Establishing Medical Necessity
Properly trained and licensed healthcare professionals, such as Doctors of Chiropractic, can diagnose and develop a treatment plan for their patients. Their decision-making skills allow them to determine the frequency of the patients’ visits and what services the patients will receive. As long as the doctor exercises good judgement and meets or exceeds the standard of care, all of the care is clinically appropriate. However, not all care meets the definition of medically necessary. The definition of medically necessary care varies from payer to payer. They establish the definition.
For Medicare, there must be a documented spinal subluxation that is causing a neuromusculoskeletal condition. The ability to improve the patient’s function through treatment is also a requirement. The best way to prove medical necessity is through the provider’s documentation which includes the initial intake, history, exam, daily treatment notes, a treatment plan with measurable functional goals, and possibly imaging. When medical necessity is established, it is called active treatment in Medicare and is designated with an AT modifier when billing. The patient’s care is deemed maintenance care when these criteria are not met. Only spinal manipulations deemed active treatment are payable by Medicare.
The essence of medical necessity in Medicare is being able to prove that a subluxation exists, since the only coverage for chiropractic treatment is manual manipulation of the spine to correct a subluxation. However, a subluxation that is not associated with a secondary neuromusculoskeletal condition, and/or is not causing a loss of function may not…
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Medicare Benefit Policy Manual
Medicare publishes helpful documents and alerts to keep providers in the know about important topics. The Benefit Policy Manual is the rulebook that must be followed for Medicare. Chapter 15, and Section 240 is the section that is devoted to the policy guidelines for chiropractic coverage and care. This Reference Document is only Section 240, which is 10 pages out of about 300 in this Chapter. Download, study, and save this document in your Medicare training materials as an essential reference for chiropractic Medicare.
Medicare Benefit Policy Manual – Section 240, Chapter 15
Documenting PART During Routine Office Visits
The PART Process initials are an acronym for the required elements of examination that quantify the existence of a subluxation to meet Medicare requirements. The elements of PART are Pain, Asymmetry or Misalignment, Range of Motion Abnormalities, and Tissue Tone Changes. These elements are generally present in the initial examination by the chiropractor at the beginning of an episode of care. Therefore, the subluxation is established during the initial visit of the episode for that treatment plan.
There is some discrepancy in the language published by the Center for Medicare and Medicaid Services (CMS) vs. the language published by many Medicare Administrative Contractors (MAC) regarding the requirement to demonstrate PART on each subsequent visit of an episode of care. However, because the elements of PART are usually included in standard objective findings during a subsequent visit anyway, it’s a simple way to better document those findings day to day. Therefore, we recommend that you not only include the changes since the last visit in the objective findings but also document 2 of the 4 elements of PART, one being Asymmetry or Range of Motion. The following table illustrates the thought process or considerations that may help in document PART on a routine visit basis.
| Documenting PART During Routine Office Visits |
| P |
Pain |
- Pain can be expressed in pain scale numbers or illustrated as painful upon palpation
- Pain assessments should include quality descriptors
|
| A |
Asymmetry/Misalignment |
- Asymmetry may be assessed each visit with updated segmental listings
- Posture may be reassessed each visit with specific notations
- Comment on how these assessments of asymmetry and posture differ from the previous or initial visit
|
| R |
Range of Motion |
- Assessment of regional or segmental range of motion (ROM) limitations should be noted in your findings
- ROM may be assessed manually or with a digital goniometer
- Asymptomatic, but compensatory regions may be assessed and documented
- Document changes in ROM from visit to visit to show progression or lack thereof
|
| T |
Tissue Tone Changes |
- Palpatory tissue and tone changes may be described as hyper- or hypo- tonicity with changes noted from visit to visit
- Spasticity may be documented when present
- Grading these changes as mild, moderate, or severe can help document the patient’s improvement, or lack thereof
|
Using Clinical Judgement to Document PART Medicare requires that medical necessity be proven using the components of PART: Pain, Asymmetry, Range of motion, and Tissue tone changes. Two of these four elements must be present, and one must be Asymmetry or Range of motion. These are findings that are usually discovered during the initial evaluation…
This content is reserved for our student Chiropractors in training!
This short training summarizes the purpose of PART and how it fits into the initial and day to day visits within an episode of care. Most providers find that when they incorporate PART into the look and feel of the objective section of the note, for all patients, it provides a template for proving medical…
This content is reserved for our student Chiropractors in training!