Initial Visit - Documenting Level of Subluxation

The precise level of the subluxation must be specified in the medical record by the exact bones (C5, C6, etc.) or the area if it implies only certain bones such as occipito-atlantal (occiput & C1 [atlas]). Other terms may be used if they are clear to mean bone/joint space, position, or motion changes of the vertebral elements.

Medicare is looking for the level of subluxation to the bone. If the exact bone is not apparent, name the specific areas. Be certain to indicate ALL levels of subluxation and what may have caused the subluxation (degenerative changes, an injury, etc.).

A spine drawing, appropriately labeled and numbered, with the area marked is acceptable.