Mario Fucinari DC, CCSP, MCS-P

Mario Fucinari DC, CCSP, MCS-P

Many are seeing increased denials of care for medical necessity in Medicare. A closer look at the reasons for the denials reveals a change in Medicare’s interpretation of medical necessity and progress in care. The evolution of their interpretation actually compliment what chiropractors have been saying for several years – we do not only treat pain!

As more and more baby boomers enter into the over 65 age group, we can easily observe a loss in function in several of our friends, family and patients. Chiropractic is poised to answer the call to not only decrease chronic pain in the elderly population, but to also improve their function. Just make sure your notes properly document the deficiencies and progress. If it is not written down, it never happened.

Medicare regulations dictate that your initial report documents a plan of treatment, treatment goals, and a method to document progression toward goals. Medical necessity continues to be a major criterion in determining reimbursement by Medicare. Medical Necessity has a three-step test to determine necessity of care. The first, the patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services must have a direct therapeutic relationship to the patient’s condition. A “significant health problem” could be classified as a loss of function. An objective measure of loss of function is best accomplished with outcome assessment tests (OATs). OATS include tests such as Roland-Morris, Oswestry and Neck Pain Disability tests. Keep in mind that although disability may be in the name of the test, OATS measure functional impairment.

The second step in the medical necessity test is that you must have a reasonable expectation of recovery or improvement of function. We must document what our expectations are in the milestones of care. This is satisfied in your treatment goals. Notice that this step indicates an “expected recovery or improvement of function”.

The third and last step indicates that the patient must have a subluxation. This is demonstrated either by x-ray or with the use of P.A.R.T.

Railroad Medicare

In a class presented by Palmetto GBA, the carrier for Medicare railroad retirees, they indicated that providers are often not documenting their evaluation of treatment effectiveness in the documentation of treatment. They further indicated that documentation of effectiveness is often not specific and/or measureable. The documentation of treatment effectiveness must be specific and measureable and relate back to the treatment plan initiated by the provider. Documentation of measurable functional improvement is a key element to meeting Medicare guidelines for reimbursement.

When we apply these principles to our documentation of the treatment plan, it becomes apparent that you should be asking each patient not only their pain levels, but also questions in relation to their progress with any functional deficiency such as problems with standing, sitting, walking or sleeping.

As an example, if the patient presents with pain levels of nine on a scale of one to 10, your goal may be to decrease their pain level to a one. While that is a worthwhile goal, it still would not satisfy the criteria for an objective measurable goal.

If in addition, the provider indicated that the patient reported that they were only able to stand for 10 minutes without pain, the if the provider documented that their goal for that patient was able to stand for more than 30 minutes, then that would qualify as an objective measure. When documenting the progress of the patient, you would follow through with those goals on each encounter. The initial visit lays the foundation for your future services, so each time you go to treat the patient on subsequent visits, you would address those goals

For further information, you can access the Palmetto transcript at:

Dr. Fucinari will be presenting several classes and webinars to aid the doctor and staff in correct compliance procedures. For an updated schedule of classes and locations, go to Dr. Fucinari is the author of several books, including, ICD-10 Coding of the Top 100 Conditions for the Chiropractic Office, available at Dr. Fucinari is a Certified Medical Compliance Specialist and a Certified Insurance Consultant. For further information on chart audits, compliance audits, manuals or consulting, please contact Dr. Fucinari at