Clinical Documentation: The Key to Reimbursement for Chiropractic Claims

Clinical Documentation

This section was compiled by Frank M. Painter, D.C.
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FROM:   ACA Today, March 2001

The Key to Reimbursement for Chiropractic Claims

ARLINGTON, VA During its recent meeting, the American Chiropractic Association (ACA) House of Delegates passed a resolution to assist doctors of chiropractic in successfully being reimbursed for necessary patient care by insurance companies. ACA is now committed to disseminating the recommendations contained in the resolution to doctors of chiropractic, chiropractic organizations and chiropractic colleges nationwide.

Last year, representatives from 13 of the largest insurers in the United States met with ACA representatives during the second meeting of the ACA-sponsored Claim Solutions Work Group. Based on the suggestions made during this meeting and on recent trends, ACA recommends certain basic requirements be considered as appropriate clinical documentation in patient record keeping. Some of the insurers present at the meeting agreed that using these practices will also reduce clinical record requests by 50 percent.

"The mutual goal of the insurers and doctors of chiropractic at this meeting was to simplify the claims process," explained Pat Jackson, vice president of professional development for ACA. "This way, chiropractors can reduce administrative costs and get paid for more covered claims, and insurers can reduce claims expenses." According to Ms. Jackson, many insurers are already adopting the recommended guidelines resulting from the meeting in order to educate their claim personnel on appropriate requests for chiropractic clinical documentation.

The ACA also contends that a concerted effort by the chiropractic profession to standardize clinical documentation will improve reimbursement experience exponentially for doctors of chiropractic. For this reason, a special effort will be made to share this information with chiropractic colleges so it can be incorporated into the curricula.

ACA recommends the following documentation procedures:

1.   The nationally accepted HCFA billing 1500 form must be completed in detail. This means all required fields must be completed.

2.   Subjective, objective, and treatment (if rendered) components should be incorporated into patient records on each visit. A customized format is not needed but these elements must exist consistently. Any significant changes in the clinical picture (e.g. significant patient improvement or regression) should be noted.

3.   All ICD-9-CM diagnosis codes and CPT treatment and procedure codes must be validated in the patient chart and coordinated as to the diagnoses and treatment code descriptors.

4.   Uniform chiropractic language should be used within the profession for describing care and treatment. Non-standard abbreviations and indexes should be defined.

5.   Documentation for the initial (new patient) visit, new injury or exacerbation should consist of the history and physical and the anticipated patient treatment plan. The initial treatment plan, except in chronic cases, should not extend beyond a 30-45 day interval.

Subsequent patient visits should include significant patient improvement or regression if demonstrated by the patient on each visit. As the patient progresses, the treatment plan needs to be reevaluated and appropriately modified by the treating doctor of chiropractic (chiropractic physician) until the patient can be released from care, if appropriate.

6.   If the patient is disabled, a statement(s) on the extent of disability and activity restriction is needed at initial and subsequent visits as appropriate over the course of care.

7.   Records can be attached to each billing to pre-empt requests; however, it is not mandatory. Local insurers should be contacted for preferences (i.e., No fault PIP insurers may require records every visit while health insurers may not).

8.   All records must be legible and understandable, released within the authority given by the patients, in a secure, confidential manner and in compliance with existing state (or federal) statutes.

9.   The patient name and initials of the person making the chart notation (especially in multi-practitioner offices) should appear on each page of the medical record.

10.   If the above recommendations have been met, then the answers as to why the necessity for continuing treatment are answered.

11.   The insurance industry must improve their claim adjusting procedure by using chiropractic consultants. The ACA can use its resources to assist in this initiative.

The Newsletter of the American Chiropractic Association

Contact the American Chiropractic Association Office of Professional Development by phone at (800) 986-4636, ext. 222, or by e-mail at for more information.



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