16 I Summer 2019 www.anjc.info In April, 2019, CMS designed a Medicare Documentation Job Aid for DCs. Its purpose is to assist every DC with compliance in meeting the documentation requirements. Please use the following as a template and check list to help achieve this goal. Hope this helps… Patient Information Name of beneficiary and date of service on all documentation Subluxation Subluxation demonstrated by X-ray, date of X-ray: ________ •  A CT scan and/or MRI is acceptable evidence if subluxation of spine is demonstrated •  Documentation of chiropractor’s review of the X-ray/ MRI/CT, noting level of subluxation •  The X-ray must have been taken reasonably close to (within 12 months prior or 3 months following) the beginning of treatment. In certain cases of chronic subluxation (for example, scoliosis), an older X-ray may be accepted if the beneficiary’s health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent. — or — Subluxation demonstrated by physical examination (Pain, Asymmetry/misalignment, Range of Motion abnormality, Tissue Tone changes [P.A.R.T.]; at least 2 elements, 1 of which must be A. or R.) •  Include dated documentation of initial evaluation •  Primary diagnosis of subluxation (including level of subluxation) Documentation of presence or absence of subluxation must be included for every visit Any documentation supporting medical necessity Initial Evaluation History • Date of initial treatment • Description of present illness •  Symptoms bearing a direct relationship to level of subluxation causing patient to seek treatment • Family history (if relevant) (recommended) • Past health history (recommended) • Mechanism of trauma (recommended) • Quality and character of symptoms/problem (recommended) • Onset, duration, intensity, frequency, location and radiation of symptoms (recommended) • Aggravating or relieving factors (recommended) •  Prior interventions, treatments, medication, and secondary complaints (recommended) Contraindications (e.g., risk of injury to patient from dynamic thrust, discussion of risk with patient) (recommended) Physical examination (P.A.R.T.) •  Evaluation of musculoskeletal/nervous system through physical examination Documentation of presence or absence of subluxation must be included for every visit Treatment given on day of visit •  Include specific areas/levels of spine where manipulation was performed Treatment Plan Frequency and duration of visits Specific treatment goals Objective measures to evaluate treatment effectiveness Subsequent Visit History •  Review of chief complaint •  Changes since last visit •  System review (if relevant) Physical examination (P.A.R.T.) •  Assessment of change in patient condition since last visit •  Evaluation of treatment effectiveness (address objective measures included in treatment plan) Documentation of presence or absence of subluxation must be included for every visit Treatment given on day of visit (include specific areas/ levels of spine where manipulation was performed) General Guidelines Ensure medical records submitted support the service is “corrective treatment,” rather than maintenance •  For Medicare purposes, an AT modifier must be placed on a claim when providing active/corrective treatment to treat acute or chronic subluxation – Do not use Modifier AT when maintenance therapy has been performed –  Modifier AT must only be used when chiropractic manipulation is “reasonable and necessary” as defined by national and local policy –  NOTE: Presence of the AT modifier may not in all instances indicate the service is reasonable and necessary. As always, contractors may deny if appropriate after medical review. Be aware of these policies along with any local coverage determination in your area to better understand how active/corrective chiropractic services are covered. Submit records for all dates of service on claim Medicare Update O By Dr. Richard C. Healy ANJC Medicare Consultant