Paxson Question of the Month (Vol. 7: Exercises and Treatment Plans)

Each month, we feature a real question asked by one of your fellow ICS members through Paxson, our closed-system AI assistant built just for Illinois chiropractic physicians. Paxson provides quick, accurate, and member-directed support on a wide range of topics—from insurance issues and licensure requirements to documentation, compliance to social media posts, and more.

These featured questions offer valuable insights you can use in your own practice—and serve as a reminder that help is just a click away.

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Exercises and Treatment Plans

ICS Member Question:

“Does all exercises need to written out in treatment plan”

Paxson’s Response:

When documenting a treatment plan, it is important to include enough detail so that the plan clearly communicates the services being provided, the goals of care, and how progress will be measured. For therapeutic exercises and activities, the documentation should specify:

• The type of modality or procedure used (e.g., stretching, strengthening, range of motion exercises)
• The anatomical region(s) being treated
• The duration and frequency of the exercises
• Specific exercises or activities to be performed, including repetitions and techniques if relevant

While you do not need to write out every single exercise in exhaustive detail, your treatment plan should provide enough information so that the purpose and structure of the therapy are clear to reviewers, payers, and other healthcare providers. For example, you might document: “Therapeutic exercises for lumbar spine flexibility and strength, including stretching and core stabilization, 2x/week for 4 weeks.”

Each therapy should be linked to a specific, measurable goal (e.g., “increase lumbar range of motion by 20 degrees” or “improve ability to perform ADLs without pain”). At each re-examination, you should assess progress toward these goals and update the plan as needed.

For billing and compliance, especially when using codes like 97110 (therapeutic exercises) or 97530 (therapeutic activities), documentation must show:

• The functional loss being addressed
• The specific exercises or activities performed
• The patient’s progress toward the stated goals

If you use a modifier (such as GP), ensure your records reflect a clear therapy plan and that the exercises are not arbitrarily added.

In summary: You do not need to list every exercise in minute detail, but your treatment plan must be specific enough to justify medical necessity, support billing, and demonstrate a clear link between the therapy provided and the patient’s functional goals.

Would you like a sample template or example language you can use to document exercises in your treatment plans?

ICS Member Follow-up:

“create a sample template”

Paxson’s Response:

Certainly! Below is a sample template for documenting therapeutic exercises in a treatment plan. You can copy and paste this text into your records and customize it for your specific patient and clinical scenario.

—

Therapeutic Exercise Treatment Plan Template

Patient Name: ___________________________ 

Date: ___________________________ 

Diagnosis: ___________________________ 

Treatment Plan Period:

Start Date: ____________  End Date: ____________

Frequency & Duration: 

[ ] times per week for [ ] weeks (e.g., 2x/week for 4 weeks)

Anatomical Region(s) Treated:

(e.g., lumbar spine, right shoulder, cervical region)

Therapeutic Exercises to be Performed:

• [List specific exercises, e.g., lumbar stretching, core stabilization, shoulder abduction with resistance band, etc.]
• [Include repetitions/sets if relevant, e.g., 3 sets of 10 reps]
• [Include any specific techniques or equipment, e.g., Swiss ball, resistance bands]

Goals of Care:

Short-Term Goals: 

• [e.g., Increase lumbar flexion by 20 degrees within 4 weeks] 
• [e.g., Reduce pain with ADLs from 7/10 to 3/10]

Long-Term Goals: 

• [e.g., Restore ability to lift 20 lbs without pain] 
• [e.g., Return to work full duty]

Plan of Care: 

• Therapeutic exercises as listed above, performed under direct supervision
• Progress to be reassessed every [ ] visits or at re-exam
• Adjust exercises and goals based on patient progress and outcomes assessment

Outcomes Assessment Tools: 

• [e.g., Oswestry Disability Index, Neck Disability Index, etc.]

Re-examination Date: 

____________

Provider Signature: ___________________________ 

Date: ___________________________