Compliance is a big part of your practice, and ever-increasingly important to keeping your patient retention and care reimbursement on track.
If you want to boost your practice, strengthening your compliance in this area can help tremendously. Claims continue to be a weak area for many chiropractic clinics. In fact, many chiropractors ignore claims issues at their own peril. Establishing medical necessity in your patient charts for every treatment and session can help you receive better reimbursements from Medicare and other payers. It can also help if you ever experience audits.
In this article, you will find tips and ideas for better claims and reimbursement. Implementing some basic changes to how you document patient visits may help tremendously–keep reading to learn how.
The right record components
If a patient shows improvement, write it down! Subjective, objective and treatment should be added to your patient’s record if you do make these determinations during the visit. Add these components to your documentation and you may satisfy more compliance elements that way. If anyone looks for this information later (or if you are audited), you will have everything right where it needs to be.
Be sure you code correctly. The American Chiropractic Association recommends that you record every diagnosis accurately in the patient chart and correspond each treatment, procedure and diagnosis with the right code.
Avoid just using the same code for every procedure, visit or patient encounter unless it is appropriate and validated. Choosing the wrong code can delay your claim or lead to rejection altogether.
Record treatment plans
Patient treatment plans should be recorded carefully. For new patients, you could record the treatment plan along with a history and physical. Unless your patient is being treated for a chronic condition, try to keep the treatment plan within a 45 day window.
Use standard terminology
Use standard chiropractic language whenever possible. Know what others in your profession use to refer to specific procedures, diagnoses, treatments and concerns. If you do find a situation where a non-standard abbreviation is necessary, be sure to define everything carefully.
Common-sense record keeping
Follow common sense practices and you may avoid compliance headaches altogether. Of course, you should strive to comply with all local and federal regulations, HIPAA, and other rules. Write and record information legibly so you don’t have to worry about whether or not anyone else can read it later.
Initial every chart so there’s no ambiguity about who worked with a particular chart during a specific patient encounter. Protect confidentiality and have patients release records appropriately.
Keep measurements objective
Objective measurements allow your records, documentation and claims to stay accurate and relevant. You can keep patient care consistent from patient-to-patient and between each encounter. This allows patients to receive a standard of care that is dependable and meets the expectations of payers, as well.
If, for instance, you can report objective progress, then reimbursements may become more straightforward as payers see the benefit and medical necessity of the care your patients are receiving.
Objective measurements can be more easily compared between different clinics, may be easier to use with MACRA and MIPS requirements, and allow you to track your own metrics. If you share records with other clinics, having objective measurements can make it easier for others to use and add to these records. Essentially, objective measurements are often particularly useful for your practice.
Accurate documentation can also help advance chiropractic as a profession, too. As more people learn about the results your patients see every day in your clinic, it may become easier for more people to benefit from chiropractic care in the future. Having clear documentation and presentable evidence of the benefits has value that extends beyond your clinic.