Continuing Education 

Chiropractic Documentation

Dr. Scott Munsterman teaches this four-hour course on coding and documentation for the chiropractor. He reviews documentation essentials, as well as explain upcoming changes to keep chiropractors in compliance. Topics in this course include coding and documentation of patient history, diagnosis, treatment, informed consent, evaluation and management, and subsequent visits. Finally, Dr. Munsterman will examine select case studies to demonstrate concepts.



Module 1 Outline
  • Standard of Care
  • Defining an episode of care
  • Active treatment v. maintenance
  • Acute and chronic subluxation definitions
  • QUIZ



Module 2 Outline
  • Initial visit documentation
  • History of present illness
  • Review of systems
  • Past family, medical, social history
  • QUIZ



Module 3 Outline
  • Mechanism of Trauma
  • Insidious Onset
  • Time lapse of treatment
  • QUIZ



Module 4 Outline
  • Physical exam components
  • Red and yellow flags
  • Subluxation demonstration by x-ray or P.A.R.T.
  • Prognosis and risk factors
  • QUIZ



Module 5 Outline
  • Importance of accurate and specific diagnosis
  • Establishing medical necessity
  • Selectin ICD-10 CM codes
  • Coding hierarchy
  • QUIZ



Module 6 Outline
  • Treatment plans
  • Using specific measurable goals
  • Progress evaluations
  • QUIZ



Module 7 Outline
  • Additional considerations for treatment plan
  • Barriers to care
  • Aggravation/exacerbation
  • Chronic pain management
  • QUIZ



Module 8 Outline
  • Informed consent components
  • Reasonable patient, physician, & chiropractor standard
  • Case studies: informed consent
  • QUIZ



Module 9 Outline
  • Informed consent process & when to review
  • New treatment/diagnosis
  • Procedures and timing
  • Informed refusal and documentation
  • QUIZ



Module 10 Outline
  • Evaluation and management coding
  • Definitions: new and established patients
  • History of E/M codes: 7 components
  • Proposed changes & updates 
  • QUIZ



Module 11 Outline
  • Deletion of 99201 and why
  • Definitions of terms in E/M codes
  • Problem/CC definition
  • Diagnostic procedures
  • Management options
  • QUIZ



Module 12 Outline
  • Medical Decision Making (MDM)
  • Overview of Risk table for MDM
  • Components & Levels of MDM
  • QUIZ



Module 13 Outline
  • Levels of Complexity for MDM
  • Levels of complexity of data
  • Risk levels of management
  • Codes associated with levels
  • QUIZ



Module 14 Outline
  • Changes: Using time for selection of E/M codes
  • Total time definition, documentation requirements
  • Timetable with associated E/M codes
  • Impact of coding changes on revenue
  • QUIZ



Module 15 Outline
  • Medicare documentation for subsequent visits
  • Cloning of notes discussion
  • Signature requirements
  • Scribe documentation requirements
  • QUIZ



Module 15 Outline
  • Initial visit case study 
  • Initial visit documentation errors in case study
  • Subsequent visit case study
  • Subsequent visit errors in case study
  • QUIZ




Scott Munsterman, D.C.

CE Hours



  • Each module contains a video presentation and a short quiz.  You must view the video prior to taking the quiz. 
  • FOR HELP: If you have technical issues, please contact the Continuing Education Department at 1-800-452-5032 or email at 
  • DISCLAIMER: While Palmer College of Chiropractic endeavors to bring diverse topics and viewpoints for continuing education options for Doctors of Chiropractic, the opinions of presenters do not necessarily represent the views of Palmer College.