This article explores what you need to know about Medicare documentation in a way that’s both approachable and easy to follow.
What does Medicare actually cover?
Here’s the deal: Medicare only covers spinal adjustments for chiropractic care and only when they’re deemed medically necessary. This means there needs to be a clear and documented reason for the treatment, such as a neuromusculoskeletal condition that will benefit from chiropractic adjustments. It’s all about restoring function and improving your patient’s health.
However, Medicare won’t cover what’s known as maintenance therapy or ongoing treatments that aim to keep a patient in their current state of health. They’re only interested in active care that’s expected to improve the patient’s condition. So, any treatment you provide should be clearly tied to helping the patient recover or make measurable progress.
How to document a subluxation: Meet the PART system
One of the biggest things Medicare looks for is proof that a subluxation (spinal misalignment) exists, and that’s where the pain, asymmetry, range of motion and tissue/tone changes, or PART system, comes into play. You’ll need to document at least two of these four components during the physical exam, and one of those needs to be either asymmetry or range of motion.
Here’s a quick breakdown:
- Pain (P). This is all about where and how much pain the patient is feeling. You can use a scale, like asking the patient to rate their pain on a scale from 1-10, or you can use pain questionnaires to get detailed feedback.
- Asymmetry (A). Here, you’re looking for misalignment in the spine. You can note this through observation, palpation or even diagnostic imaging. Be specific — Medicare wants to know exactly which vertebrae are misaligned.
- Range of motion (R). You’ll need to document any abnormalities in how the patient moves, especially if there’s a reduction in flexibility or movement in the spine. Keep track of these changes from visit to visit to show progress.
- Tissue/tone changes (T). This involves any changes in the muscles and tissues around the spine, such as spasms, tightness or inflammation. You can note these changes through observation or palpation.
By using the PART system to document your findings, you’ll provide clear evidence of the subluxation, which is the foundation for Medicare coverage of your chiropractic adjustments.
What Medicare needs from your initial visit
The first visit with a patient sets the stage for everything else, so it’s essential to get the documentation right. Here’s what Medicare wants to see:
- Patient history. You’ll want to collect detailed information about the patient’s condition, including how and when their symptoms started, what treatments they’ve tried and any relevant family or personal medical history. Basically, you’re piecing together the whole story of why they’re coming to you.
- Diagnosis. Medicare needs you to pin down the diagnosis to a subluxation. Make sure it’s specific to the vertebrae involved, and don’t forget to document any related conditions that could impact the treatment plan.
- Treatment plan. This is your chance to lay out a game plan for the patient’s recovery. Include how often the patient will need visits, what the goals are (like increasing mobility or reducing pain) and how you’ll measure progress along the way.
- Initial treatment. On that first visit, you’ll want to document the specific adjustments you performed. This shows that the treatment is directly tied to the diagnosed subluxation and sets the expectation for future care.
Keep it simple with SOAP notes
For every follow-up visit, Medicare expects to see subjective, objective, assessment and plan (SOAP) notes. Don’t worry — this isn’t as intimidating as it sounds; it’s a straightforward way to track the patient’s progress over time.
- Subjective (S). This is what the patient tells you. Are they feeling better? Experiencing less pain? It’s always good to ask about how their condition is affecting their daily life, such as being able to sit longer or move more freely.
- Objective (O). Here’s where you record your findings. Did their range of motion improve? Are there changes in tissue tone? You’re collecting measurable data to show progress.
- Assessment (A). This is your evaluation of how the patient is doing. Are they on track with their treatment goals or do you need to adjust the plan?
- Plan (P). Outline what you did during the visit, such as which spinal regions you adjusted, and note any changes to the treatment plan.
By using SOAP notes, you keep your records organized and show that the care you’re providing is necessary and effective.
The importance of using the right Medicare modifiers and codes
One of the most important things you’ll need to do is use the right CPT codes and modifiers to get reimbursed properly. Here’s a quick look at the codes Medicare expects:
- 98940: For adjusting 1-2 regions of the spine
- 98941: For adjusting 3-4 regions
- 98942: For adjusting 5 regions
When it comes to modifiers, the AT modifier is crucial. This modifier tells Medicare that you’re providing active care, which means treatment aimed at improving the patient’s condition, not just maintaining their current health. Medicare won’t cover maintenance care, so using the AT modifier helps ensure you’re only billing for treatments that meet Medicare’s requirements.
Another modifier you might use is the GA modifier, which is for visits where you’ve had the patient sign an advanced beneficiary notice (ABN). This lets the patient know Medicare may not cover the visit, and they could be responsible for the bill.
Active care vs. maintenance therapy: Understanding the difference
One of the trickiest parts of Medicare is knowing when care shifts from active treatment to maintenance therapy. Active care is all about improving the patient’s condition — doing things such as reducing pain, increasing mobility or helping them get back to their normal activities. Medicare will cover this care as long as it’s medically necessary and progress is being made.
Maintenance therapy, on the other hand, is for patients whose condition has stabilized. The goal here isn’t improvement but rather keeping things from getting worse. Since Medicare doesn’t cover maintenance care, it’s crucial to clearly document when the transition happens. And when it does, be sure to get an ABN signed, so the patient understands they’ll be financially responsible moving forward.
Wrapping it all up
Medicare documentation doesn’t have to be a headache! By sticking to the PART system, using SOAP notes and making sure you’re using the right codes and modifiers, you’ll not only meet Medicare’s requirements but also provide top-notch care for your patients. Good documentation protects your practice, ensures you get paid for your services and helps you track the progress your patients are making.
Final thoughts
Remember, clear, accurate records are your best defense against audits and claim denials, so keep everything well-documented and up to date. Plus, your patients benefit from having a treatment plan that’s specific to their needs, with goals that help guide them to better health. So, let’s make sure you’re set up for success — because the better your documentation, the better care you can provide!
MARK SANNA, DC, ACRB LEVEL II, FICC, is the CEO of Breakthrough Coaching. He is a Board member of the Foundation for Chiropractic Progress, a member of the Chiropractic Summit and a member of the Chiropractic Future Strategic Plan Leadership Committee. He is the author of Cracking the Code: Marketing Chiropractic — How Chiropractors Align Spines and Minds, available on Amazon.com. To learn more, visit mybreakthrough.com.
