Chiropractic Medical Necessity: The Reviewer Perspective
Because it is an alternative practice of medicine, chiropractic treatment requires documentation to substantiate its medical necessity by most third party insurance payers. Documentation nearly always includes a patient's past and present history, consultation form, chart notes and any required imaging.
By Alan Margolis, DC
Third party insurance payers demand documentation to substantiate the medical necessity of chiropractic treatment. This documentation should support care by providing evidence that a treatment was necessary for relief from a condition and to alleviate a patient´s symptoms. When a third party payer requests records, there are necessary documents and information that must be included for review. These include a patient´s past and present history, consultation form, chart notes and any required x-rays.
The patient´s past and present history must explain why the patient sought chiropractic care, the nature of the complaints, the duration of the complaints and whether the patient was involved in a traumatic event. The documentation should also explain if the patient has exhibited the same or similar complaints previously, whether there is a family history of illness or injury, and if there are contraindications to chiropractic care.
It's important that the chiropractor include a consultation form. This reiterates the reasons the patient sought chiropractic care. The form should explain any previous medical and chiropractic treatment, as well as any prior examinations and test results, if known. This indicates whether the patient´s condition is acute or chronic and what treatment, if any, has been provided to the patient, along with the prior outcome of treatment.
The initial examination findings are also important. These findings should describe range of motion (orthopedic and neurological), chiropractic palpation and postural abnormalities. If treatment proceeds beyond a brief course of care, progress examination findings are necessary to show progress between objective examinations.
Although x-rays can be integral in formulating a chiropractic diagnosis and treatment plan, they are not necessary for each patient. An unexplained long-standing complaint, or incident of trauma, and the age of the patient; along with the consultation and examination findings and clinical experience, will determine the need for x-rays.
A patient´s chart notes are vital to assess the necessity of chiropractic care and critical to the review process. They show if the patient has improved and whether the objective findings (range of motion, palpation and postural) reveal improvement. Chart notes show a patient´s response to treatment, the reasonableness of care and the treatment plan. If a home program was instituted, they tell whether the patient is taking charge of his or her own healthcare and if it appears that the patient´s condition is progressing or being alleviated.
