The Texas Board of Chiropractic Examiners has just adopted a new rule laying out specific criteria for all doctors of chiropractic with regard to how they must conduct examinations, make diagnoses and treatment plans and document their services. You can read the text of newly adopted Board Rule 80.5 by going to the TBCE’s web site.
The new rule has incorporated documentation guidelines that have previously been established by the American Chiropractic Association’s Clinical Documentation Manual, the American Medical Association’s CPT Code Book, the 1997 Documentation Guidelines for Evaluation and Management Services and the Chiropractic Service Manual Guidelines set forth by CMS.
Under the TBCE’s new rule all patient records for an initial visit must include: patient history, description of symptomatology or wellness care, exam findings, including imaging and lab records when clinically indicated, diagnosis, prognosis, assessment(s), treatment plan, treatment provided or recommended and, periodic reassessment(s) when appropriate (minimum of once per CY). Each patient’s visit following the initial visit will be considered a “subsequent visit” unless there is a new illness or injury. The following information must be reported in each patient’s file on each subsequent visit: (1) an updated history including a review of chief complaint(s) and changes, if any, since last visit, (2) a physical examination including examination of the area(s) involved in the diagnosis and an assessment of any change in the patient’s condition since the last visit, and (3) the treatment provided – including (1) documentation of treatment provided, (2) documentation of patient’s response to the treatment on the date of service, and (3) change(s) in the treatment plan or planned referrals, if indicated.
Texas doctors should immediately take care to implement changes to your practice protocols if they vary, at all, from the requirements of the board’s new rule, as summarized above. It is anticipated that the board will begin reviewing doctor’s documentation in all enforcement cases pending before the board. Failure to implement and adhere to these expanded documentation protocols can result in adverse sanctions against a doctor’s license. Not being aware of the new rule’s requirements will not be a valid defense.