The first two articles in this series ("Documentation and Standardized Care Plans," and "Standardizing the Process of Chiropractic Care,") provided information geared toward the chiropractic clinician and included components of a chiropractic management system and the development of individualized patient-database required intake forms, such as a patient registration form (e.g., the reason for the patient's visit, medications, past medical history, surgical history), family history intake, review-of-systems intake, and baseline outcome assessment intake.
The next step for the treating chiropractor is to initiate obtaining a history, performing a physical examination, identifying the problem, and formulating an initial plan of action, aka the chiropractic care plan.The follow-up office visit is generally a report of findings or what is known today as a "counseling session," during which the plan of action is discussed and patient consent is obtained. Once the patient enters into the care plan (subsequent visits), documentation occurs that may be handwritten in the form of progress notes/chart notes.
In this era of cost-conscious medicine, chiropractic interventions that place an emphasis on today's chiropractic education and knowledge base should be emphasized not only to our patients, but also to our medical physician providers. Hence, the purpose of this article is to illustrate suggestions for chiropractic clinicians to utilize when writing reports, and thus to optimize chiropractic clinical and economic success. At the end of this article, I have included a sample format of what entails a 99245 or specialty office (comprehensive) consultation report. This is utilized once a medical referral is generated and your opinion is requested. No treatment is preformed at the time of the specialty consult examination; however, the care plan may include the patient returning for chiropractic care. I leave it to the chiropractor to learn the required reporting elements of each level of examination, established or new, as this template is interchangeable.
First, here is an example of the required elements of a 99243 to enhance your understanding: "A requested specialty office consultation, identified as 99243, was performed, consisting of approximately 40 minutes face-to-face, including six minutes in counseling; hence, the basis for today's report." The following elements are required: chief complaint, history (extended) of the present illness, extended ROS (musculoskeletal only), pertinent past medical history, social history, pertinent family history, physical examination (affected and related organ systems). Include one paragraph on NMS and extremity findings. Finally, include a diagnosis of moderate complexity (example: piriformis syndrome, aka sciatic neuritis). Conclude your report with one brief paragraph under the subheading, "Discussion (Recommendations in Management)." The 99243 should only be about two pages in length. Vital signs are required on all new patients.
The following example of a comprehensive specialty consultation 99245 can be used as a template (when tailoring for a specific patient, omit fields that are not needed; data included is for illustrative purposes only).
Click here for previous articles by Nancy Martin-Molina, DC, QME, MBA, CCSP.