Medicare Chiropractic Subsequent Visit Note (CMT)

Patient Information

Patient Name: [Patient full name]

DOB: [Date of birth]

Date of Service: [Date]

Rendering Provider: [Provider name, credentials]

Visit Type: Medicare Chiropractic Subsequent Visit (CMT)

Episode Info: [Initial treatment or exacerbation date] | [Visit X of Y] | [Date of last re-evaluation if applicable] (If any element is unknown, insert "[RECONCILE BEFORE CLAIM SUBMISSION]")

Medical Necessity

[Encounter-specific medical necessity statement] (1–3 sentences confirming: (1) patient has an active neuromusculoskeletal condition requiring treatment, (2) today's CMT directly treats that condition, and (3) reasonable expectation of continued functional improvement exists. If maintenance/supportive care with no expectation of improvement, explicitly state that and note non-covered status.)

Subjective

[Interval history since last visit] (Brief paragraph including: chief complaint/reason for today's visit; pain status with location, intensity, and character; functional changes with specific ADL tolerances; response to last treatment with duration of relief [better / same / worse]; new events or flares with dates. If no changes, state "no interval change." If history not obtainable, document "not obtained" with reason.)

Objective

(Focused exam of involved spinal region(s). Note whether findings are improved, unchanged, or worsened compared to prior visit.)

• P (Pain/Tenderness): [Location(s)] | [Severity] | [Palpatory findings] | [improved / unchanged / worsened]
• A (Asymmetry/Misalignment): [Postural/segmental findings] | [Level(s)] | [improved / unchanged / worsened]
• R (Range of Motion): [Region] | [Direction(s)] | [Degrees or % limitation] | [improved / unchanged / worsened]
• T (Tissue Tone/Texture): [Hypertonicity/spasm/edema] | [Location/side] | [improved / unchanged / worsened]
• Neurologic/Orthopedic: [neuro screen unchanged / indicated tests and results] (Include only if clinically indicated)
• Treatment Effectiveness Measure: [Objective change captured today]

Assessment

Diagnosis: [Primary subluxation/segmental dysfunction with specific spinal level(s)]; [Secondary neuromusculoskeletal diagnosis describing symptomatic condition]

Progress: [improved / unchanged / worse] — [1–2 supporting facts tied to objective findings or ADL tolerances; reference functional goals or outcome scores if used]

Care Status: [Active/corrective / Transition phase / Maintenance] (Active/corrective: improvement expected and supported by progress trend. Transition: nearing goals with tapering frequency. Maintenance: stable with no expectation of further improvement—non-covered.)

Plan

• Treatment Today (CMT): [Technique] | [Positioning] | [Specific regions/levels adjusted] | [Patient tolerance]
• Immediate Response: [Post-treatment change]
• Follow-up: [Next visit timing] | [Re-evaluation due date] | [Discharge criteria] (Include plan modifications or home program updates if applicable)

Provider Signature / Date / Credentials: [Signature block]