For services provided and billed to HNS contracted payors, clinical examination findings must objectively substantiate the medical necessity of the services provided and must be consistent with the patient's chief complaint, diagnoses and treatment plan.
The examination and all clinical findings must be properly documented in the patient’s health care record. The health care record must include documentation to support the level of E/M service reported to the payor.
The examination should include a consultation to ascertain history and such relevant orthopedic, neurological and chiropractic tests as are necessary to establish the extent and severity of the injury or condition.
The health record must clearly indicate the specific tests performed as well as the results of the tests.
Vital signs must be obtained as part of any examination; results must be documented in the health care record and must include, at a minimum:
A. Weight
B. Pulse
C. Blood Pressure
Clinical examinations should include an examination of the area(s) indicated in the patient's chief complaint.
Written clinical exam findings must include specific segments and location of subluxations.
There are two ways in which the level of subluxation may be specified:
1. The exact bones may be listed, for example: C5, C6, etc.
2. The area may be reported if it implies only certain bones such as: Occipital-atlantal
(occiput and C1 (atlas)), lumbo-sacral (L5 and sacrum), sacro-iliac (sacrum and
ilium).
To report CMT to HNS contracted payors, subluxations must be demonstrated, and must be demonstrated by one of two methods: x-ray or physical examination.
To demonstrate a subluxation based on a physical examination, two of the four criteria below are required, one of which MUST be asymmetry/misalignment or range of motion
abnormality.
1. Pain/tenderness evaluated in terms of location, quality and intensity
2. Asymmetry/misalignment identified on a sectional or segmental level
3. Range of motion abnormalities (changes in active, passive, and accessory joint movements resulting in an increase or decrease of sectional or segmental mobility)
4. Tissue changes in the characteristics of contiguous, or associated soft tissues; including skin, fascia, muscle, and ligament
Reexaminations
Reexaminations should be performed as appropriate but no less frequently than is required by applicable state licensing boards.
Per the N.C. Board of Chiropractic Examiner Practice Guides:
"The physician should re-evaluate the appropriateness of further care after whichever comes first, approximately twelve office treatments or four weeks of care (i.e., one treatment cycle)."
For services provided and billed to HNS contracted payors, clinical examination findings must objectively substantiate the medical necessity of the services provided and must be consistent with the patient's chief complaint, diagnoses and treatment plan.
The examination and all clinical findings must be properly documented in the patient’s health care record. The health care record must include documentation to support the level of E/M service reported to the payor.
The health record must clearly indicate the specific tests performed at each reexamination as well as the results of the tests.
Vital signs must be obtained as part of any examination; results must be documented in the health care record and must include, at a minimum:
A. Weight
B. Pulse
C. Blood Pressure
Per the N.C. Board of Chiropractic Examiner Practice Guides:
"The physician should re-evaluate the appropriateness of further care after whichever comes first, approximately twelve office treatments or four weeks of care (i.e., one "treatment cycle").
If the patient shows improvement, the physician may recommend another treatment cycle.
For as long as improvement can be objectively demonstrated, the patient may continue treatment cycles.
However, if re-evaluation fails to demonstrate additional improvement after any two consecutive treatment cycles, the physician should assume that maximum therapeutic benefit has been reached.
Patients who have reached maximum therapeutic benefit may be candidates for supportive care, elective care, referral or release.
Once the goals of treatment have been realized, the patient may continue to need supportive care in order to prevent deterioration or relapse.
If a patient with an uncomplicated condition fails to show initial improvement after two treatment cycles, or a patient who initially showed improvement subsequently fails to show further improvement after one additional treatment cycle, the physician should assume that maximum therapeutic benefit has been achieved.
Patients who have reached maximum therapeutic benefit may be candidates for supportive care, elective care, referral or release."
ADL Forms 
clinical examinations / Reexaminations