Cigna / ASH Medical Coverage Policies

Cigna / ASH Medical Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document may differ significantly from the standard benefit plans upon which these Cigna / ASH Medical Coverage Policies are based. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Cigna / ASH Medical Coverage Policy. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document.

Determinations in each specific instance may require consideration of:

1. the terms of the applicable benefit plan document in effect on the date of service
2. any applicable laws/regulations
3. any relevant collateral source materials including Cigna-ASH Medical Coverage Policies
4. the specific facts of the particular situation

Where coverage for care or services does not depend on specific circumstances, reimbursement will only be provided if a requested service(s) is submitted in accordance with the relevant guidelines and criteria outlined in this policy, including covered diagnosis and/or procedure code(s) outlined in the Coding Information section of this policy. Reimbursement is not allowed for services when billed for conditions or diagnoses that are not covered under this policy. When billing, providers must use the most appropriate codes as of the effective date of the submission. Claims submitted for services that are not accompanied by covered code(s) under this policy will be denied as not covered.

Cigna / ASH Medical Coverage Policies relate exclusively to the administration of health benefit plans. Cigna / ASH Medical Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines. Some information in these Coverage Policies may not apply to all benefit plans administered by Cigna. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make benefit determinations. References to standard benefit plan language and benefit determinations do not apply to those clients. Coverage for chiropractic care varies across plans. Refer to the customer’s benefit plan document for coverage details. When covered, chiropractic care may be subject to the terms, conditions and limitations of the applicable benefit plan’s Short-Term Rehabilitative Therapy or Chiropractic Care Services benefit and schedule of copayments.

A chiropractic treatment visit is defined as up to a one-hour session of treatment on any given day. Inclusive of this, each date of service is limited to a maximum of 4 timed codes. Chiropractic care provided to treat an injury or condition that is work-related or was sustained in the workplace may require coordination of benefits (COB). Please refer to the applicable benefit plan document to determine the terms, conditions and limitations of coverage.

Chiropractic Care (CPG 278)

If coverage for chiropractic care is available, the following conditions of coverage apply.

GUIDELINES

Medically Necessary

I. Chiropractic services are considered medically necessary when ALL of the following conditions are met:

• The service is aimed at diagnosis, and treatment of musculoskeletal and related disorders and the effects of these on the nervous system and general health
• The service is for conditions that require the unique knowledge, skills, and judgment of a chiropractor for education and training that is part of an active skilled plan of treatment
• The program is individualized, and there is documentation outlining quantifiable, attainable treatment goals.

• The individual's condition has the potential to improve or is improving (and has not reached maximum improvement). Improvement is evidenced by successive objective measurements over a defined time frame.
• The services are delivered by a qualified provider of chiropractic services

2. Upper extremity manipulation/mobilization is considered medically necessary as part of a multimodal treatment program for shoulder complaints, dysfunction, disorders and/or pain. If examination/evaluation of any other UE condition indicate restricted joint play, addition of manipulation/mobilization with standard care is reasonable.
3. Use of lower extremity manipulation/mobilization is considered medically necessary as part of a multimodal treatment of ankle inversion sprains. If examination/evaluation of any other LE condition indicate restricted joint play, addition of manipulation/mobilization with standard care is reasonable.
4. Supportive care, also referred to as ongoing care, or long-term treatment or care, may be necessary as a treatment for individuals who have reached a maximum benefit but fail to sustain the benefit and progressively deteriorate when removed from treatment programs. The potential for the individual to develop dependency on ongoing care should be considered in treatment planning. Once a maximum benefit has been reached, continuing chiropractic care is considered not medically necessary.

Not Covered or Reimbursable

I. Chiropractic services are not covered or reimbursable if any of the following is determined:

• Chiropractic services are considered maintenance /preventive:

• Maintenance/preventive care is defined as elective healthcare that is typically long- term, by definition not therapeutically necessary, but provided at intervals (preferably regular) to prevent disease, promote health and enhance the quality of life.
• Ongoing preventive/maintenance care may include patient education, screening procedures to identify risk, a home exercise program (HEP), and lifestyle modifications in the hope of promoting optimal health.
• The service is not aimed at diagnosis, and/or treatment of disorders of the musculoskeletal system, and the effects of these disorders on the nervous system and general health.
• The service is for conditions for which therapy would be considered routine educational, training, conditioning, or fitness. This includes treatments or activities that require only routine supervision.
• The service(s) are not expected to result in a practical improvement in the level of functioning within a reasonable and predictable period of time.
• The documentation fails to objectively verify functional progress over a reasonable period of time.

Improvement or restoration of function could reasonably be expected as the individual gradually resumes normal activities without the provision of skilled therapy services. For example:

1. An individual suffers a transient and easily reversible loss or reduction in function which could reasonably be expected to improve spontaneously as the individual gradually resumes normal activities;
2. A fully functional individual who develops temporary weakness from a period of bed rest.

Chiropractic services that do not require the skills of a qualified provider of chiropractic services. Examples include but not limited to:

• Activities for the general good and welfare of the individual:

• General exercises (basic aerobic, strength, flexibility or aquatic programs) to promote overall fitness/conditioning
• Services/programs for the primary purpose of enhancing or returning to athletic or recreational sports.
• Massages and whirlpools for relaxation

General public education/instruction sessions

• Activities and services that an individual can practice independently and can be self-administered safely and effectively:

1. Activities that require only routine supervision and NOT the skilled services of a chiropractor
2. When a home exercise program is sufficient and can be utilized to continue therapy (examples of exceptions include but would not be limited to the following: if individual has poor exercise technique that requires cueing and feedback, lack of support at home if necessary for exercise program completion, and/or cognitive impairment that doesn’t allow the individual to complete the exercise program)

The physical medicine and rehabilitation modalities are not preparatory to other skilled treatment procedures or are not necessary in order to safely and effectively provide other skilled treatment procedures. Treatments/services that are not supported in peer-reviewed literature and not performed in accordance with this and other applicable standards of practice and clinical practice guidelines or medical policies.

Services provided to reduce potential risk factors where significant improvement is not expected

Use of upper extremity manipulation/mobilization as a part of multimodal treatment program for epicondylitis/epicondylalgia and carpal tunnel syndrome.

• In the absence of contraindications and if examination/evaluation suggest additional findings indicating manipulation/mobilization of UE joints in addition to standard care may be beneficial (e.g., restricted joint play of humeroradial joint, restricted joint play of radiocarpal joint), use of these interventions is reasonable.

Use of lower extremity manipulation/mobilization combined with multimodal treatment program for the treatment of hip osteoarthritis, knee osteoarthritis, and/or plantar fasciitis.

• In the absence of contraindications and if examination/evaluation suggest additional findings indicating manipulation/mobilization of LE joints in addition to standard care may be beneficial (e.g., restricted joint play of iliofemoral joint, restricted joint play of the proximal tibiofibular joint)), use of these interventions is reasonable.

II. The following treatments are not covered or reimbursable because they are nonmedical, educational or training in nature. In addition, these treatments/programs are specifically excluded under many benefit plans:

• back school
• vocational rehabilitation programs and any program with the primary goal of returning an individual to work
• work hardening programs

III. Duplicative or redundant services expected to achieve the same therapeutic goal are not covered or reimbursable. For example:

• Multiple modalities procedures that have similar or overlapping physiologic effects (e.g., multiple forms of superficial or deep heating modalities)
• Same or similar rehabilitative services provided as part of an authorized therapy program through another therapy discipline.

When an individual receives rehabilitation from a physical therapist, occupational therapist, chiropractor or other rehabilitation professional, each practitioner should provide different treatments that reflect each discipline's unique perspective on the individual's impairments and functional deficits and not duplicate the same treatment. They must also have separate evaluations, treatment plans, and goals.

When an individual receives manual therapy services from a physical therapist and chiropractic or osteopathic manipulation, the services must be documented as separate and distinct and must be justified as non-duplicative.

The medical necessity of neuromuscular reeducation, therapeutic exercises, and/or therapeutic activities, performed on the same day, must be documented in the medical record.

Not Covered or Reimbursable

I. The following chiropractic modalities/services have been deemed to provide minimal to no clinical value independently or within a comprehensive treatment for any condition and/or not considered the current standard of care within a treatment program and are not covered or reimbursable:

• Vasopneumatic device
• The treatment visit extends beyond 4 timed unit services per date of service per provider (equivalent to one hour). Infrared light therapy

Not Covered or Reimbursable

I. Chiropractic manipulation and adjunct therapeutic procedures/modalities (e.g., mobilization, therapeutic exercise, traction) for treatment of non-musculoskeletal conditions are not covered or reimbursable.

II. Use of any of the following treatments are not covered or reimbursable:

• Dry hydrotherapy/aquamassage/hydromassage
• Non-invasive Interactive Neurostimulation (e.g., InterX®)
• Microcurrent Electrical Nerve Stimulation (MENS)
• H-WAVE®
• Elastic therapeutic tape/taping (e.g., Kinesio™ tape, KT TAPE/KT TAPE PRO™, Spidertech™ tape)
• Dry Needling
• Vertebral axial decompression therapy and devices (e.g., VAX-D, DRX, DRX2000, DRX3000, DRX5000, DRX9000, DRS, Dynapro™ DX2, Accu-SPINA™ System, IDD Therapy® [Intervertebral Differential Dynamics Therapy], Tru Tac 401, Lordex Power Traction device, Spinerx LDM)
• MedX lumbar/cervical machines
• Cybex back system/Biodex
• Digital radiographic mensuration
• Digital postural analysis
• Thermography
• Spinal/paraspinal ultrasound
• Surface electromyography /paraspinal electromyography
• Iontophoresis or phonophoresis

Massage Therapy
Massage therapy is NOT covered or reimbursable when it is provided in the absence of other covered chiropractic modalities or physical therapy/occupational therapy. It must be provided as part of a multi-modal rehabilitation program.

Chiropractic Care (CPG 278)

Note: Massage therapy may be provided by several types of providers. To qualify for coverage, the provider must meet the definition of provider contained in the benefit plan. Please refer to the applicable plan language to determine benefit coverage for the rendering provider.

DESCRIPTION

Chiropractic is a health care profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health. Chiropractic services are used most often to treat musculoskeletal and related conditions. Chiropractic services are intended to improve, adapt or restore functions which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality involving goals an individual can reach in a reasonable period of time. Benefits will end when treatment is no longer medically necessary and the individual stops progressing toward those goals. The specific time frames for which one would expect practical functional improvement is dependent on various factors. A reasonable trial of care for chiropractic services is generally 2-8 weeks and is influenced by the diagnosis; clinical evaluation findings; stage of the condition (acute, sub-acute, chronic); severity of the condition; and patient-specific findings (age, gender, past and current medical history, family history, and any relevant psychosocial factors). Chiropractic care may be a primary method of treatment for some medical conditions, such as lower back pain, or may complement or support medical treatment for other conditions by relieving the musculoskeletal aspects associated with the condition.

Chiropractors may refer patients to the appropriate health care provider when chiropractic care is not suitable for the patient’s condition, or the condition warrants co-management in conjunction with other health care providers.

Spinal manipulation (sometimes referred to as a "chiropractic adjustment") is a common, therapeutic procedure performed by doctors of chiropractic. The purpose of spinal manipulation is to restore joint mobility by manually applying a controlled force into joints that have become hypomobile, or restricted in their movement, as a result of a tissue injury. Tissue injury can be caused by a single traumatic event or through repetitive stresses. In either case, injured tissues undergo physical and chemical changes that can cause inflammation, pain, and diminished function. Manipulation, or adjustment of the affected joint and tissues, restores mobility, thereby alleviating pain and muscle tightness allowing tissues to heal.

In addition to manual therapy other procedures/modalities, both passive and active, are often used as adjunct treatments throughout the treatment program.

GENERAL BACKGROUND

Chiropractic spinal manipulation requires professional skills to identify spinal segmental joint dysfunction characterized by altered joint alignment, motion, or physiologic function in an intact spinal motion segment. The primary objectives of chiropractic spinal manipulation are to alleviate musculoskeletal pain, muscle spasm, and functional impairment of the spine. This form of manipulation is a therapeutic procedure characterized by controlled force, leverage, direction, amplitude, and velocity (directional, high velocity, low amplitude thrust) (Peterson & Bergmann, 2002).

Response to chiropractic treatment typically occurs within two to eight weeks. The medical necessity of continued chiropractic care is dependent on documented progress toward therapeutic goals. Maximum therapeutic benefit has been reached when the patient fails to show improvement, or when a pre-injury level of functioning has been reached.

Chiropractic physicians should document in clinical records the objective findings and subjective complaints that support the necessity for a chiropractic treatment regimen. A treatment plan should be developed with planned procedures/modalities (frequency and duration), measurable and attainable short- and long-term goals, and anticipated duration of care.

At a minimum, documentation is required for every treatment day and for each area or spinal segment treated and for each therapy performed. Each daily record should include: the date of service, the total treatment time for each date of service, and the identity of the person(s) providing the services; the type and specific location of CMT including segment(s) adjusted, subluxation listings/dynamic restrictions, direction(s) of corrective thrust(s), and specific technique(s) used; the name of each modality and/or procedure performed, the parameters for each modality (e.g., amperage/voltage, location of pads/electrodes), area of treatment, and total treatment time spent for each therapy (mandatory for timed services).

Failure to properly identify and sufficiently document the parameters for each therapy on a daily progress note may result in an adverse determination (partial approval or denial).There should be a reasonable expectation that the identified goals will be met.

The following are recommended:

• If conservative care is appropriate, a short course (not to extend beyond eight weeks) is warranted.
• If the patient demonstrates objective evidence of improvement, additional care may be appropriate.
• The provider should attempt to integrate some form of active care as early as possible.

Continued use of passive care modalities may lead to patient dependency and should be avoided. Passive modalities may be helpful for short term relief of the acute signs of inflammation (e.g., pain, muscle spasm, swelling, loss of function). The utilization of passive modalities is not considered medically necessary once the acute phase of care is over. The utilization of more than 2 passive modalities per office visit is typically considered excessive and is not supported as medically necessary. Use of more than 2 modalities on each visit date should be justified in the documentation. These rules hold true for acute, chronic and postsurgical cases. No matter what specific treatment is chosen, it must yield identifiable, objective outcomes to establish the necessity of care.

Duplicated / Insufficient Information

1. Entries in the medical record should be contemporaneous, individualized, appropriately comprehensive, and made in a chronological, systematic, and organized manner. Duplicated/nearly duplicated medical records (a.k.a. cloned records) are not acceptable. It is not clinically reasonable or physiologically feasible that a patient’s condition will be identical on multiple encounters. (Should the findings be identical for multiple encounters, it would be expected that treatment would end because the patient is not making progress toward current goals.) This includes, but not limited to:

• duplication of information from one treatment session to another (for the same or different patient[s]);
• duplication of information from one evaluation to another (for the same or different patient[s]).

Duplicated medical records do not meet professional standards of medical record keeping and may result in an adverse determination (partial approval or denial) of those services.

2. The use of a system of record keeping that does not provide sufficient information (e.g., checking boxes, circling items from lists, arrows, travel cards with only dates of visit and listings) should not be submitted. These types of medical record keeping may result in an adverse determination (partial approval or denial) of those services.

Effective and appropriate documentation that meets professional standards of medical record keeping that adequately detail a proper assessment of the patient’s status, the nature and severity of patient complaint(s) or condition(s), and/or other relevant clinical information (e.g., history, parameters of each therapy performed, objective findings, progress towards treatment goals, response to care, prognosis.) is expected.

Modalities and Procedures

In some states, Chiropractic physicians are required to hold a specific certification to use physical medicine modalities in practice. The American Medical Association (AMA) Current Procedural Terminology (CPT) manual defines a modality as "any physical agent applied to produce therapeutic changes to biologic tissue; includes but is not limited to thermal, acoustic, light, mechanical, or electric energy” (AMA, 2018). Modalities may be supervised, which means that the application of the modality doesn’t require direct one-on-one patient contact by the practitioner; or modalities may involve constant attendance, which indicates that the modality requires direct one-on-one patient contact by the practitioner. Examples of supervised modalities include application of hot or cold packs, mechanical traction, and unattended electrical stimulation. Examples of modalities that require constant attendance include ultrasound, manually applied electrical stimulation, and iontophoresis. Passive modalities are most effective during the acute phase of treatment, since they are typically directed at reducing pain, inflammation, and swelling.

They may also be utilized during the acute phase of the exacerbation of a chronic condition. The use of passive modalities are not generally considered medically necessary unless they are preparatory and essential to the safe and effective delivery of other skilled treatment procedures (e.g. chiropractic manipulation, therapeutic exercise training, etc.). After one or two weeks, the clinical effectiveness of passive modalities begins to decline significantly. The need for passive modalities beyond two weeks should be objectively documented in the clinical record. The AMA CPT manual defines therapeutic procedures as "A manner of effecting change through the application of clinical skills and/or services that attempt to improve function" (AMA, 2018). Examples of therapeutic procedures include therapeutic exercise to develop strength and endurance, range of motion and flexibility; neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioceptive activities; aquatic therapy; and manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction); or therapeutic activities using dynamic activities to improve functional performance (direct one-on-one patient contact by the practitioner). Transition from passive physiotherapy modalities to active treatment procedures should be timely and evidenced in the medical record, including instructions on self/home care. And in most cases, active treatment should be initiated in addition to modality use at a level that is appropriate for the patient. Active therapeutic procedures are typically started as swelling, pain, and inflammation are reduced. The need for stabilization and support is replaced by the need for increased range of motion and restoration of function. Active care elements include increasing range of motion, strengthening primary and secondary stabilizers of a given region, and increasing the endurance capability of the muscles. Care focuses on active participation of the patient in their exercise program. Activities of Daily Living (ADLs) training, muscle strengthening, movement retraining, and progressive resistive exercises are considered active procedures. In general, patients should progress from active procedures to a home exercise program.

Certain physical medicine modalities and therapeutic procedures are considered duplicative in nature and it would be inappropriate to perform or bill for these services during the same session, such as:

• Functional activities and ADLs;
• More than one deep heating modality;
• Massage therapy and myofascial release;
• Orthotics training and prosthetic training; and
• Whirlpool and Hubbard tank.

The medical necessity of neuromuscular reeducation, therapeutic exercises, and/or therapeutic activities, performed on the same day, must be documented in the medical record. Only one heat modality would be considered medically necessary during the same treatment session, with the exception of use of one form of superficial heat and one form of deep heat (i.e., ultrasound or diathermy and hot packs). Use of two forms of deep or superficial heat would not be acceptable. Hot or cold packs should not be used in the absence of other modalities or manipulation and must be part of a multi-modal rehabilitation program.

Exacerbation/Re-injury

According to the CCGPP consensus recommendations for the management of chronic spine related conditions, “An exacerbation is characterized by a return of atypical pain and/or other symptoms and/or pain-related difficulty performing tasks and actions equivalent to the appropriate minimal clinically important change value for the outcome of interest.” (Farabaugh, et al., 2010).

Exacerbation/Re-injury

Once maximum therapeutic benefit has been reached and documented, additional chiropractic services may be warranted when there is an exacerbation of the condition or re-injury. Management of chronic pain conditions involves an understanding and compliance with self-directed home care, and when self-directed care fails to sustain previously achieved gains during exacerbation or re-injury, a short course of treatment (i.e., 1-6 visits per episode) may be necessary (Farabaugh, et al., 2010 [Council of Chiropractic Guidelines and Practice Parameters [CCGPP]). The evaluation and documentation of the need for chiropractic services for exacerbation or re-injury should include detail surrounding the individuals response to previous and current modalities of treatment, response to absence of treatment, that maximum therapeutic benefit was reached and documented, analgesic pattern use, patient- centered outcome assessment tools, and any other health care services that have been used to manage symptoms (Farabaugh, et al., 2010). Clinical documentation should clearly describe the condition that requires additional treatment sessions, and that the condition is an exacerbation or re-injury.

DOCUMENTATION GUIDELINES

Evaluation

An initial evaluation service is essential to determine whether any services are medically necessary, to gather baseline data, establish a treatment plan, and develop goals based on the data. The initial evaluation is usually completed in a single session. An evaluation is needed before implementing any chiropractic treatment. Initial evaluations include an Evaluation and Management (New Patient or Established Patient E/M) service and may include, as necessary, imaging, laboratory studies, and other diagnostic tests and measures. The initial evaluation service must include:

• A level of clinical history, examination, and medical decision-making relevant and appropriate to the individual’s complaint(s) and presentation;
• Prior functional level, if acquired condition;
• Specific standardized and non-standardized tests, assessments, and tools;
• Analytic interpretation and synthesis of all data, including imaging studies, special tests, lab reports, and/or reports/records from other healthcare providers;
• Objective, measurable, and functional descriptions of an individual's deficits using comparable and consistent methods;
• Summary of clinical reasoning and consideration of contextual factors with recommendations;
• The establishment of a working diagnosis;
• Plan of care with specific treatment techniques or activities to be used in treatment sessions that should be updated as the individual's condition changes;
• Frequency and duration of treatment (treatment dose);
• Functional, measurable, and time-framed long-term and short-term goals based on appropriate and relevant evaluation data;
• Rehabilitation prognosis and discharge plan.

Note: Appropriate range of motion (ROM) testing (CPT codes 95851- 95852), including digital wireless inclinometers or other such electronic device that measures ROM using a handheld device are integral within Evaluation/Reevaluation codes. Computerized isokinetic muscle strength and endurance testing using a machine, such as a Biodex, would be considered a physical performance test or measurement using CPT code 97750 – “Physical performance test or measurement (e.g. musculoskeletal, functional capacity), with written report, each 15 minutes.”

Treatment Sessions

Chiropractic treatment can vary from Chiropractic Manipulative Therapy alone (CMT CPT codes 98940-98943) to the use of a variety of physical medicine and rehabilitation modalities and procedures depending on the patient’s condition, response to care, and treatment tolerance.

A chiropractic treatment session lasts up to one-hour on any given day and all services must be supported in the treatment plan and be based on an individual's medical condition. Consistent with Centers for Medicare & Medicaid Services (CMS) Local Coverage Determinations (LCDs), up to a maximum of 4 timed codes (modalities and procedures) will be allowed. Chiropractic services in excess of 60 minutes per day are generally not demonstrated to have additional medical benefit in an outpatient setting. A chiropractic treatment session may include:

• Chiropractic Manipulative Therapy (CMT). A brief evaluation of the patient’s progress and response to previous treatment(s) is included in the work value of a CMT.
• Passive physical medicine modalities such as electrotherapeutic and mechanical modalities preparatory to other skilled services
• Active physical medicine procedures such as therapeutic exercise, including neuromuscular reeducation, coordination, and balance;
• Functional training in self-care and home management;
• Functional training in and modification of environments (home, work, school, or community), including biomechanics and ergonomics;
• Manual therapy techniques, including soft tissue mobilization, joint mobilization, and manual lymphatic drainage;
• Assessment, design, fabrication, application, fitting, and training in assistive technology, adaptive devices, and orthotic devices;
• Training in the use of prosthetic devices;
• Skilled reassessment of the individual's problems, plan, and goals as part of the treatment session;
• Coordination, communication, and documentation;

Chiropractic Care (CPG 278)

Reevaluation, if there is a significant change in the individual's condition or there is as need to update and modify the treatment plan. Documentation of treatment sessions should include at a minimum:

• Date of treatment;
• Specific treatment(s) provided that match the procedure codes billed;
• Total treatment time;
• The individual's response to treatment;
• Skilled ongoing reassessment of the individual's progress toward the goals;
• Any progress toward the goals in objective, measurable terms using consistent and comparable methods;
• Any problems or changes to the plan of care;
• Name and credentials of the treating clinician.

Progress Reports

In order to reflect that continued chiropractic services are medically necessary, intermittent progress reports must demonstrate that the individual is making functional progress. Progress reports may be in the form of an expanded treatment session note (e.g. S.O.A.P. note format) or a more formal report. Progress reports should include at a minimum:

• Start of care date;
• Time period covered by the report;
• Working diagnoses;
• Statement of the individual's functional level at the beginning of the progress report period;
• Statement of the individual's current status as compared to evaluation baseline data and the prior progress report, including objective measures of the individual's function that relate to the treatment goals;
• Changes in prognosis and why;
• Changes in plan of care and why;
• Changes in goals and why;
• Consultations with other professionals or coordination of services, if applicable;
• Signature and title of qualified professional responsible for the therapy services.

Reevaluation

The Chiropractic Manipulative Therapy (CMT) service includes a brief reevaluation of the patient’s condition, as well as documentation of the patient's response to the treatment. Routine use of E/M services is not medically necessary. A reevaluation (an Established Patient E/M service) is indicated when there are new clinical findings, a rapid change in the individual's status, or failure to respond to treatment interventions.

There are several routine reassessments that are not considered reevaluations. These include ongoing reassessments that are part of each skilled treatment session, progress reports, and discharge summaries. The E/M services may include all or some of the components of the initial evaluation, such as:

• Data collection with objective measurements taken based on appropriate and relevant assessment tests and tools using comparable and consistent methods;
• Determining effectiveness of intervention(s) and whether chiropractic care is still warranted;
• Organizing the composite of current problem areas and deciding a priority/focus of treatment;
• Modification of intervention(s);
• Revision in plan of care if needed;
• Correlation to meaningful change in function; and
• Updating the discharge plan as appropriate.

Identifying the appropriate intervention(s) for new or ongoing goal achievement;

Standardized Tests and Measures/Functional Outcome Measures (FOMs)

Measuring outcomes is an important component of chiropractors’ practice. Outcome measures are important in direct management of individual patient care and for the opportunity they provide the profession in collectively comparing care and determining effectiveness. The use of standardized tests and measures early in an episode of care establishes the baseline status of the patient, providing a means to quantify change in the patient's functioning. Outcome measures, along with other standardized tests and measures used throughout the episode of care, as part of periodic

Chiropractic Care (CPG 278)

reexamination/reevaluation, provide information about whether predicted outcomes are being realized. As the patient reaches the termination of chiropractic services and the end of the episode of care, the chiropractor measures the outcomes of the chiropractic services. Standardized outcome measures provide a common language with which to evaluate the success of chiropractic interventions, thereby providing a basis for comparing outcomes related to different intervention approaches. Measuring outcomes of care within the relevant components of function (including body functions and structures), activity, and participation, among patients with the same diagnosis, is the foundation for determining which intervention approaches comprise best clinical practice.