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 (DOWC) specifies the required elements for medical record documentation in Rule 16-9.
Progress and procedure notes
These documentation requirements apply to electronic and written formats:
Re-evaluations
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.
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.
Acceptable example:
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:
Insufficient documentation example: “Completion of activities”
For each modality, the documentation should include:
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 Pinnacol’s provider medical billing auditors at 303.361.4940 or billingsuccess@pinnacol.com.