Q/A: I’m Being Audited? Is There a Documentation Template I can use?
Question: Our Medicare contractor is auditing claims with 98942. Do you have any suggestions for a template for documentation to warrant the use of 98942?
Answer: When you submit a claim with code 98942 you are stating that you have determined that it was medically necessary to adjust all 5 of the spinal regions. Therefore, your documentation MUST reflect that fact. This means that your documentation must include the fact that the patient had complaints in all five regions. Historically code 98942 is frequently targeted by auditors because many providers adjust full spine without having documentation which supports and establishes the medical necessity for all five regions. Essentially, you must have documentation which addresses each area with a patient complaint, relevant objective findings, a clear plan for resolution, and demonstrable progress.
It is always a good idea to conduct your own internal audit on a regular basis. Appendix D of the 2019 ChiroCode DeskBook includes information on how to do this annual task.