Subsequent visit - what are documents required

SUBSEQUENT VISITS

The following documentation requirements apply whether the subluxation is demonstrated by X-ray or physical examination:

1. History:

* Review of chief complaint.

* Changes since last visit.

* System review if relevant.

2. Physical exam:

* Exam of area of spine involved in diagnosis.

*Assessment of change in patient condition since last visit.

* Evaluation of treatment effectiveness.

3. Documentation of treatment given on day of visit.

Failure to document the medical necessity of the chiropractor’s manual spinal manipulation(s) may result in denial of claim(s).