One of the biggest challenges faced by doctors of chiropractic is how to justify the clinical necessity of your care. Before trying to master the nuances of documentation coding, start with the basics — simple patient recordkeeping guidelines. The basic requirements for any health record are the building blocks for good recordkeeping — and getting reimbursed. Your records should be:
• Legible. Doctors often get a bad reputation for handwriting. If poor penmanship is your particular cross to bear, consider implementing electronic health records, dictation, or voice-recognition software. “They” say if it’s not written down, it doesn’t exist. Likewise, if you can’t read it, what good is it?
• Accurate. An accurate health record is honest, factual, and descriptive. Accuracy involves much more than just recording the services you performed on the correct dates. It includes describing the patient’s condition, diagnosis, and treatment plan.
• Indelible. This means, “Don’t erase.” If you need to make a correction, do not white it out or use correction tape. Simply cross through the wrong information and write the correct information next to it with your initials.
• Comprehensive. List everything you did in the exam and treatment.
For example: When you dispense a pair of orthotics to a patient, your notes should not only reflect the treatment performed on that visit, but also the dispensing of the orthotics, any instructions given to the patient, and documentation of the time spent in the instruction phase. If you want to get paid for the service, the notes must reflect each aspect of the service.
• Written with standard abbreviations. Don’t make up your own abbreviations for treatment, protocols, or procedures. Use standard abbreviations in your notes, which are available in documentation manuals.
HANDLING RECORD REQUESTS
From time to time, you will receive requests for a patient’s records, usually from another healthcare professional. Proper documentation guidelines dictate that any request for records you receive (or, for that matter, you initiate) should include the following information:
• Requester’s name and address;
• Patient’s name, address, date of birth (DOB), and social security number (SSN);
• Your name and address; and
• The patient’s (or patient’s legal guardian’s) signature authorizing the release.
Maintain a three-ring binder with a log sheet so when you actually prepare the records for release, you are able to note the following:
• Signature/authorization date;
• Specific records requested;
• Name/initials of team member filling request;
• Records sent; and
• Date sent with method used (postal, FedEx, fax, or other method).
When you need to request a patient’s records from another healthcare professional, be sure to follow the same protocol as indicated previously.
And, keep a log to document your requests and when they were made.
When you (the doctor) actually receive the patient’s records from the other healthcare professional, it is important for you to record:
• Date of receipt and/or review;
• Name of the provider/entity from whom the records were received;
• ID (name of patient) of records received;
• Receipt and review of the patient health record;
• Signature/initials of the staff member recording the receipt; and
• Format in which the records were received (fax, electronic transfer, mail, or other method).
Upon review of the records received, document:
• ID (name of patient) of the records reviewed;
• Date of your review; and
• Signature/initials attesting to the fact that you reviewed the records.
Remember, once you lay eyes on records received from outside the office, you are now responsible for them. Initial each page and write any pertinent reports that indicate the records have been reviewed.
For example: When you review outside x-rays, write your own report. If it is necessary to discuss any details in the record with the patient, document the date of the discussion and what was discussed during that time.
RULES FOR RECORD RETENTION
Most malpractice insurers advise never to rid of patient records. Be aware that laws regarding record retention vary from state to state and may be different for adults as opposed to minors. Comply with all HIPAA regulations.
Don’t dismiss these simple documentation guidelines and requirements as mundane. They can mean the difference between getting paid or not.
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 and can be reached for service and questions by e-mail at Kathy@kathymillschang.com or through her Web site, www.kathymillschang.com.