For documentation required by third-party payers, which two diagnoses must be documented?

• A. Subluxation and fracture
• B. Subluxation and the condition that the subluxation is referring to
• C. Subluxation and sprain
• D. Subluxation and chronic pain

Answer: (B)

When third-party payers require documentation, you must show the subluxation diagnosis along with the underlying condition it refers to. This pairing demonstrates the clinical reason for the subluxation and ties the chiropractor’s findings to a real diagnosed issue, which supports medical necessity and accurate coding. So, the correct approach is to document both the subluxation and the condition that the subluxation is referring to. Pairing the subluxation with an unrelated finding (like a fracture, sprain, or chronic pain) fails to establish that essential link between the subluxation and a specific, identifiable condition.