While chiropractors may have been busy having some summer fun, CMS announced that there was a revision in the Medicare Chiropractic Documentation guidelines.

The guidelines were released on June 18, 2018 and this change effects every Medicare carrier in the country.  So if you are a chiropractor who treats Medicare patients – regardless of whether you are PAR or NON-PAR – this is a document you need to review.

Why the Change?

Medicare notes that the reason for the change is in response to two-years worth of comments from the chiropractic community and requests for more educational materials on the for chiropractors.

What Medicare Chiropractic Documentation Guidelines Reveal

If you have never seen the Medlearn SE16101 document, this is perhaps Medicare’s most basic guide on how to document your chiropractic services, so it’s not one to miss! (click link above to download the entire document)

In this 8-page document, CMS reveals the Medicare Chiropractic Documentation Guidelines for the Initial Visit and Subsequent visits in a simple and easy to read format.

You should note, however, that this document is not 100% comprehensive in it does refer to other documents such as the Medicare Policy Manual for Chiropractors, the guide to billing active treatment vs maintenance and additional MedLearn publications instructing chiropractors on the proper use of the –AT modifier.  But…these Medicare Chiropractic Documentation Guidelines are probably one of the best resources you can get in a single document.

What Changed in the Medicare Chiropractic Documentation Guidelines?

The really good news in respect to this update is that there was only one significant change in the guidelines!

The change was in reference to your chiropractic treatment plans and the word “always” was removed from the following sentence:


  1. Treatment Plan: The treatment plan should always include the following:
  • Recommended level of care (duration and frequency of visits);
  • Specific treatment goals; and
  • Objective measures to evaluate treatment effectiveness.
  • Date of the initial treatment.


So, the new version omits the “always” which obviously notes that the four bullet items in the Treatment Plan do not necessarily need to be present on every treatment plan.

What else? That’s a great question – but nothing else was changed!

The main reason that I wanted to bring this to your attention was that this is an extremely helpful document that too few chiropractors ever use to improve their chiropractic documentation.  And since a change was recently made, this gives you a great opportunity to make this year the year that you actually make the effort to improve your notes to adhere to the Medicare Chiropractic Documentation Guidelines!


Obviously, the change in the “always” is the easy part.  Now you need to get to work on the rest of your documentation so that you can be compliant, prevent audits and get the treatment that your patients need to be paid for!

With the ongoing audits that Medicare is conducting all over the country, chiropractors are still a target because of our poor documentation patterns.  Don’t be a victim and instead, make the determination that you will improve your notes to protect yourself and your practice.

When you know what Medicare is looking for, it is not an impossible feat!


If you would benefit from some “hands-on” assistance, creating simple, efficient and compliant Medicare documentation is just SOME of what I will be teaching in my upcoming Smarter Chiropractic Seminars – where you will learn how to quickly create a great Medicare note, use our Easy E/M Template™ to document & code your Exams (For Medicare, Private Payers & PI) and much much more.

Register today to join us for the Smarter Chiropractic Seminar where we will be teaching Best Practices for Profitable & Compliant Chiropractic, Massage & Rehab Billing, Coding, Documentation & Business Strategies So You Can Work SMARTER in 2018, Not Harder!