This section provides guidance to licensees of how
clinical necessity for chiropractic care under §
5.51(c) (relating
to patient records) may be documented.
(1)
Definitions. As used in
this section, the following words and terms, have the following meanings,
unless the context clearly indicates otherwise:
Acute condition-A patient's condition
where the onset of the condition or symptoms, or both, has occurred or
substantively worsened within a 6-week period prior to presentation and which
is caused by some intervening event or trauma whether known or unknown.
Chronic care-Treatment of a chronic
condition that is not expected to improve or resolve the chronic condition but
is nonetheless expected to result in improvement in the patient's functional
status that has regressed after a withdrawal of care.
Chronic condition-A patient's condition
when the condition or symptomatology has existed for longer than 6 weeks.
Classification of a condition as chronic in no way affects the expectation of
whether the condition can be resolved or improved with treatment.
Elective care-Treatment delivered in
the absence of symptoms or positive findings following examination or
testing.
Exacerbation-A sudden, marked
deterioration of the condition being treated, which causes a marked worsening
in the patient's functional status, and which is caused by some intervening
event or trauma, whether known or unknown.
Maintenance care-Treatment after maximum
therapeutic benefit has been achieved from a course of treatment or care
rendered for a chronic condition, which is not reasonably expected to improve
substantively the patient's condition or functional capacity. Maintenance care
is generally rendered on a predictable frequency and includes care for which
the outcome is preventative, palliative or elective.
Palliative care-Treatment for an acute
or chronic condition that is not reasonably expected to resolve or
substantively improve the underlying injury, disease or defect and that is
rendered with the sole expectation of ameliorating the patient's symptoms as
opposed to significantly improving the patient's condition or capacity to
function.
Preventive service-Service provided
with the expectation of preventing worsening in a patient's chronic condition,
preventing the onset of a condition, or reducing the risk of recurrence in a
condition that has been treated and resolved. A service provided based upon
findings uncovered during a preventive service examination is not a preventive
service.
Recurrence-A return of an acute
condition which was previously treated and resolved or stabilized and which has
been quiescent for a period of time.
Restorative care-A course of active
care provided that is reasonably expected to substantively improve the
patient's condition or the patient's capacity to function.
Supportive care-Treatment for a
condition once maximum therapeutic benefit has been established and after
therapeutic treatment has been withdrawn two or more times with the patient
failing to sustain previous therapeutic gains.
(2)
Restorative care. The
patient record regarding restorative care should contain documentation of the
development of the patient's symptoms to include the mechanism of onset and the
functional limitations associated with the presenting symptoms. The
documentation should additionally detail the diagnostic test results and
examination findings/indications (diagnosis) that form the objective basis for
the symptoms and functional limitations. The course of treatment necessary to
ameliorate the patient's condition should be identified to include the specific
therapeutic modalities or procedures to be utilized. The documentation should
also identify the specific functional results or goals of treatment that are
planned. Subsequent documentation should identify changes in the patient's
subjective or objective state that provide evidence of the provider's
continuing expectation that additional improvement will occur with additional
treatment. Any changes in the plan of care or anticipated outcomes should be
identified to include the clinical rationale for these changes. When the
patient reaches a functional plateau, the documentation should detail the
results obtained and whether the patient was transitioned to another form of
care or was discharged. When the patient self-dismisses or otherwise terminates
care, the documentation should so indicate and identify the rationale for
termination and the results achieved, if any. Documentation of restorative care
and necessary chronic care should contain information to support that it
satisfies at least one of the following:
(i)
It was reasonably expected to improve the patient's condition at the time it
was rendered.
(ii) It assisted the
patient to achieve maximum functional capacity in performing daily,
recreational, social or occupational activities.
(iii) It improved the patient's
condition.
(iv) It was provided
consistent with the treating doctor's diagnosis.
(v) It was provided consistent with the
patient's active symptomatology, functional complaint, or abnormal physical
findings.
(3)
Maintenance care. The patient record regarding maintenance
care should demonstrate how the care sought to promote health or functional
status, or both. Documentation of maintenance care should contain information
to support that it satisfies at least one of the following:
(i) It assisted the patient to maintain the
patient's capacity to perform daily, recreational, social or occupational
activities.
(ii) It was provided
consistent with the treating doctor's diagnosis.
(iii) It was provided consistent with the
patient's active symptomatology, functional complaint, or abnormal physical
findings.
(4)
Palliative care. The patient record regarding palliative care
should demonstrate how the care was intended to relieve continued pain and to
positively affect the patient's symptomatology, and to demonstrate the need for
the frequency of palliative care. Documentation of palliative care should
contain information to support that it satisfies at least one of the following:
(i) It alleviated the patient's
pain.
(ii) It mitigated the
severity of the patient's symptoms.
(iii) It was provided consistent with the
treating doctor's diagnosis.
(iv)
It was provided consistent with the patient's active symptomatology, functional
complaint, or abnormal physical findings.
(5)
Preventative care. The
patient record regarding preventive care should include a history and
documentation of examination, counseling and risk factor reduction.
Documentation of preventative care should contain information to support that
it satisfies at least one of the following:
(i) It prevented the onset of a condition
that might result in permanent disability.
(ii) It prevented the worsening of the
patient's condition.
(iii) It
reduced the risk of subsequent injury.
(iv) It was provided consistent with the
treating doctor's diagnosis.
(v) It
was provided consistent with the patient's active symptomatology, functional
complaint, or abnormal physical findings.
(6)
Elective care. The
patient record regarding elective care should demonstrate how care was intended
to enhance the patient's level of health, wellness or general well-being.
Documentation of elective care should contain information to support that it
satisfies at least one of the following:
(i)
It was reasonably expected to improve the patient's level of health, wellness
or general well-being.
(ii) Where
applicable, it was provided consistent with the treating doctor's
diagnosis.
(7)
Supportive care. The patient record regarding supportive care
should contain documentation of at least two trials of withdrawal of
therapeutic treatment that have failed to sustain previous therapeutic gains
following an aggravation, exacerbation or recurrence. The patient record need
not demonstrate functional improvement beyond the previously established
maximum therapeutic level.
(8)
Diagnostic tests. Documentation concerning diagnostic tests
should address at least one of the following:
(i) The rationale for ordering the diagnostic
test so that without the diagnostic test the doctor of chiropractic could not
establish a differential diagnosis to a reasonable degree of chiropractic
certainty.
(ii) The extent to which
the diagnostic test facilitated the proper or effective management or control
of the patient's condition, including monitoring of condition.
(iii) How the diagnostic test quantified an
objective status of the patient's condition or functional capacity.
