Documentation Standards Flashcards
7 cards from real CBP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation Standards flashcards as text
For Medicare chiropractic claims, which documentation can establish the presence of subluxation?
Answer: An x-ray or a physical exam showing at least two PART findings, one being asymmetry/misalignment or ROM abnormality
Medicare accepts x-ray or exam with two of four PART elements, one of which must be A or R.
Which modifier indicates active/corrective treatment on Medicare chiropractic manipulation claims?
Answer: AT
The AT modifier marks active treatment; maintenance care billed without it is not covered.
What does a CBP treatment plan need to state so it is defensible to payers?
Answer: Specific measurable goals, frequency, duration, and planned re-examination dates
Measurable goals with defined frequency, duration, and re-evaluation show medical necessity.
How should a chart correction be made in a paper record?
Answer: Draw a single line through the error, keep it legible, and initial and date the change
Corrections must leave the original visible and show who changed it and when.
Under HIPAA, which is generally allowed without the patient's written authorization?
Answer: Sharing PHI with another provider for treatment
HIPAA allows PHI disclosure for treatment, payment, and operations without separate authorization.
Why should CBP documentation record the patient's lateral cervical ARA alongside anterior head translation (AHT)?
Answer: Both describe sagittal alignment and guide mirror-image extension traction setup
Lordosis angle and head translation together describe the sagittal deformity and direct corrective setup.
How long should adult chiropractic records generally be kept in the US?
Answer: As set by state law, often 5–10 years after the last visit
Retention periods depend on state law and payer rules, and are commonly several years past the last visit.