Chiropractic Case History

CPT CODE

HISTORY

/ EXAM / MEDICAL DECISION
99201 / FOCUSED:
3 elements of HPI
No review of system
No past/family/social / FOCUSED:
Problem focused
Limited exam of
Affected body area / STRAIGHTFORWARD:
Minimal DX
Minimal review of data
Minimal risk
99202 / EXPANDED:
3 elements of HPI
Positive/Negative review of related systems / EXPANDED:
Expanded exam of
Affected body area
and its related symptoms / STRAIGHTFORWARD:
Minimal DX
Minimal review of data
Minimal risk
99203 / DETAILED:
4 elements of HPI
2-9 system reviewed
One type of history / DETAILED:
Detailed exam of
Affected body area
Plus other related
symptoms / LOW:
Limited DX
Limited review of data
Low risk
99204 / COMPREHENSIVE:
4 elements of HPI
10 systems reviewed
1 item of each of 3 types of histories / COMPREHENSIVE:
Multi-system or complete single system / MODERATE:
Multiple DX
Moderate review of data
Moderate risk
99205 / COMPREHENSIVE:
4 elements of HPI
10 systems reviewed
1 item of each of 3 types of histories / COMPREHENSIVE:
Multi-system or complete
Single system / HIGH:
Extensive DX
Extensive review of data
High risk
CPT CODE / HISTORY / EXAM / MEDICAL DECISION
99211
99212 / FOCUSED:
3 elements of HPI
No review of system
No past/family/social / FOCUSED:
Problem focused
Limited exam of
Affected body area / STRAIGHTFORWARD:
Minimal DX
Minimal review of data
Minimal risk
99213 / EXPANDED:
3 elements of HPI
Positive/Negative review of related systems / EXPANDED:
Expanded exam of
Affected body area and
Its related symptoms / LOW:
Limited DX
Limited review of data
Low risk
99214 / DETAILED:
4 elements of HPI
2-9 system reviewed
One type of history / DETAILED:
Detailed exam of
Affected body area
Plus related symptoms / MODERATE:
Multiple DX
Moderate review of data
Moderate risk
99215 / COMPREHENSIVE:
4 elements of HPI
10 systems reviewed
1 item of each of 3 types of histories / COMPREHENSIVE:
Multi-system or complete
Single system / HIGH:
Extensive DX
Extensive review of data
High risk

Chiropractic Case History

Name______Sex M F Date______

Address______State______Zip______

H. Phone(______)______W. Phone______Date of Birth______Age______

Referred by______Social Security #______

Occupation______Employer______

Have you ever received Chiropractic Care?YesNo If yes, when?______

1. Primary reasons for seeking chiropractic care:

Primary reason: ______

Secondary reason: ______

Other factors contributing to the primary and secondary reasons: ______

2. Chief Complaint: ______

Location of Complaint: ______

Complaint Began when and how? ______

Please circle the Quality of the complaint/pain: dull aching sharp shooting burning throbbing deep nagging other ______

Does this complaint/pain radiate or travel (shoot) to any areas of your body? Where?______

Do you have any numbness or tingling in your body? Where? ______

Grade Intensity/Severity (No complaint/pain) 0 1 2 3 4 5 6 7 8 9 10 (Worst possible pain/complaint imaginable)

How frequent is complaint present, how long does it last? ______

Does anything aggravate the complaint? ______

Does anything make the complaint better? ______

3. Previous interventions, treatments, medications, surgery, or care you’ve sought for your complaint: ______

______

_
4. Past Health History:

A. Previous illnesses you’ve had in your life: ______

______

B. Previous injury or trauma:______

______

Have you ever broken any bones? Which? ______

C. Allergies ______

D. Medications:

MedicationReason for taking

______

E. Surgeries:

Date Type of Surgery

______

F. Females/ Pregnancies and outcomes:

Pregnancies/Date of DeliveryOutcome

______

What was the date of the beginning of your last menstrual period? ______

Family Health History:

Associated health problems of relatives: ______

______

Deaths in immediate family:

Cause of parents or siblings’ deathAge at death

______

Social and Occupational History:

Level of Education:

O high schoolO some collegeO college graduateO post graduate studies

Job description: ______

Work schedule: ______

Recreational activities: ______

E. Lifestyle (hobbies, level of exercise, alcohol, tobacco and drug use, diet):______

______

I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize

this office of Chiropractic to provide me with evaluation and possible treatment of chiropractic care, for my condition.

Parent or Guardian Signature ______Date ______

Doctors Signature ______Date ______

Informed Consent

I hereby request and consent to treatment from this doctor/clinic including the performance of chiropractic adjustments and other chiropractic procedures, including physical medicine therapy and rehab; diagnostic x-rays, examinations or other testing for my condition.

I have had an opportunity to discuss with the doctor of chiropractic and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I fully understand that results are not guaranteed.

I understand and am informed that, as with all treatment, in the practice of chiropractic there are some risks. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to him or her, is in my best interest.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to begin treatment.

I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I may continue to seek treatment from this facility.

Patient’s Signature______Date ______

Witness’ Signature ______Date______

Audit of E/M Services

Patient: / Provider:
DOS: / Amount Billed: / Billed as:  NEW  Established
History / Date last seen:
Chief Complaint: / Date of last occurrence:
 Brief HPI 1 to 3 Elements – no ROS /  Detailed HPI 4 + ROS 2 to 9 + one type family
 Expanded HPI 1 to 3 + ROS directly related to CC /  Comprehensive HPI 4 + 10 ROS + one each PFSH

History of Present Illness

Review of Systems

Location



Documentation

Systems



Documentation

Location

Constitutional

Quality

Eyes

Severity

Ears/Nose/Mouth/Throat

Timing

Cardiovascular

Associated Signs/Symptoms

Respiratory

Duration

Gastrointestinal

Modifying Factors

Genitourinary

Context

Musculoskeletal

Integumentary

Neurological

Psychiatric

Endocrine

Hematologic/Lymphatic

Allergic/Immunologic

Past Medical History

/ Family History / Social History
Illnesses / Family Illness/Disease / Smoking
Operations / Mother / Drug Use
Injuries or Treatment / Father / Material Status
Current Medications / Sibling(s) / Occupation
Past Hospitalizations / Cancer / Hobbies
Allergies / Diabetes / ADL
COPD
Heart

EXAM

 Problem Focused /  Expanded Problem Focused /  Detailed /  Comprehensive
Limited exam of
affected body area / Exam of affected body area
+ other symptomatic or related / Extended exam of affected area + other systems / Complete single specialty exam
Or comprehensive multi-system

MEDICAL DECISION MAKING

Number of DX

/ Minimal / Limited / Multiple / Extensive

Amount of Data

/ Minimal / Limited / Moderate / Extensive

Risk of Complications

/ Minimal / Low / Moderate / High

Levels

/ Straight Forward / Low Complexity / Moderate Complexity / High Complexity

CONSULT FORM

PATIENT’S NAME: ______TODAY’S DATE: ______

CHIEF COMPLAINT(s):

HISTORY OF PRESENT ILLNESS

Location
Quality
Severity
Duration
Timing
Context
Modifying Factors
Associated Signs & Symptoms

REVIEW OF SYSTEMS (ROS): (see patient form)

 Constitutional EENTM

 Musculoskeletal  Neurological

 Cardiovascular Respiratory

 Endocrine Integumentary

 Gastrointestinal  Psychiatric

 Genitourinary Hematologic/lymphatic

 Allergic/immunologicOther comments:

PAST HISTORY:

Recent Illnesses
Operations
Medications
Other injuries
Previous treatment

SOCIAL HISTORY:currentlypreviouslynumber/amt.

Alcohol
“Recreational” drugs
Chemical Dependency

Tobacco use
Marital status
Hobbies
Occupation
Other activities

FAMILY HISTORY: (diseases that may put the patient at hereditary risk)

______

COMMENTS: ______

DOCTOR’S NAME: ______SCRIBED BY: ______

MEDICAL DECISION FORM

PATIENT’S NAME: ______TODAY’S DATE: ______

PATIENT’S CHIEF COMPLAINT(s):

______

MEDICAL DECISION MAKING

Number of DX

/ Minimal / Limited / Multiple / Extensive

1. PRIMARY:______(ICD10):______

2. SECONDARY:______(ICD10):______

3. TERTIARY:______(ICD10):______

4. QUATERNARY:______(ICD10):______

ADDITIONAL:______(ICD10):______

RULE OUT:______

COMMENTS: ______

Amount of Data Reviewed

/ Minimal / Limited / Moderate / Extensive

COMMENTS: ______

Risk of Complications

/ Minimal / Low / Moderate / High

COMMENTS: ______

DECISION

Level

/ Straight Forward / Low Complexity / Moderate Complexity / High Complexity

DOCTOR’S SIGNATURE: ______
SPECIAL TESTING ORDERS

PATIENT’S NAME: ______TODAY’S DATE: ______

PATIENT’S CHIEF COMPLAINT(s):

______

WORKING DIAGNOSIS: ______

INDICATIONS FOR FURTHER TESTING:

______

RULE OUT:

______

TESTS ORDERED: ______

REFER TO: ______

COMMENTS: ______

DOCTOR’S SIGNATURE: ______
TREATMENT PLAN WORKSHEET

PATIENT:______DATE OF ONSET:______

_____INITIAL PLAN _____SUBSEQUENT PLAN

DIAGNOSIS: ______

TREATMENT: (list modalities, procedures and physical medicine activities with rationale for each procedure)

Adjust/Mobilize: Regions C______T______L______S______P______Upper/E ____ Lower/E ____

Specific type:______

diversified, activator, blocking, mobilization, cox, etc.

Specific region:______

Spine, extremity, rib, sacral-iliac, pelvic, knee, ankle, wrist, etc.

Physical Medicine: (type) Region: Time: Setting: Rationale: Diagnosis:

______

FREQUENCY OF TREATMENT:______

How often per week

DURATION OF TREATMENT:______

How many weeks

EXPECTED CLINICAL RESPONSE TO TREATMENT:

______

Short-term goals: ______

Long-term goals: ______

NEXT RE-EVALUATION PLANNED: ______

TREATING DOCTOR: ______DATE: ______

MEDICARE TREATMENT PLAN

NAME: ______DATE: ______

Diagnosis:

Primary Subluxation Region: ______Symptom: ______

Secondary Region: ______Symptom: ______

Third Region: ______Symptom: ______

Fourth Region: ______Symptom: ______

Fifth Region: ______Symptom: ______

Date of first adjustment for this course of treatment: ______

(date in box 14 on claim form)

Treatment Plan:

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

Specific treatment goals;

Objective measures to evaluate treatment effectiveness.

(examination findings, Functional Rating Index and Pain Scale)

Doctor’s Signature: ______

PHYSICAL REHABILITATION TREATMENT PLAN

Patient:______Date:______

Diagnosis: ______

Date of original injury:______

Area(s) to be treated:______

Short term Goal(s):

Long term Goal(s):

Subjective: (*before starting) Pain (0-10)______Location______

Resistance tubing: ______

Endurance Machines: ___Stair climber___ Bike ___Lifecycle ___Treadmill

Level:______TimePeriod:______RPM:______HeartRate:______BPM

Upper Back, Shoulders, Chest:

Seated Row - Bar Type: Narrow WideWeight______Reps______Sets_1__2__3__

Lat Pull - Bar Type: Narrow WideWeight______Reps______Sets_1__2__3__

One Arm Row Weight______Reps______Sets_1__2__3__

Butterfly Weight______Reps______Sets_1__2__3__

Bench Press, Machine / Free BarWeight______Reps______Sets_1__2__3__

Seated Back ExtensionWeight______Reps______Sets_1__2__3__

Codman’s ExercisesWeight______Reps______Sets_1__2__3__

Biceps / Triceps:

Arm Curls Weight______Reps______Sets_1__2__3__

Triceps Extension Weight______Reps______Sets_1__2__3__

Bar Dips - GravitronWeight______Reps______Sets_1__2__3__

Pull Ups - GravitonWeight______Reps______Sets_1__2__3__

Shoulder PressWeight______Reps______Sets_1__2__3__

One Arm Shoulder PressWeight______Reps______Sets_1__2__3__

Cervical Region:

Shoulder ShrugsWeight______Reps______Sets_1__2__3__

FlexionWeight______Reps______Sets_1__2__3__

ExtensionWeight______Reps______Sets_1__2__3__

Right Lateral FlexionWeight______Reps______Sets_1__2__3__

Left Lateral FlexionWeight______Reps______Sets_1__2__3__

Gravity Resisted Cervical ExerciseWeight______Reps______Sets_1__2__3__

PHYSICAL REHABILITATION – page 2

Patient: ______Date: ______

Low Back, Abdominals:

Back Extensions, Naut.Weight______Reps______Sets_1__2__3__

Side Bends, DumbbellsWeight______Reps______Sets_1__2__3__

Rotary TorsoWeight______Reps______Sets_1__2__3__

CrunchesWeight______Reps______Sets_1__2__3__

Abdominals, Naut.Weight______Reps______Sets_1__2__3__

Legs AndGlutes:

Leg ExtensionsWeight______Reps______Sets_1__2__3__

Leg CurlsWeight______Reps______Sets_1__2__3__

AdductorsWeight______Reps______Sets_1__2__3__

AbductorsWeight______Reps______Sets_1__2__3__

LungesWeight______Reps______Sets_1__2__3__

Ankle Flex/ExtendWeight______Reps______Sets_1__2__3__

Subjective: (*upon completion) Pain (0-10)______Location______

Compliance:_____Excellent_____Good_____Fair_____Poor

Comments/Notes:______

Next appointment ______Doctor: ______

PMR ORDERS

PATIENT’S NAME: ______TODAY’S DATE: ______

SPECIAL INSTRUCTIONS:

______

PLACEMENT OF PADS/AREA:TYPE OF PMR REQUESTED:

PATIENT’S COMMENTS: ______

ORDERING DOCTOR:______PERFORMED BY:______

DAILY NOTES

PATIENT’S NAME: ______TODAY’S DATE: ______

PATIENT’S COMMENTS/ DEMEANOR/ OBSERVATIONS:

______

PHYSICAL EXAMINATION

Patient / DOB / M / F / Date / Doctor
Pulse: / L / R / Blood pressure / L
/ / R
/ / VBI: / L  / R  / Carotid / Sublcavian Auscultation / L  / R 
Temperature / Respiration / Height / Weight
CHIEF COMPLAINT
Development /  Poor /  Fair /  Good

 Posture ______

 Gait ______

ACTIVE RANGE OF MOTION

Lumbar
Flexion (90)
Extension (30)
Lateral flexion (20)
Rotation (30)
Cervical
Flexion (45)
Extension (55)
Lateral flexion (45)
Rotation (70)
Shoulder
Flexion (180)
Extension (40)
Internal rotation (70)
External rotation (90)
Abduction (180)
Adduction (30)

 TMJ AROM: ______

CRANIAL NERVES:

 I
 II - periph. vision
 III, IV, VI - field. of gaze
 V, VII - corneal reflex
 VIII - watch
 Weber
Rinne /  II - light
 III - accommodation
 V - bite
 VII - facial expression
 IX, X - ahh
 XI - trap, SCM
 XII - tongue
 skin, temp, temp of extremities, moisture. Describe:
 (circle) hamstrings, TFL, piriformis, gluteus maximus, gluteus, medius, SI, gastro-soleus, paraspinals, quadratuslumborum, other
Describe:
 (circle) Parotid, masseters, thyroid, trachea, lymph nodes, SCM, suboccipitals, posterior cervical, trapezius, levator scapula.
Describe:

PALPATION:

______

ABDOMEN / SENSORY / MOTOR
 / observation / - face /  /  / Deltoid C5, C6 (axillary)
 / auscultation /  /  / Light touch /  /  / Biceps C5, C6 (musculocutaneous)
 / percussion /  /  / Sharp / Dull /  /  / BrachioradialisC6, C7, C8 (radial)
 / palpation /  /  / Triceps C6, C7, C8, T1 (radial)
 / strength / - upper extremity /  /  / Wrist extensors C6, C7, C8 (radial)
 / Beevor’s sign /  /  / Light touch /  /  / Wrist flexors C6, C7 (ulnar, median)
 /  / inguinal nodes /  /  / Sharp / Dull /  /  / Finger flexors C7, C8, T1 (ulnar, median)
 /  / ASIS /  /  / Vibration /  /  / Interossei C7, C8, T1 (ulnar)
 /  / Tibialis anterior L4, L5 (deep peroneal)
FEET / - lower extremity /  /  / Extensor hallicus long. L4, L5, S1 (deep peron.)
 /  / dorsal pedal pulse /  /  / Light touch /  /  / Peronius long. L5, S1 (superficial peroneal)
 /  / posterior tibial pulse /  /  / Sharp / Dull
 /  / internal rotation /  /  / Vibration
 /  / external rotation
REFLEXES
 /  / Babinski /  /  / Patellar L2, L3, L4 (femoral) /  /  / Biceps C5, C6 (musculocutaneous)
 /  / Achilles S1, S2 (tibial) /  /  / BrachioradialisC6, C7, C8 (radial)
 /  / Triceps C6, C7, C8, T1 (radial)
/ / Segmental Motion
__ C0 __
__ C1 __
__ C2 __
__ C3 __
__ C4 __
__ C5 __
__ C6 __
__ C7 __
__ __ T1 __ __
__ __ T2 __ __
__ __ T3 __ __
__ __ T4 __ __
__ __ T5 __ __
__ __ T6 __ __
__ __ T7 __ __
__ __ T8 __ __
__ __ T9 __ __
__ __ T10 __ __
__ __ T11 __ __
__ __ T12 __ __
__ L1 __
__ L2 __
__ L3 __
__ L4 __
__ L5 __
__ SI __
coccyx
 /  / heel walk L3, L4, L5 /  /  / SLR active / OTHER TESTS
 /  / toe walk S1 /  / DSLR
 / squat / rise /  /  / SLR passive (Lasegue’s)
 / finger to nose /  /  / Braggard’s
 / arm drop /  /  / Goldthwait’s
 / Adam’s sign /  /  / Patrick Fabere’s
 / Trendelenburg /  /  / Thomas
 / Cervical resistive muscle tests /  /  / Gaenslen’s
 / Cervical compression neutral, max L, R /  /  / Hip circumduction
 / Cervical distraction /  /  / SI distraction
 /  / Shoulder depression /  /  / Active hip abduction
 /  / Adson’s (anterior scalene) / Allis (>, <, =)
 /  / Eden’s (costoclavicular) / leg length (visualized)
 /  / Wright’s (pectoralis minor) /  /  / hip internal rotation
 / Spinous percussion /  /  / hip external rotation
 /  / Kemp’s (standing / seated) /  /  / active hip extension
 / Active cervical flexion (supine) /  /  / Nachlas, Ely’s, Hibb’s
 / Cervical PROM /  /  / Yeoman’s
 / Soto Hall / Brudzinski’s /  /  / SI provocation

First / Last Name ______Date of Exam: ______

Cervical / pulling / pain / Normal
Flexion / 50
Extension / 60
Left Lat. Flex / 45
Right Lat. Flex / 45
Left Rotation / 80
Right Rotation / 80
Lumbar
Flexion / 60
Extension / 25
Left Lat. Flex / 25
Right Lat. flex / 25
Penning / measurement / normal / X ray date:
C2-3 / 12.5 / break in George’s line at…
C3-4 / 18 / loss of normal lordotic curve
C4-5 / 20 / Kyphotic cervical spine
C5-6 / 21.5
C6-7 / 15.5

Re-exam date:

Re-exam Date:

X-ray Report

PATIENT: ______DOB:______

AGE______SEX: M / F EXAM DATE: ______ACCOUNT:______

X-RAY EXAM/Area:CervicalThoracicLumbarSacral / Pelvic Extremity

VIEWS TAKEN:

TECHNIQUE:

CLINICAL HX:

FINDINGS:

Bone Density:Good -- Fair -- Poor

Congenital Anomalies:

Spina Bifida:

Scoliosis:

Kyphosis:

Lordosis:

George’s Line:

Head tilt:

Pelvic tilt:

Spinal Canal Stenosis:

Anterior/Retro/Spondylolisthesis:

Spondylosis:Level______Grade______

Osteoarthrosis:

Segmental Dysfunction - Subluxations/Disc Spaces Abnormalities:

Cervical:

Thoracic:

Lumbar:

Other: (Specify)

Trauma:Recent / Previous

Compression Facture(s): Level(s)______Recent / Previous

PATHOLOGIES:

COMPARISON FILMS: TAKEN ON:

CONCLUSIONS:

RECOMMENDATIONS:

Referral(s):

Doctor’s Name: ______Today’s Date:______

Signature:______

COVER LETTER FOR

DENIAL BASED ON MEDICAL NECESSITY

Date Certified Mail No.______

Insurance Company

Inside Address

RE:

SS#:

Date of Service(s):

TO WHOM IT MAY CONCERN:

NOTIFICATION OF MEDICAL NECESSITY

According to the Explanation of Benefits on the above mentioned claim, payment was denied due to "excessive visits" compared to the usual and customary.

Your company's reimbursement plan, which is based on a systematic "schedule" of averages, is neither justified nor acceptable. Conditions may appear similar due to the limited diagnostic codes available. However, patients are individuals. Age, weight, muscle tone, previous injuries, overall physical health, social and employment activities all affect healing time to any condition.

As this patient's doctor, I make recommendations of treatment based on objective test results, symptomatic exacerbations experienced by the patient and physical findings observed.

While your company's denial does not change the need for care, it does interfere with compliance due to the stress of financial obligation placed solely on the patient. Therefore, I find your actions an obstruction of the doctor/patient relationship and a threat to the patient's health.

Objective and subjective findings are well documented and are in compliance with the standard definition of “Clinical necessity.” Your company has arbitrarily denied benefit payments without regard to this information, (see attached). I recommend that a reconsideration be made on this claim and the need for subsequent care.

Failure to respond within 10 days will result in a formal complaint being filed with the State Insurance Commissioner regarding your company's negligence.

Sincerely,

______

Doctor's Signature

Attached: medical report/narrative

REDUCTION BASED ON "U/C" LETTER

Date Certified Mail No.______

Insurance Company

Inside Address

RE:

SS#:

Dates of Service(s):

TO WHOM IT MAY CONCERN:

NOTICE OF IMPROPER REDUCTIONS

We have received a reduced payment for the above dates of service. Your company has claimed that the fee for my services exceed the "usual and customary."

Our office diligently selected a fee structure for procedures based on a variety of factors: the workers' compensation fee schedule; the average fees being charged in this healthcare community; and a fair and reasonable exchange for the level of service rendered.

Based on these standards, our fees are not only "usual and customary," in some instances, they are below the norm in comparison to my colleagues.

Your company's accusation that my office over-charges is an affront to my professional integrity and creates discord between the doctor/patient relationship I have worked hard to establish.

If your company is rescinding on your commitment to pay benefits as per the patient's policy, I advise that you refrain from discrediting my good standing as a way to methodically reduce your obligations.

I suspect that your company is in violation of unfair claim settlement practices, benefit neglect and harassment. If substantiation of your position is not sent to this office within 15 days from the date of this letter, I will join my patient in filing a joint complaint against your company to the State Board of Insurance.

Your prompt response is required.

______

(Doctor's Signature)

cc: (patient's name)

UR WITHOUT MEDICAL RECORDS

Date Certified Mail No.______

Insurance Company

Inside Address

RE:

SS#:

Date of Service(s):

TO WHOM IT MAY CONCERN:

NOTICE OF VIOLATION

We have received notice of a reduced and/or denied claim for the above captioned patient based on your company's utilization review process.

In accordance with (state's UR law article number) standard review procedures and acceptable evaluation criteria are required. It appears that your company has violated these guidelines and have rendered a decision of denial based solely on the insurance claim filed.

Our office, as provider of record, has never been contacted to furnish clinical information which is vital to the determination of clinical necessity.

Furthermore, when clinical necessity or appropriateness of health care services are questioned, the health care provider should be afforded a reasonable opportunity to discuss the plan of treatment for the patient prior to an adverse determination.