Chiropractic Medical Necessity: The Reviewer Perspective

 

by: AllMed Healthcare Management

 

Third party payers demand documentation to substantiate the medical necessity of a chiropractic treatment. This documentation should support care by providing evidence that a treatment was necessary for relief from a condition and to alleviate a patient’s symptoms. When a third party payer requests records, there are necessary documents and information that must be included for review. These include a patient’s past and present history, consultation form, chart notes and any required x-rays.
The patient’s past and present history are needed. These must explain why the patient sought chiropractic care, the nature of the complaints, the duration of the complaints and whether the patient was involved in a traumatic event. The documentation should explain if the patient has exhibited the same or similar complaints previously, whether there is a family history of illness or injury and if there are contraindications to chiropractic care.
It is important that the chiropractor include a consultation form. This reiterates the reasons the patient sought chiropractic care. The form should explain any previous medical and chiropractic treatment, as well as any prior examinations and test results, if known. This indicates whether patient’s condition is acute or chronic and what treatment, has been provided to the patient, along with the prior treatments outcome. Diagnoses are necessary.
The initial examination findings are important. These findings should describe range of motion, orthopedic and neurological, chiropractic palpation and postural abnormalities. If treatment proceeds beyond a brief course of care, progress examination findings are necessary to show progress between objective examinations.

Although x-rays can be integral in formulating a chiropractic diagnosis and treatment plan, they are not necessary for each patient. An unexplained complaint of long standing, trauma, and age, along with the consultation and examination findings and clinical experience, will determine the need for x-rays.

A patient’s chart notes are vital to assess the necessity of chiropractic care and critical to the review process. They show how the patient has improved or not, whether the objective findings (at least, range of motion, palpation and postural) reveal that the patient is improving. Chart notes also show how a patient’s response to treatment, the reasonableness of care and the treatment plan presented. If a home program was instituted, they tell whether the patient is taking charge of his or her own healthcare and if it appears that the patient’s condition is progressing or being alleviated.

About The Author

AllMed Healthcare Management: Founded in 1995, AllMed (http://www.allmedmd.com , http://www.allmedmd.com/blog/index.htm) is a URAC-accredited Independent Review Organization (IRO) serving insurance payers, providers, TPAs and claims managers nationwide. Reviews are conducted by board-certified physicians in active practice. AllMed's growing customer base includes premier organizations, such as Educator's Mutual Life, IMS Managed Care, Tenet Healthcare Corporation, HealthGuard, several Blue Cross Blue Shield organizations, TriWest Healthcare Alliance, Allianz and many other leading healthcare payers.