial visit should include no less than a patient history, description of the presenting complaint, evaluation findings, diagnosis, treatment plan, and date of initial visit.
History: Statement of health, past health history, social/family history, description of the presenting complaints and any secondary complaints.
Presenting complaint: Symptoms, mechanism of trauma, quality and character of the pain, onset, duration, intensity, frequency, location, and radiation of symptoms, aggravating/relieving factors, prior interventions, treatments, and medications.
Evaluation: Physical examination and evaluation of the musculoskeletal/nervous system. Document everything you do and detail your findings.
Diagnosis: The primary diagnosis must be subluxation, including the level. The description must include reference to the condition of the spinal joint involved or to the direction/position assumed by the named joint. The secondary diagnosis would refer to the NMS condition and should be directly/causally related to the subluxation noted.
Treatment plan: Include the recommended level of care with duration and frequency of visits, specific treatment goals, and objective measures to evaluate treatment effectiveness. Always include the date of the initial treatment and sign it!