Page 240 - Medicare Benefit Policy Manual

Evaluation of musculoskeletal/nervous system to identify:

Pain/tenderness evaluated in terms of location, quality, and intensity;

Asymmetry/misalignment identified on a sectional or segmental level;

Range of motion abnormality (changes in active, passive, and accessory joint
movements resulting in an increase or a decrease of sectional or segmental mobility);
and

Tissue, tone changes in the characteristics of contiguous, or associated soft tissues,
including skin, fascia, muscle, and ligament.

To demonstrate a subluxation based on physical examination, two of the four criteria
mentioned under “physical examination” are required, one of which must be
asymmetry/misalignment or range of motion abnormality.

The history recorded in the patient record should include the following:

Symptoms causing patient to seek treatment;

Family history if relevant;

Past health history (general health, prior illness, injuries, or hospitalizations;
medications; surgical history);

Mechanism of trauma;

Quality and character of symptoms/problem;

Onset, duration, intensity, frequency, location and radiation of symptoms;

Aggravating or relieving factors; and

Prior interventions, treatments, medications, secondary complaints.

A. Documentation Requirements: Initial Visit

The following documentation requirements apply whether the subluxation is
demonstrated by x-ray or by physical examination:

1. History as stated above.

2. Description of the present illness including:

Mechanism of trauma;