Carol, a woman in her late sixties walks into your office after dealing with recurring back pain she’s had for eight months. She noticed your practice on the way to the gym one morning and decided to make an appointment. Do you know what to do when a new patient insured by Medicare needs treatment?

Working with Medicare is inevitable and not particularly difficult. Actually, they are an easy payer to work with if you know what to expect.  To keep on the right track, here are three key elements you must include to prove medical necessity when documenting a Medicare patient.

History, Physical Exam, and Description of Present Illness

You need to know why your patient is there but also a little bit about their history and their current status. After conducting a physical exam, clearly complete an outcome assessment that should be used before, during, and after treatment. This assessment would be used to establish a baseline after the initial appointment.

Finally, you need to describe the reason why they came into your office in the first place. Detail the presence of a subluxation, symptoms, aggravating and relieving factors, and prior treatments, medications, and other existing problems.

Diagnosis for area(s) of treatment

The primary diagnosis must be segmental and somatic dysfunction of either the cervical region (M99.01), thoracic region (M99.02), lumbar region (M99.03), sacral region (M99.04), and/or pelvic region (M99.05). Basically, you need to diagnose the subluxation through an x-ray or a physical exam.

The secondary diagnosis must be degenerative arthritis based on the presenting problem. Here, you can list all primary and secondary for each region that is treated and billed. However, only claims where the subluxations that are supported by the diagnosed degeneration will be accepted.

Also, complicating factors should also be diagnosed, if relevant. Make sure to create “Provider Documentation Guides” for your most commonly used diagnoses and learn to document a “Diagnostic Statement” that matches the code requirements.

Treatment plan, goals and timeline

Detail your treatment plan by listing line item procedures that will be performed on the patient to aid in their treatment. Also make sure to state why you will perform the respective procedure. Recommendations for plan of care should describe if and when home care and lifestyle modifications are necessary. The timing and reinforcement of such should also be noted.

Your timeline for treatment must align with the plan and goals. When describing your time frame for treatment, state what part of the body this procedure will affect and how many visits will be required before a re-evaluation.

When documenting for Medicare, make sure to be as detailed as possible. Explaining everything makes it easier for your claims to be accepted. And not only does it show a high-level of care, this could transcend into a better patient experience.

ACOM Health