Required Documentation That Was Deficient – Physical Exam
Component of the Documentation That Was Missing or Incomplete
The missing information included:
* Previous diagnosis.
* An exam of the area of the spine involved in the diagnosis.
* Assessment of change in the patient’s condition since the last visit and an evaluation of treatment.
Plan of care – Component of the Documentation That Was Missing or Incomplete
The plan of care was incomplete in that it lacks specific treatment goals and objective measures to evaluate treatment effectiveness.
Documentation to support chiropractic manipulation
* Document the service rendered in the medical record.
* If non-standard abbreviations or acronyms are used, a legend needs to be submitted with medical records.
PART exam – Exam did not document either the Range of Motion (ROM) or asymmetry/misalignment, one of which must be documented in the PART exam.
