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What is Medical Necessity?

What is Medical Necessity?

The Chiro.Org Blog

SOURCE:   A Chiro.Org Editorial

“Medical Necessity” is the slippery slope, according to the Physician’s News Digest

“There are almost as many definitions of medical necessity as there are payors, laws and courts to interpret them. Generally speaking, though, most definitions incorporate the principle of providing services which are “reasonable and necessary” or “appropriate” in light of clinical standards of practice. The lack of objectivity inherent in these terms often leads to widely varying interpretations by physicians and payors, which, in turn, can result in the care provided not meeting the definition.”

Medicare defines “medical necessity” as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

From an Insurers standpoint, this is why documentation of the patient encounter is so important. The standard note taking format for every patient encounter is the SOAP note. Medical (chiropractic) necessity is defined by your own notes. Let’s review what actually defines reasonable and necessary in the SOAP note:

There are more articles like this @:

The new SOAP Notes Page and our

Documentation Section

S stands for subjective complaints.
During the first part of every patient encounter, the doctor uses their interviewing skills to paint a picture. If the patient has complaints in multiple regions, it’s best to cover them one region at a time. For example:

Neck: Right sided neck pain in the C4-C5 region of a 6/10 severity, which radiates into the right trapezius region, increases to 8/10 with R rotation or R lateral bending, decreases with rest. Patient also experiences neck stiffness of a 5/10 severity, making it difficult and uncomfortable to parallel park safely.

Low Back: Left sided low back pain in the SI region of a 7/10 severity, with referral to the L buttock and L inguinal region. Pain is decreased with ice, and increases with sit-to-stand after long sitting. This pain has forced the patient to discontinue bowling for the last 2 weeks.

NOTE: If you use any form of shorthand in your notes, make sure that each page has a key at the top that translates your notes back into English.

Examples of Chiropractic Shorthand:

↓CIR = Reduced Circumduction of Lumbar or Cervical Spine w/ LB;
LB = Lateral Bending;
↓ LB = Reduced Lateral Bending;
↓ FM = Reduced Fluid Motion;
↓ ROT = Reduced Rotation;
MP = Motion Palpation;
E = Edema;
w/ = With;
TT = Taut and Tender;
MM = Muscle Spasm;
A = Anterior
P = Posterior;
LCS = Left Cervical Syndrome;
RCS = Right Cervical Syndrome;
BR = Body Right;
BL = Body Left;
OCC = Occiput;
SI = Sacroiliac Joint;
LB = Low Back;
TrP = Trigger Point;
PIR = Post Isometric Relaxation;
+SLC = Positive Sacral Leg Check;
VSC = Vertebral Subluxation Complex;
↑ DC = High Volt DC;
US = Ultrasound;
Pain Scale: Least (1, 2, 3, 4, 5, 6, 7, 8, 9, 10) Most severe

O stands for objective findings.
Here’s where we document what we find. Orthopedic tests that were positive at the beginning of care…are they still positive? Has ROM (range of motion) improved? Palpation findings for vertebral rotations, fixations (listings), muscle knots (spasm), and trigger points (myofascial disorder) should be documented.

A stands for assessment.

This is where we state what we found (diagnosis). An example could be as simple as:

Cervical subluxation of C5 with related segmental myospasm, cervicalgia, and attendant myofascial disorder of the upper extremity.

P stands for plan.
After the first visit we design a Care Plan. An excellent selection of care plans are available in Robert Mootz, D.C.’s article:
Chiropractic Care Parameters for Common Industrial Low Back Conditions.

They have been saved in Word format, and are available for your use.

Dr. Mootz gave us permission to reproduce this wonderful article titled:

Maximizing the Effectiveness and Efficiency of Clinical Documentation

In it, he goes into depth about documenting with exam forms and SOAP notes, and also provides a handy Problem List to make it easy to track the progress of each of the patient’s original and subsequent subjective complaints.

Nataliya Schetchikova, PhD also gave us permission to reproduce her article:

Surviving the Scrutiny, which addresses red flagging of claims, and how to avoid it.

We hope you will find this information useful!

3 comments to What is Medical Necessity?

  • Chiropractic Provider

    Thanks for this terrific refresher! The Dr. Mootz article was extremely helpful. Thanks.

  • hagar golan

    When I get peer reviewed the reviewer always states that stim and massage are only medically necessary at 12th visit and not past the 12 th visit even though we document the medical necessity for these services.
    Can you help

    • Hagar,

      Insurers exist in their own little world, and in that world the policy of coverage limits dictates what they are obligated to do, and what they will and won’t pay for. Sadly, you’d need a lawyer to read their policy to determine whether they are playing by their own rules.

      I can’t speak for massage, but Stim is traditionally used to manage acute pain. Thus, it is quite reasonable to wonder why someone would still be experiencing acute pain after 12 visits.

      If there was a documented incident that could have re-ignited her acute pain (an exacerbation from a slip, fall, catching a falling baby, etc.) then you *might be* on solid ground, and should demand reconsideration.

      In general, using *passive* pain treatments. beyond the first few weeks, typically raises red flags.

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