If when evaluating a patient before adjusting, the doctor finds a cervical subluxation but the patient has no compliants in that area, can the doctor adjust it but not bill it?
A.- The doctor can adjust the area if there are no complaints as long as there is documentation and a treatment plan to back up the procedure, e.g., your cervical subluxation findings treated with cervical adjustments. It runs the risk of malpractice to adjust in areas with no diagnosis or plan for treatment. If this area is being treated as wellness or maintenance, then the patient should pay cash for the services rendered. In the treatment plan, the ICD-9 diagnosis of subluxation can be replaced by v70.9 or Unspecified General Medical Examination, which remains an internal code for the office and does not require billing for the service. As a reminder, if you are billing insurance for this, the documentation for the area must contain a direct therapeutic relationship (DTR) between the complaint, exam, diagnosis and treatment plan set up with regards to recommended frequency and level of care and treatment specific to the diagnosis. Documentation must also include objective measures t
