Q/A: What do I Need to Document for Periodic Adjustments on a Medicare Patient?

by  Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow
Jul 22nd, 2019

Question:

What type of documentation is required for a Medicare patient with degenerative joint disease who get adjusted once or twice a month for occasional flare-ups of the D. J. D. region? The noted adjustments give good relief of the patient's symptoms.

Answer:

There is no question that these adjustments would be considered clinically appropriate, Medicare may not consider this type of treatment to be medically necessary without some sort of exacerbation or new condition. However, CMS does state that chronic subluxations are not considered maintenance care. Documentation of functional improvement is the difference. 

About Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow

Dr. Gwilliam is a licensed chiropractic physician with a master's in business administration.  He is also a certified professional coding instructor, compliance specialist, and medical auditor.  He has published articles in multiple trade journals and travels the country to deliver training to physicians and staff on coding, documentation, and compliance.