General Information
Documentation Requirements
Medical Documentation Guidelines
To comply with medical documentation requirements outlined in HFS 106.02(9)(a), Wis. Admin. Code, providers are required to include documentation at the time of the initial and subsequent office visits.
Initial Office Visits
Providers are required to include the following information in the documentation regarding the initial office visit at the time of the initial office visit, per HFS 106.02(9), Wis. Admin. Code:
- Date of service.
- Recipient’s full name, date of birth, Medicaid identification number, and current address.
- Examining/treating provider’s name.
- Name and address of the clinic or office where the service is provided.
- Accurate, complete, and legible description of the chief complaint, such
as:
- History and onset of the trauma or illness.
- Previous episodes of complaint.
- Palliative and provocative factors.
- Quality, radiation, frequency, and severity of pain.
- Clinical findings, such as:
- Palpation.
- Provocative orthopedic and neurologic tests.
- Range of motion.
- Reflexes.
- Vital signs.
- Diagnosis or medical/chiropractic impression.
- Plan of care (POC), which must include:
- Estimated number of manipulations required to treat the subluxation over the anticipated period of time.
- Home exercises and/or modification of daily activity, if applicable.
- Short- and long-term goals.
- Treatment and other therapies, if applicable.
- Studies ordered and report of findings, such as laboratory or X-ray studies. (Refer to the X-Rays section of this chapter.)
- Examining/treating chiropractor’s signature and date signed.
Subsequent Visits
Wisconsin Medicaid requires that providers document all office visits, including those subsequent to the initial visit. Providers are required to include the following information in the documentation at the time of the subsequent office visit(s):
- Examining/Treating provider’s full legal name.
- Name and address of the clinic or office where the service is provided.
- Recipient’s full name and address, if the address has changed.
- Date of service.
- Relevant entries of change(s) compared to the previous DOS, such as:
- Patient’s chief complaint.
- Objective findings.
- Diagnostic impression/assessment.
- Plan of care, including treatment schedule for the current DOS in relation to the initial DOS (e.g., "2nd treatment of 6 treatments anticipated" or "2 of 6 Tx").
- Changes to the POC.
- Examining/Treating provider’s signature and date signed.
X-Rays
Providers are required to include the following information in the documentation on all laboratory and X-ray study orders:
- Examining/Treating provider’s full legal name.
- Name and address of the clinic or office where the service is provided.
- Recipient’s full name, date of birth, Medicaid identification number, and current address.
- Date of laboratory or X-ray study.
- Reason for the study.
- Complete report of the findings.
- Provider’s signature and date signed.
Spinal Supports
The spinal support documentation must include the following:
- Reason for prescribing the spinal support.
- Type of support including a description, the manufacturer, and brand name.
- Copy of the instructions given to the recipient.
- Recipient’s dated signature indicating specifically which support was received.
- Follow-up documentation at two to three weeks or the next visit thereafter which includes recipient compliance and evaluation of equipment effectiveness.
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Chiropractic Services Handbook
PHC 1306, October 2004