by Mario Fucinari •
DC, CPCO, CPPM •
Chiropractors often face the challenge of providing services while also meeting insurance and compliance requirements for medically necessary care. Recent chiropractic audits have revealed a high rate of errors due to missing documentation showing medical necessity. When one fully understands what defines medical necessity and active care, it becomes clear that compliance and medically necessary care are essentially the same.
Recent Comprehensive Error Rate Testing (CERT) findings by Medicare revealed that chiropractic documentation remains a significant source of compliance errors. The review reported a concerning 37 percent error rate, with most errors related to insufficient documentation of medical necessity. While chiropractors consistently work to improve their patients’ quality of life through restoring spinal function and overall health, this gap between clinical intent and documentation compliance presents a serious challenge for the profession.
The issue is not that chiropractors fail to deliver medically necessary care, but rather that the records often fail to demonstrate the necessity to an outside reviewer. In today’s healthcare environment, documentation serves as the primary communication tool between providers, payers, and regulators. Bridging the gap between patient care and compliance is no longer optional; it is essential to the survival and credibility of the chiropractic profession.
The Meaning of Medical Necessity in Chiropractic Care
To understand the compliance challenge, we must first revisit the definition of medical necessity within Medicare’s framework. For chiropractic services, medical necessity is based on the patient’s functional improvement. The expectation is that the patient’s ability to perform activities of daily living (ADLs)—such as walking, bending, lifting, sitting, or working—will improve as a result of care.
In other words, documentation must go beyond pain levels. While pain often brings the patient into the office, improvement in function justifies continued care. A record that focuses solely on pain scores without documenting functional progress fails to meet Medicare’s standard for medical necessity, even if the care itself is entirely appropriate.
Medicare divides chiropractic care into three categories:
- Acute Care – treatment on a short-term basis for a self-limiting condition.
- Chronic care – treatment of a neuromusculoskeletal condition with the expectation of some improvement in function.
- Maintenance care – care rendered to prevent disease and promote health (wellness care) or treatment to prevent deterioration and reoccurrence of a chronic condition (supportive care).
Only acute or chronic care is reimbursable under Medicare, provided functional improvement is expected. Once the functional status has reached maximum improvement, further care is considered maintenance care. This means that each visit must clearly demonstrate either the expectation or the attainment of functional improvement.
Why Chiropractors Struggle with Documentation
In most cases, providers are not intentionally noncompliant; they simply do not speak the same “documentation language” as the reviewers. A clinician may note that “the patient is improving” or “less stiff,” but a reviewer needs objective measures of that improvement. Without measurable data, such as range of motion (in degrees), functional questionnaires, or specific ADL changes, reviewers cannot verify that medical necessity exists.
Furthermore, chiropractors often fail to close the loop in their documentation. They may establish functional goals at the start of care—such as improving the ability to walk for 30 minutes or sit for one hour without pain—but neglect to record whether those goals were ever met. This omission gives the impression that care is continuing without measurable progress, which Medicare interprets as maintenance care.
Why Payers Cut Benefits
Clinical outcomes set expectations. Clinical expectations aim for improvement within two weeks. If the doctor cannot objectively demonstrate functional progress, insurance companies consider the care not medically necessary. Two weeks of treatment usually involves about six treatments. Care is stopped at six treatments. Sound familiar?
When Insurance Benefits are Inadequate
Insurance companies should not interfere with the doctor-patient relationship. However, when patients live paycheck to paycheck, financial worries arise. Offering alternatives to insurance plans, such as a medical discount plan, gives patients hope of reaching their goals (remember the Hallmark Moment) without creating a financial burden. A membership-based discount plan, such as ChiroHealthUSA, is a legal way for patients to receive reduced rates without violating the Anti-Kickback Statute’s prohibition on dual-fee schedules.
Aligning Clinical Goals with Compliance Standards
The solution lies in bridging the gap between clinical practice and documentation compliance—a bridge built from clear goals, measurable outcomes, and consistent updates.
- Start with a functional consultation. The patient should be steered away from a pain model and more into a functional model. Ask the patient, “What is it you would like to do that you cannot because of your pain?” I call this the Halmark Moment. It ties an emotion of joy and fulfillment to function and not pain relief. Work to achieve functional happiness with the patient.
- Document Measurable Functional Goals
Each treatment plan should state what specific function the provider expects to improve. These goals will be established through the patient’s “Halmark Moment” and Outcome Assessment tools, such as the Neck Pain Disability Index and Revised Oswestry.For example:
- “Patient will be able to lift 10 pounds without low back pain.”
- “Patient will increase cervical range of motion by 20 degrees to allow safe driving.”
- “Patient will be able to sit for 45 minutes without leg numbness.”These statements translate clinical findings into measurable objectives that reviewers can recognize as medically necessary.
- Perform Re-evaluations Every 30 days.
By pausing care to re-evaluate the patient’s progress, you not only have an opportunity to compare and document it, but also to establish new goals. Once you reach a goal, what is the next step?
- Discuss the Functional Improvement with the Patient
By performing a meaningful re-report of findings with the patient, you work collaboratively to achieve true wellness, not just pain relief. When a patient says to you, “I’ll call you when I need you,” you have failed to educate them properly on the importance of function.
Integrating Compliance Without Losing the Human Touch
A common fear among chiropractors is that compliance will reduce care to a checklist or “paper exercise.” In reality, strong documentation enhances patient care by providing a structured way to measure progress and communicate outcomes. Patients often appreciate seeing objective evidence of their improvement. It validates both the doctor’s and the patient’s efforts in the treatment process. When providers explain functional goals in patient-centered terms (“Let’s work on getting you back to gardening for an hour without pain”), they not only meet regulatory expectations but also connect with what truly matters to the patient.
The Path Forward
The recent CERT review serves as a wake-up call, not a condemnation. A 37 percent error rate means that more than one in three chiropractic claims fail to show medical necessity—not because the care was inappropriate, but because the documentation didn’t tell the full story. By focusing on functional improvement, clear goals, and objective outcomes, chiropractors can bridge the gap between compliance and care.
Bridging this gap isn’t just about passing audits—it’s about raising the standard of chiropractic care and ensuring our commitment to enhancing our patients’ function and quality of life is clearly reflected in every note we write.
Dr. Mario Fucinari is a Certified Professional Compliance Officer, Certified Physician Practice Manager, Certified Insurance Consultant, and a Medicare Carrier Advisory Committee member. As a ChiroHealthUSA Speaker’s Bureau member, Dr. Fucinari travels throughout the year, speaking to audiences nationwide and sharing his chiropractic expertise and insights on best practices in documentation, compliance, billing, and coding. To have Dr. Fucinari speak at your conventions or webinars, contact him at doc@askmario.com or call ChiroHealthUSA for availability.
