Medicare Chiropractic Documentation & Billing Checklist
Ensure all required documentation and billing steps are completed for Medicare chiropractic services.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Provider Name
*
First Name
Last Name
Date of Service
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Diagnosis (ICD-10 Code)
*
Treatment Provided
*
Please Select
Spinal Manipulation
Therapeutic Exercise
Manual Therapy
Other
Objective Findings Documented?
*
Yes
No
Treatment Plan Includes:
*
Diagnosis
Goals
Type/Duration of Therapy
Frequency of Visits
Other
Progress Notes Completed for This Visit?
*
Yes
No
Billing Checklist
*
Rows
Completed
N/A
Medicare ABN issued (if applicable)
1
2
Proper CPT code selected
3
4
Documentation supports medical necessity
5
6
Modifiers applied correctly
7
8
Patient eligibility verified
9
10
Additional Notes (optional)
Provider Signature
*
Submit Checklist
Submit Checklist
Should be Empty: