Table 3.

Documentation requirements for chiropractic services provided under Medicare

Initial visit
1. History, including:
a. Symptoms causing patient to seek treatment
b. Family history if relevant
c. Health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history)
d. Mechanism of trauma
e. Quality and character of symptoms/problem
f. Onset, duration, intensity, frequency, location, and radiation of symptoms
g. Aggravating or relieving factors
h. Prior interventions, treatments, medications, secondary complaints
2. Description of present illness, including:
a. Mechanism of trauma
b. Quality and character of symptoms/problem
c. Onset, duration, intensity, frequency, location, and radiation of symptoms
d. Aggravating or relieving factors
e. Prior interventions, treatments, medications, secondary complaints
f. Symptoms causing patient to seek treatment
3. Evaluation of musculoskeletal/nervous system through physical examination
4. Diagnosis, including:
a. Primary diagnosis (spinal level of vertebral subluxation)
b. Secondary diagnosis (neuromusculoskeletal condition necessitating treatment)
5. Treatment plan, including:
a. Recommended duration and frequency of visits
b. Specific treatment goals
c. Objective measures to evaluate treatment effectiveness
6. Date of initial treatment

Subsequent visits
7. History, including:
a. Review of chief concern
b. Changes since last visit
c. System review if relevant
8. Physical examination, including:
a. Examination of area of spine involved in diagnosis
b. Assessment of change in patient condition since last visit
c. Evaluation of treatment effectiveness
9. Documentation of treatment given on day of visit