Documentation

Our No. 1 Medicare Documentation Error

By Frank M. Painter|January 18, 2014|Documentation, Medicare|

Our No. 1 Medicare Documentation Error

SOURCE: Dynamic Chiropractic ~ January 15, 2014

By Susan McClelland

We have all heard that chiropractic documentation is being reviewed by multiple Medicare contractors and that we are failing these reviews miserably. So, where are we going wrong? In this and subsequent articles, let’s address the top reasons we are failing review, starting with the No. 1 reason – our treatment plan documentation.

Medicare regulations require that we create a treatment plan when treating Medicare beneficiaries.

This treatment plan must include three elements or it will fail review:

1) recommended level of care
(duration and frequency of visits);

2) specific treatment goals;

3) objective measures to evaluate treatment effectiveness.

To repeat, the treatment plan must include all three of these elements or it will fail review.

Unfortunately, many doctors of chiropractic are not creating treatment plans at all. For those who do, the plans generally include the recommended level of care (e.g., “Two times a week for two weeks followed by once a week for two weeks. To be re-evaluated for further care at that time”). We generally fall short when it comes to the second and third elements.

There are more articles like this @ our:

Medicare Page

(more…)

0

Keep Your Records Clean With SOAP

By Frank M. Painter|November 7, 2013|Documentation|

Keep Your Records Clean With SOAP

The Chiro.Org Blog

SOURCE: ACA News ~ November 2013

By Gina Shaw

If you are asked what a SOAP note is used for, what would be your answer? A SOAP note is used:

1. To defend yourself against a malpractice suit;2. To justify your charges in a third-party payer audit;

3. To track your patients’ progress; or

4. By medical doctors only.

The correct answer? 1, 2 and 3.

There are many systems used by health care professionals to track patients’ progress, but SOAP is probably the most common format for maintaining progress notes. Using SOAP to keep clear, complete, concise, accurate, patient- and encounter- specific records is not just for medical doctors. It’s one of the best ways for the doctor of chiropractic to monitor patients’ progress, as well as to maintain complete records that can be used as a defense in third-party audits or malpractice suits.

Unfortunately, says Susan McClelland of McClelland Consulting, one of the nation’s top experts on chiropractic record keeping, “a lot of providers are not documenting the necessary information, especially for Medicare. Medicare has very specific requirements about what you must have in your notes, and those requirements really don’t differ a lot from what today’s standard of care demands.”

There are more articles like this @:

The new SOAP Notes Page and our

Documentation Section

(more…)

2

Bulletproof Your Documentation

By Frank M. Painter|July 13, 2013|Chiropractic Care, Documentation|

Bulletproof Your Documentation

The Chiro.Org Blog

SOURCE: Chiropractic Economics

By Kathy Mills Chang

Part 1: Ensure your admitting and ongoing paperwork isn’t slipping through the cracks

Because of the many different techniques and philosophies involved in chiropractic, you can be assured different doctors utilize different admitting and ongoing paperwork.

A recent survey of 80 chiropractors revealed that 72 percent of them collected paperwork for their clinic from various sources, creating a patchwork effect. Because very few utilized an actual system of paperwork, they admitted concern that some documentation could fall through the cracks.

So, what paperwork should you have in your office?

History

Most state chiropractic boards that have a standard of care for patients include taking patient history. If one were to follow the evaluation and management documentation guidelines, history is a significant portion of the value.

Because the requirements entail collecting information about the chief complaint; the history of the present illness; a review of systems; and the patient’s past, family, and social history, there is a substantial amount of information that can and should come from the patient.

Having information laid out in a clear fashion on your admitting paperwork allows the patient to answer the majority of the essential initial consultation questions. Using your admitting paperwork as a template allows you to ensure the required bullet points will be answered by the patient and reviewed by the physician.

There are many more articles like this @ our:

Chiropractic Assistant Page

(more…)

0

MEDICARE INFO: Cross-Referencing Regions of Complaint, PART Findings, Diagnoses and CPT Codes

By Frank M. Painter|June 18, 2013|Documentation, ICD-10 Coding, Medicare|

MEDICARE INFO: Cross-Referencing Regions of Complaint, PART Findings, Diagnoses and CPT Codes

The Chiro.Org Blog

SOURCE: Dynamic Chiropractic ~ June 15, 2013

By K. Jeffrey Miller, DC, DABCO

In 2012 the Centers for Medicare and Medicaid Services and CMS-contracted reviewers performed chiropractic Medicare reviews nationwide. The results of their efforts were not good news for the chiropractic profession.

The reviews pointed to poor record-keeping and billing practices throughout the profession. Claims were also made of inappropriate billing of maintenance care resulting in significant overpayments for chiropractic services. [1] Unfortunately, these findings were consistent with previous CMS chiropractic reviews. [2]

Of the current review findings, the one that is most disappointing is our consistency from one CMS review to the next. It is difficult to respond to our many Medicare problems all at once. It can be overwhelming. However, while we cannot fix everything at once, we can fix something.

There are a specific set of closely related problems that can and should be addressed together. In actuality, the problems are so intertwined that they are really a single concern: matching the number of symptomatic spinal / pelvic regions; the number of spinal /pelvic regions with PART and/or X-ray findings of subluxation; the number of diagnoses, the number of regions adjusted; and the CPT code used to bill for the adjustment.

Volumes have already been written about this concern. Here, I offer a set of questions to help guide doctors in documenting the number of patient complaints, subluxations, diagnoses, regions adjusted and the appropriate billing codes. This series of questions is accompanied by comments and tables to clarify the importance of each question.

Questions to Ask Yourself After Examining a Medicare Patient

How many regions of the spine / pelvis did the patient list as painful or symptomatic? Medicare is not purely subluxation based, despite the original and lasting rule that a subluxation must be documented in any region adjusted. The diagnostic criteria also require a symptom code for each region of subluxation. With this in mind, Medicare assumes the patient to have a complaint in each region treated and that the patient reported these complaints during their history. This is a common expectation for many other carriers as well. Carriers do not feel treatment of a region that is asymptomatic is necessary. “Asymptomatic” for Medicare and many other carriers translates to “no problem or no condition.”

There are more articles like this @ our:

Medicare Information Page

(more…)

0

SOAP Notes: A Chiropractic Perspective

By Frank M. Painter|May 25, 2013|Documentation|

SOAP Notes: A Chiropractic Perspective

The Chiro.Org Blog

SOURCE: Dynamic Chiropractic ~ March 1, 2013,

By Ronald Short, DC, MCS-P

S.O.A.P: We all learned it in school and we all do our best to follow it in our daily charting of patient encounters. My good friend Dr. Mario Fucinari expresses it as a formula:

S+O=A yields P.

Your subjective findings plus your objective observations equal your assessment, which leads to your plan. Simple. Easy to understand.

The important thing to remember regarding the SOAP is that it was designed for the practice style of a medical doctor. To illustrate this, let’s assume a scenario. You are working in your garden, clearing under a rose bush, when you are startled by a small snake. You reflexively jerk your arm back and cut your forearm on one of those monstrous thorns that reside at the base of the rose bush. You now are the proud owner of a 4-inch gash on your forearm. You know you should go inside, and clean and bandage it, but you are nearly done and it is getting dark, so you blot it with a towel (that isn’t too dirty) and keep working.

Two days later, your forearm is swollen, red, painful, and hot to the touch. You go to your MD and tell them of your gardening misadventure. This is the subjective portion of the encounter. The doctor then examines your arm, noting the redness and swelling, and how you flinch when they instinctively touch the sorest point on your arm. They order a CBC and note an elevated white count. This is the objective portion of the encounter.

The doctor determines that you have an infection. This is their assessment. They write you a prescription for a course of amoxicillin and tell you to take four pills each day for the next 10 days, and to come back if the arm gets worse or if the pain, swelling, and redness are not gone by the time the pills are gone. This is their plan.

You take the prescription to your pharmacy and purchase 40 units of therapy, which you take home and self-administer. By the time the pills are gone the pain and swelling are nothing more than a bad memory. You are done and the whole episode lasted less than two weeks. This is how a medical doctor practices.

Chiropractors practice similarly, but with a few significant differences. When you jerked away from the snake, you felt a “pop” in your low back and the pain has been getting progressively worse and has started to radiate down your right leg. You go to your chiropractor and tell them of your gardening misadventure, and that the pain is getting worse and radiating down your right leg. This is the subjective portion of the encounter and is essentially the same as it was with the medical doctor.

There are more articles like this @:

The new SOAP Notes Page and our

Documentation Section

(more…)

4

SOAP Notes: Is It Time for a Cleaning?

By Frank M. Painter|May 17, 2013|Documentation|

SOAP Notes: Is It Time for a Cleaning?

The Chiro.Org Blog

SOURCE: Dynamic Chiropractic – May 15, 2013

By James Edwards, DC

I have been planning for some time to write an article about how traditional SOAP notes do not fit chiropractic practice, and the unfairness of holding DCs to a model clearly created for and primarily applicable to medical physicians.

But Dr. Ronald Short beat me to the punch with his outstanding article:
“SOAP: A Chiropractic Perspective” [March 1, 2013 issue], in which he masterfully illustrated the problem. Hopefully, claim reviewers and documentation gurus will finally realize the difference between a chiropractic “assessment” visit and a chiropractic “treatment” visit.

As Dr. Short so ably pointed out, to require orthopedic and neurological testing on each chiropractic visit is the equivalent of requiring a medical doctor to perform blood tests after each antibiotic pill. I could not have said it better myself.

It is important to remember that doctors of chiropractic are unique because we wear two very different hats. First, we are physicians who examine and diagnose (assessment) the patient. Then, after doing so, we carry out our treatment plan by providing care (treatment) to the patient. Failing to realize the distinct difference between a chiropractic “assessment” visit and a chiropractic “treatment” visit places undue, unfair and unnecessary examination and documentation requirements on doctors of chiropractic, and it is time for it to stop.

This problem has been known for years, yet no one has been successful in sensitizing the chiropractic “powers that be” about this unfairness. The American Chiropractic Association’s Clinical Documentation Committee, during the process of authoring the third edition of the ACA Clinical Documentation Manual, attempted to directly address the issue by approving and submitting the following provision:

There are more articles like this @:

The new SOAP Notes Page and our

Documentation Section

It is important to understand that the chiropractic physician has two responsibilities to their patients.

(more…)

4