Avoiding documentation distress

Your paperwork affects your patients in addition to your practice.

“Documentation” covers a wide swath of day-to-day business within a chiropractic office. Patient visits are documented at sign-in. Patient consultation notes, treatment plans, X-ray results, and requests for medical histories are also documented. But more often, when documentation is referenced, it is to describe the Centers for Medicare and Medicaid Services (CMS) documentation requirements.¹

Short of choosing to deny patients covered under the program, DCs do not have the choice to opt out of Medicare or Medicaid. The number of Medicare claims submitted per practice varies wildly. However, there is no doubt that choosing not to treat patients covered by Medicare would mean a substantial lost of income.²

Keeping accurate, up-to-date documentation is the best way to avoid problems if you are investigated or audited by the Office of the Inspector General. Using a certified electronic health records (EHR) system can help—as long as it is being implemented properly.

Use a common sense approach

The American Chiropractic Association offers useful guidelines for documentation. Their advice is down-to-earth: “What may be appropriate documentation for one visit may not be adequate in another when other factors are taken into consideration such as frequency, duration of condition, severity of condition, past history, other documentation, etc.”³

Record keeping for improved patient outcomes

Many DCs find CMS regulations and guidelines burdensome, but it’s important to remember that documentation can be an integral part of providing care for patients, as well as part of the process of getting paid.

Tom Necela, a chiropractic consultant and blogger, examined the notes from auditors doing Comprehensive Error Rate Testing (CERT) reviews. One problem the auditor noted was that services were billed as active treatment for seven months, but no initial or subsequent treatment plans were included in the documentation. The author noted, “It’s hard to establish that the patient is progressing when there is no roadmap to follow.”⁴

Form the documentation habit

Establish habits of keeping careful notes and documenting patient visits, treatment plans, treatments provided, and other details of each patient. This is the best way ensure bills are paid on time, that your practice is protected in the case of an audit, and patients benefit from a reliable history of their progress and care.

Additional Resources

References
¹ Medicare Learning Network. Chiropractic Services. Centers for Medicare & Medicaid Services. http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Chiropractic_Services_Booklet_ICN906143.pdf. Published October 2013. Accessed July 2015.
² Whedon J, Song Y. Geographic variations in availability and use of chiropractic under Medicare J Manipulative Physiol Ther. 2012; 35(2): 101–109. Available from NCBI. Accessed July 2015.
³ American Chiropractic Association. Medicare Documentation. https://www.acatoday.org/content_css.cfm?CID=1217. Published February 2002. Accessed July 2015.
⁴ Necela T. “7 Medicare Documentation Errors From Recent Chiropractic Audits”. Strategic DC. http://www.strategicdc.com/7-medicare-documentation-errors-from-recent-chiropractic-audits/. Published March 2012. Accessed July 2015.