Q:  I have been treating Medicare patients the same way for the last three years, but my CA told me there are specific guidelines for initial visits. I conduct a history and examination, and take x-rays, but do not follow any special system. Should I be doing something different?

A:  You should probably be doing something different, but it is difficult to be certain without knowing what you presently document for the history, exam, and x-ray findings. Your CA is correct in that Medicare has specific guidelines to follow.

The following items must be documented in the patient’s clinical record on the initial visit, whether the subluxation is demonstrated by x-ray or physical examination:

1. History. A chief complaint must be documented, including the symptoms present that caused the patient to seek chiropractic treatment.

2. Present illness. This documentation can include any mechanism of trauma; quality and character of problem/symptoms; intensity, frequency, location, radiation, onset, and duration of symptoms; aggravating or relieving factors; prior interventions or treatments, including medications; secondary complaints; and symptoms causing the patient to seek treatment.

For example: The patient stated lumbar pain is present about 75 percent of the day. This condition requires the patient to take frequent breaks to rest her lower back. The patient stated this condition started suddenly five days ago after lifting a laundry basket.

The patient rates this pain as severe and an eight out of 10. Due to this condition, the patient has had difficulty doing simple chores around the house, such as yard work, and was unable to sleep comfortably throughout the night for the past four nights.

The patient also stated she cannot stand for more than 10 minutes without pain suddenly increasing in her lower back. Ice helps relieve the pain for a short period of time. This problem has occurred in the past. The last episode was about two years ago and the patient did not seek any chiropractic/medical attention. The patient has never been to a chiropractor and is not taking medication for this problem.

3. Family history.Include a statement of family history. For example: The patient stated her father had osteoarthritis and mother had osteoporosis.

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