Page 241 - Medicare Benefit Policy Manual

Quality and character of symptoms/problem;

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

Aggravating or relieving factors;

Prior interventions, treatments, medications, secondary complaints; and

Symptoms causing patient to seek treatment.

These symptoms must bear a direct relationship to the level of subluxation. The
symptoms should refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo or
osteo), rib (costo or costal) and joint (arthro) and be reported as pain (algia),
inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of
spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and
foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in
general other symptoms must relate to the spine as such. The subluxation must be causal,
i.e., the symptoms must be related to the level of the subluxation that has been cited. A
statement on a claim that there is “pain” is insufficient. The location of pain must be
described and whether the particular vertebra listed is capable of producing pain in the
area determined.

3. Evaluation of musculoskeletal/nervous system through physical examination.

4. Diagnosis: The primary diagnosis must be subluxation, including the level of
subluxation, either so stated or identified by a term descriptive of subluxation. Such
terms may refer either to the condition of the spinal joint involved or to the direction of
position assumed by the particular bone named.

5. Treatment Plan: The treatment plan should include the following:

Recommended level of care (duration and frequency of visits);

Specific treatment goals; and

Objective measures to evaluate treatment effectiveness.

6. Date of the initial treatment.

B. Documentation Requirements: Subsequent Visits

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

1. History