Point-Counterpoint: The best chiropractic documentation tips

What are some of the “musts” of documentation and “shortcuts” to avoid when it comes to chiropractic documentation tips?

Doctors of chiropractic share their chiropractic documentation tips, tricks and warnings for maintaining compliancy.

Ditch the paper and pen

If you’re still using paper, how many times have you experienced a fire drill because of a missing file? These types of occurrences can be eliminated with an EHR system. And if you choose a web-based platform, you can access what you need in the office, at home, or on the go. Insurance providers are increasingly requiring the use of EHR technology for maximum reimbursement. This is no longer specific to Medicare and Medicaid.

— D. Rottinghaus, DC

Medical necessity is key

It is interesting when we ask doctors how their documentation of patient notes are — we hear “It’s fine,” “I’m on top of it,” or “I am 100% compliant.” Perhaps, a more appropriate question should be, how healthy are your notes and do they demonstrate medical necessity? Many times as human beings we do the same things over and over, day after day; we can develop a tendency to start taking shortcuts and not even realize it. When taking shortcuts, the attention to detail in documentation is lost, critical and necessary elements of treatment notes are left out … the documentation must show a direct correlation between presenting complaints and treatment delivered. Documentation must include any testing or exams utilized to demonstrate medical necessity, the area of the spine adjusted, the technique used for each area of adjustment, and finally how the patient tolerated the treatment … For the health of your practice, it is important to have your documentation and claims screened to ensure your documentation is healthy as well, and is able to stand the scrutiny of an audit or investigation.

— D. Barton, DC, MCS-P, CIC

Chiropractic documentation tips: Don’t inadvertently wave red flags

Doctors know the treatment they give an individual patient and therefore feel justified in how they code the service — but if documentation doesn’t support the code, there is a problem. Remember, as far as a third-party payer (or auditor) is concerned, if it isn’t in writing, it didn’t happen. If, for example, you bill a chiropractic manipulative treatment (CMT) code for a certain level of service, but the documentation only justifies a lower number of regions treated, you’ve just waved another red flag.

Most documentation software programs start with the notes from the last visit, so you can modify from there. The mistake here is when you get rushed or lax and are tempted to minimally modify and move on. Resist the impulse, and make sure each visit and its documentation is “encounter-specific.”

— K. Weidner, MCS-P, CCPC, CCCA

Be thorough in description of present illness

The mechanism of trauma must be documented appropriately. Many DCs are using insidious onset too frequently without properly demonstrating due diligence in their efforts to rule out other mechanisms. This has caused reviewers to question as to how a patient can have a “significant neuromusculoskeletal condition” if the patient cannot remember how it occurred.

Unfortunately, many people do not correlate activities of daily living to the mechanism of pain. That’s why it is important to be a good historian as clinicians. Ask your patients to think about things that they may have lifted, places they have ridden to, a time when they may have slipped, or any other activities of daily living that may have caused their pain. If they absolutely cannot recall anything then instead of writing “insidious onset,” write down your questioning.

For example, you may document this by explaining the mechanism of trauma: “The patient cannot correlate his pain to any specific incident. The patient stated his pain was not due to lifting, riding, slipping or any other activity, therefore it is considered insidious in nature.”

— T. Wakefield, DC, DACBSP, CSCS, CCST

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