Medical necessity, the standard of care for all medical professions, must be supported by documentation. A submitted record must stand alone as a billable encounter without additional records, personal insight or knowledge of the injured worker’s condition. Inadequate or unreadable documentation may result in reduced or denied payment for services. The Division of Workers’ Compensation specifies the required elements for medical record documentation in Rule 16-10.
Progress and procedure notes
These documentation requirements apply to electronic and written formats:
- Document pertinent, significant information on the patient’s condition at this visit (history).
- Document the exam findings, the body area treated, the testing performed and the objective findings.
- Indicate a diagnosis code, not a billing code, with a written interpretation of the patient’s condition and physical findings and how the diagnosis correlates with the objective assessment.
- Procedure codes must include details of the procedure including the area or region treated, the specific exercises performed and/or instructions, the number of repetitions (if applicable), and the patient’s response.
- Record the progress during treatment and how it correlates to the care plan.
- Document any professional interpretation services rendered at the visit.
- Include details of the injured worker’s home situation and support as it relates to his or her progress.
- Record the name and credentials of who performed the treatment.
Clinical findings must be updated at each encounter to justify medical necessity. Cloned documentation does not demonstrate re-evaluation or assessment of the current condition.
- Document the improvement or decline in functional status.
- Document changes in the diagnosis or treatment plan and the necessity for the change.
- The assessment must evaluate the response to the treatment for that visit.
Acceptable examples of E&M visit with modifier 25:
Plan of care change: Patient in today for 4th chiropractic treatment. Has not received desired benefit from previous treatment and flexion is reduced by 25% from 3rd visit. Modification to treatment plan includes ...
New problem in different body area: Patient in today for 4th chiropractic treatment of cervical spine. Patient reports significant pain and difficulty bending after picking up item from ground at work. Re-evaluation performed today due to decreased ROM and increased pain in lumbar spine.
- Documentation must include the objective, measurable assessment of functional status at the initial session and, to assess gain, at each subsequent session.
Lumbar range of motion - baseline (flexion) 30%: at chiro visit 4: ROM 85% (goal > 90%). Oswestry disability score - baseline 16; at chiro visit 4: disability score 11 (goal < 12). Patient making objective functional progress and is at or very near goals. Patient will meet goals within DOWC initial time-to-effect criteria of 6 visits. One to two additional chiropractic sessions will be offered.
Documentation for treatment plans
For physiotherapy, the plan should record:
- The therapeutic procedure or exercise to be performed
- The frequency, duration, body area and period for re-examination
- The long- and short-term goals and the expected functional gain
- Any diagnostic testing, the prognosis and the anticipated discharge
- Document patient instructions such as ice/heat treatments, exercises and home care
Insufficient documentation example: “Completion of activities”
For each modality, the documentation should include:
- The type of modality and the body area treated
- The length of time the modality is used and the intensity settings
- Whether the session is attended or unattended
- How the modality correlates with the diagnosis
When using multiple modalities, the medical decision-making for each treatment must be documented. For time-based modalities, document the direct patient-physician time for each service provided.
For Pinnacol Assurance to authorize payment for services and determine appropriateness and medical necessity, specific details for therapeutic and manual procedures must be documented.
These guidelines are not intended in any way to direct the type or duration of medical treatment that may be prescribed. We understand that you must exercise your independent medical judgment in these matters.
Pinnacol conducts pre- and post-payment documentation reviews for chiropractic services. If your documentation does not support the services being billed, your request for payment could be denied or you could receive a letter requesting a refund based on an overpayment. If you have questions, please contact firstname.lastname@example.org.