Initial Visit
The
following documentation requirements apply whether the subluxation is demonstrated
by X-ray or by physical exam.
Medicare does not reimburse the initial evaluation; however, you must perform
and document one.
- History
- Symptoms prompting visit
- Family history, if relevant
- Past health history
- Mechanism of trauma
- Quality and character of symptoms/problem
- Onset, duration, intensity, frequency, location and
radiation of symptoms
- Aggravating or relieving factors
- Prior interventions, treatments, medications, secondary
complaints
- Description of present illness
- Evaluation of musculoskeletal/nervous system through physical examination
- Diagnosis
- Supporting terms for primary diagnosis
- Documenting level of subluxation
- Billing for appropriate level of service
- Treatment Plan
- Recommended level of care
- Specific treatment goals
- Objective measures to evaluate treatment effectiveness
- Date of the initial treatment or date of exacerbation or reinjury of the
existing condition