In my last article, I discussed the MUSTs and the SHOULDs of Subjective Documentation, that being Pain Intensity, Pain Frequency and the use of Outcome Questionnaires. Now we’ll tackle the Objective Findings.
Even though many chiropractors don’t treat a lot of Medicare patients, please understand that Medicare creates many of the rules. I’ve seen other commercial payors using the Medicare documentation guidelines for their policies, which actually makes it easier for us. Medicare does a great job of narrowing down which objective findings they’re looking for, as part of their PART requirements.
The first component of PART is P - Pain and Tenderness, which can fall under the Subjective complaints we discussed in the last article. The next component is A - Asymmetry/Misalignment. Medicare tells us that this includes Posture, Gait and Subluxation/Restriction. Let’s start with the MUSTs. If you plan on performing a chiropractic adjustment/manipulation, you MUST document a reason for it, which would be the subluxation/restriction. This applies to both the spine and extremities. Medicare doesn’t care how we find these subluxations/restrictions, but they do care how we document them. They DON’T want us documenting subluxations/restrictions in regions, such as “cervical, thoracic, lumbar.” They REQUIRE us to document the specific segments, though, such as “C3, T4 and L5.” There is no requirement to document specific spinal listings. They do give another option, though, for when the subluxation/restriction crosses two areas. For example, we can document occiput and C1 or atlanto-occipital. We can document C7 and T1 or cervicodorsal. We can document L5 and S1 or lumbosacral.
When I review personal injury records, some chiropractors like to document that they found subluxations/restrictions at literally EVERY level of the spine. That tends to be an “eye roller.” We can be more specific than that.
If your treatment centers around posture or gait, and not the subluxations/restrictions, you can document these instead, which makes documentation of the subluxations/restrictions optional, as long as you’re not performing chiropractic adjustments/manipulations.
The next component of PART is R - Range of Motion Abnormality. According to the 1997 HCFA/AMA Guidelines for the Musculoskeletal System, all the E/M exam requires is a visual assessment of range of motion noting PAIN, or a palpatory assessment noting crepitation or contracture. For this part of this exam, measured range of motion is NOT required. However, if you want to use range of motion as an outcome assessment to monitor the patient’s progress, you’ll need to measure the range of motion. I don’t mean doing a visual assessment and making up a number – I mean actually measuring the range of motion. Are range of motion measurements a good outcome assessment? Sometimes it is, and sometimes it’s not. If your patient says they feel like they’re not moving well, or if you observe that they’re not moving well, measuring range of motion can be a decent outcome assessment. Make sure when you document this that you mention that you actually measured the range of motion (dual inclinometers for spine, goniometer for extremities) and document what the normal values are (AMA Guides are the most accepted). At re-exams, note the new measurements and if each planed of motion showed improvement, regression or no change, and by how many degrees/percent.
Next is the T of PART, which is Tissue/Tone Changes. Don’t document “paraspinal muscles” for this – it’s too vague and tends not to change. Instead, document more specific muscles (i.e. trapezius, levator scapulae, etc.) and if it’s left, right or bilateral. Keep in mind that muscle spasms tend to be more acute in nature, while trigger points can be more chronic. As the patient progresses, make sure you change these to reflect their improvement (or lack of).
Do we need to document all four components of PART? Not necessarily, according to Medicare. They require us to document at least 2 of the 4, but 1 of the 2 MUST be A or R. But let’s think of this more practically. If your patient has 1 or more symptoms, document the P of PART with pain intensity and pain frequency for each condition, and an outcome questionnaire for each condition at the first visit and then every 2 weeks. If you plan on adjusting your patient, you MUST document the A (restriction/subluxation) for each segment of the spine/extremity that’s restricted. If you DON’T plan on adjusting the patient, you can document the R. On a typical daily visit with no exam, all you need to do is perform a visual assessment of range of motion noting if there is an increase in pain in each plane of motion. At re-exams, you can measure the range of motion to monitor the patient’s progress. If you plan on performing Therapeutic Exercises with the patient, you’ll want to document the planes of motion that increased pain (R of PART). If you plan on performing Manual Therapy on the patient, you’ll want to document in which muscles you found spasms/trigger points. In other words, you MUST justify ALL of your treatment with your objective findings.