Q: I’ve heard that patient treatment plans are important, but I’m not sure why I need them. Do they help me get paid faster?

A: Patient treatment plans have become a standard documentation requirement. Not only can they can help you get paid faster, but they can also prevent post-payment refunds. Treatment plans should include:

1. History. Be sure to include a thorough history with the standard information such as name, age, date presented, and with what symptom(s). You also want to list any complaints the patient has and to what percent or degree.

For Example: The patient also complained of pain and numbness radiating from his low back to his right leg. He stated these conditions started suddenly seven days ago after lifting a heavy couch in his house. He stated the pain is present about 90 percent of the day, while the radiating pain and numbness is present about 75 percent of the day.

He rates the low back and leg pain a nine out of 10. Due to these conditions, the patient has had difficulty doing simple daily tasks. Recently, he’s also had difficulty sleeping through the night and cannot stand for more than 10 minutes without an increase of pain. The patient stated he had a similar episode two years ago. During that time, he had an MRI that revealed a disc herniation at L4-L5 and x-rays that revealed osteoarthritis at L4-L5 and L5-S1.

Also include information the patient shares with you, such as that he needs to take breaks and spends a large portion of his day sitting while driving to work.

2. Examination findings. Your treatment plan should also include all of your findings in detail. Ensure you include findings for constitutional (height, weight, blood pressure), general appearance, and gait and station.

You also want detailed findings on spine, ribs, and pelvis; the head and neck; right lower extremity; and left lower extremity to include inspection, palpation, tenderness, asymmetry; range-of-motion and ortho/neuro tests; stability, subluxation, laxity; and muscle strength, tone, and atrophy.

Detailed findings of the skin need to include an inspection and/or palpation of the trunk, right lower extremity, and left lower extremity. You also need findings on neurological to include deep tendon reflexes and sensation.

3. Diagnosis. When making your diagnosis, be sure to include all relevant codes and descriptions.

For example: 722.10 – lumbar disc

herniation, 724.3 – sciatica, 721.3 – lumbar spondylosis, 728.87 – muscle weakness, 724.2 – lumbar pain, 739.3 – lumbar segmental dysfunction, and 728.85 – muscle spasm

4. Treatment goals. State your treatment goals in as much detail as you can.

For example: Reduce low back pain from nine out of 10 to six out of 10 within four weeks, increase lumbar flexion from 40 degrees to 65 degrees within four weeks, and increase ability to walk without pain from 10 minutes to 20 minutes within four weeks.

5. Services to be rendered. You need to include all services to be rendered and include reasons why.

For example:

• Cryotherapy (for the first two to three visits) for vasoconstriction, analgesia, and reduced nerve inflammation. Follow that with moist hydrocollator steam packs to cause a calming effect, relax tissues, and reduce muscular spasm to the cervical and lumbar musculature.

• Mechanical traction to the cervical and lumbar regions to separate and stretch the spinal segments, promote distraction and gliding of the joint facets, and promote joint hydration.

• Chiropractic manipulative treatment (CMT) to correct subluxations and improve joint function and neurophysiological function in the cervical and lumbar regions.

• The patient will be given instructions in managing his injury at home and will receive education on proper bending, lifting, and body positioning. The patient will receive exercise instructions on how to strengthen his neck and spinal muscles. This intervention will focus on skills that will be incorporated into the patient’s home environment to reduce the potential risk of a secondary injury.

6. Treatment schedule. State the treatment schedule and make sure to include frequency and duration.

For example: The initial treatment schedule for this patient is daily for the first week and then three visits per week for one month. The patient may need an additional 30 to 60 days of treatment following this initial treatment plan. If the patient does not respond in a reasonable amount of time, a CT scan and/or EMG will be recommended.

Marty Kotlar, DC, CHCC, CBCS is the President of Target Coding. Target Coding in conjunction with Foot Levelers offers continuing-education seminar on CPT coding and compliance documentation. He can be reached at 800-270-7044, drkotlar@targetcoding.com, or through www.TargetCoding.com.