ROM Testing Coded Separately Multiple parts of an examination are included in the overarching Evaluation and Management (E/M) codes for a new or existing patient. One of those pieces is measurement of Ranges of Motion (ROM). However, there are certain instances when, given the right scenario, testing, and documentation, the Current Procedural and Terminology (CPT®)…
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Continue to explore the importance of documenting the examination conducted during an initial visit by watching this short mini class on documenting PART. PART is a Medicare requirement; it is also the best way to document your finding of a vertebral subluxation—not only on the initial visit but as you continue care through each of…
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Review this brief training class for an overview of how to document and code the full spine adjustment. It is imperative to provide correct documentation to demonstrate that you understand the value of establishing medical necessity of the primary regions to be treated and, the clinically appropriate nature of the compensatory areas to be treated….
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History of Present Illness (HPI) and OPQRST One of the most important elements of a patient evaluation is collecting his/her History of Present Illness (HPI). The HPI elements that a patient normally presents with have a direct clinical correlation to the type and severity of the condition for which they are being treated. These elements…
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This Rapid Tutorial brings to light how the history gathered from the patient leads the provider through a medically appropriate exam and explains how to differentiate between medical necessity and clinical appropriateness. Start your training for this module with a better understanding of how the patient’s history drives the exam on any initial visit and…
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Download Reference Documents These Reference Documents are helpful tools as you continue to get familiar with and follow the rules of documenting an initial office visit. The first document includes guidelines from the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) specific to low back pain. Here you will find recommendations and the necessity for…
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