|
2.3 Documentation Requirements
Manipulations must be provided in accordance with an ongoing, written treatment plan that supports medical necessity of an acute condition or an acute exacerbation of a chronic condition.
Documentation that supports medical necessity for the treatment plan includes all of the following:
• Diagnosis.
•Region(s) treated.
•Degree of severity.
•Impairment characteristics.
•Physical examination findings, X-ray, or other pertinent findings.
•Specific statements of short- and long-term goals.
•A reasonable estimate of when the goals will be reached (estimated duration of treatment).
•Frequency of treatment (number of times per week).
•Equipment and/or the techniques utilized.
The treatment plan must be updated as the client's condition changes. Treatment plans must be maintained in the medical records and are subject to retrospective review.
|
