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September 2009
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Practical Documentation: Is your routine visit documentation D-A-I-L-Y?
Part six: The fortune wheel of documentation
By Kathy Mills Chang
You took a patient history, collected a list of your patient’s functional deficits, performed an examination, provided a diagnosis, and learned the art of treatment planning.
By spending this extra time at the front end of each case, you provided the roadmap of necessity for your treatment plan. Once complete, you must continue the roadmap throughout your patient’s routine follow-up visits.
For the purpose of documentation standards, you should follow Medicare guidelines because they have laid out the minimum documentation requirement to justify medical necessity for a given visit. Because of this, it’s unlikely you will find a more stringent standard anywhere else.
And since a large majority of you will see Medicare patients, it makes the most sense to document everyone to this standard. If you have done a good job of laying the foundation in the initial case management workup, the daily visit documentation should be easy.
Expectations and guidelines
Most every Medicare carrier provides a document known as the Local Coverage Document (LCD) which lays out its expectations and guidelines for performing and billing chiropractic services for beneficiaries.
Within this document, you’ll find the following guideline for daily visit documentation.
The following documentation requirements apply whether the subluxation is demonstrated by x-ray or physical examination:
History:
• Review of chief complaint.
• Changes since last visit.
• System review if relevant.
Physical exam:
• Exam of area of spine involved in diagnosis.
• Assessment of change in patient condition since last visit.
• Evaluation of treatment effectiveness.
Documentation of treatment given on day of visit: Failure to document the medical necessity of the chiropractor’s manual spinal manipulation(s) may result in denial of claim(s).
Describing D-A-I-L-Y
In order to decipher what is meant by this, use the acronym D-A-I-L-Y.
D: Do the PART process. Medicare documentation requires that in order for chiropractic manipulation to be a covered service, you must provide documentation that a subluxation exists.
In 1999, the rules were changed so that an x-ray was no longer required to show proof of subluxation. Instead, an examination procedure documented as PART would suffice. This is how it is described in the carrier manual:
In lieu of an x-ray, a subluxation may be demonstrated by physical examination meeting the requirements listed below:
a. Pain/tenderness evaluated in terms of location, quality, and intensity;
b. Asymmetry/misalignment identified on a sectional or segmental level;
c. Range of motion abnormality (changes in active, passive, and accessory joint movements resulting in an increase or a decrease of sectional or segmental mobility); and
d. Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament.
To demonstrate a subluxation based on physical examination, two of the four criteria mentioned under “physical examination” are required, one of which must be asymmetry/misalignment or range of motion abnormality.
This process is a standard of documentation,
You’ll notice, when you have a request for records, there is almost always a request along with it for the most recent PART exam.
A: Assess functional deficits. By creating a baseline in the beginning, you can continue to measure these deficits on daily visits.
Since the requirement is to have objective measures to evaluate treatment effectiveness, this lets you check on this during routine visits and record the return to function in the areas of deficit.
For example: If the patient reported difficulty sleeping as an initial deficit, it’s reasonable to assess this on a routine visit basis.
If your stated goal was to have the patient “sleep through the night without being awakened by pain,” you can assess how long they are now sleeping.
Likewise, this addresses the guideline for “changes since the last visit.” It’s important to also review the chief complaint and focus on any changes there as well.
Always position your daily note as it refers to the chief complaint and the deficits so that it moves you toward your treatment plan goals.
I: Include objective findings. The requirement indicates you must do an exam of the area noted in the diagnosis. If you perform at least one objective test or record a finding in the area(s) you are treating, this is quite simple to do.
This can include range of motion, orthopedic tests, or the Quadruple Visual Analog scale, which will objectify your pain findings.
It’s important to do at least one of these tests each routine visit, so you can measure progress. Since it also requires that you assess the change since the last visit, using these objective tests as well as recording the functional deficits, allows you to track the progress you’re making with the patient.
While you don’t need a full examination every time, doing some objective findings on a regular basis will help you show the necessity of the visit and meet the stated requirement.
L: List what you did. One of the easiest requirements to miss is the list of everything you did in the visit. If you performed chiropractic manipulative treatment to T6, then you must list that.
In Medicare, that is a specific requirement. It is also just great documentation because it justifies the level of CMT code you selected.
Additionally, if you’ve performed modalities and/or procedures in the visit, list those.
Be sure that any ancillary staff that performed services initials, and the supervising doctor authenticates with their own initials or signature.
If you’ve laid out a very clear treatment plan in the beginning of the case, you may be able to list the specific adjustment, and then note that you followed the treatment plan for everything else.
But remember, if that date of service is requested, be sure to include all the admitting paperwork at the beginning of the case, such as the diagnosis, treatment plan, etc. to support that daily visit.
Y: You did it. Following these requirements for Medicare are not hard or labor intensive. They are detailed, complete, and explanatory.
Your job is to make them encounter specific so that each can stand alone, along with the admitting paperwork for the case.
Once you complete these things and get the hang of telling your story on a routine, daily basis, you’ll find your documentation for DAILY visits is just stellar!
Kathy Mills Chang is the founder of her own consulting firm, assisting doctors with finding financial and reimbursement ease in practice. She also serves as Foot Levelers’ insurance advisor. She can be reached at Kathy@kathymillschang.com or through www.kathymillschang.com.
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