Maintain documentation basics

By Kathy Mills Chang

One of the most important words in practice management is documentation.

 

If you do any personal-injury or workers’ compensation work or submit claims for reimbursement from insurance providers, you must have proper documentation.

 

Yet, consultants who do audits agree that results of documentation audits are often less than stellar.

 

To get on track, review the purpose of documentation and why it’s necessary. Documentation is required to:

• Demonstrate medical necessity;

 

• Create a record of a patient’s ongoing treatment;

 

• Provide a vehicle by which to communicate with other healthcare providers;

 

• Record facts, findings, and observations about a patient’s health history (past and present), examinations, diagnostic tests, treatments, and outcomes; and

 

• Provide a chronological recording of a patient’s care.

Proper documentation of a patient’s medical record allows you and anyone else involved with the patient’s care to evaluate and plan proper treatment and to monitor the patient’s healthcare over time. It also facilitates communication that is sometimes necessary among all professionals involved with the patient’s care and allows for accurate and timely review and payment of claims submitted to a third-party payer.

 

WHAT DO PAYERS WANT?

Unless you are fortunate enough to run a total-cash practice, insurance is one of those items you have to deal with in order to be reimbursed for your services. Third-party payers generally require proof that the services you are billing for are consistent with the patient’s insurance coverage and for any precertifications that have been authorized.

 

They may ask you to validate:

• Place of service;

 

• Medical necessity of care rendered;

 

• Nature of services provided; and

 

• Accurate reporting of services provided.

 

To be in compliance in a court of law, as well as to meet the rigorous demands of insurance-company audits, you need to adhere to a number of documentation principles. Adherence to these principles mitigates risk and ensures conformity across all types of office forms and procedures.

Here are the documentation principles you should adhere to in your practice:

 

• Document a patient’s progress, response to, and changes in treatment, and any revision to the working diagnosis;

 

• Identify any health-risk factors;

 

• Make sure the CPT or ICD-9-CM codes you use on third-party payer claim forms or billing statements for a patient are also documented in the patient’s medical record;

 

• Write neatly and legibly; make sure the medical record is complete;

 

• Document the reason for ordering diagnostic or other ancillary services, or make sure your rationale is easily inferred from the record; and

 

• Ensure that all past and present diagnoses are accessible to a patient’s treating and/or consulting physician.

 

The documentation of each meeting with a patient in your practice should include:

• Reason for visit, relevant history, result of physical examination, and prior diagnostic test results;

 

• Patient assessment, clinical observation/impression, and/or diagnosis;

 

• Plan for care; and

 

• Date and legible identity of the observer (chiropractor).

 

WHAT ABOUT MEDICAL NECESSITY?

Medical necessity is the vehicle that drives the payment of any claim you submit for a patient. Without proper documentation in that area, you won’t be paid, so it’s extremely important to make sure all care rendered to a patient is documented accordingly.

“Necessity” is defined as “a condition or quality of being necessary; a pressing or urgent need; the condition of being essential.” In terms of medical necessity, you must have a valid expectation at the time you render care to a patient that improvement will occur.

 

To fly under the medical necessity radar, your documentation must include:

 

• Patient consultation and history data;

 

• A record of physical examination findings, tests, and measurements;

 

• A list of subjective complaints — those voiced by the patient;

 

• Functional goals — what you hope to have this patient achieve as a result of treatment;

 

• Diagnosis/diagnoses; and

 

• Treatment plans.

 

It’s never too late to start a self-audit of your documentation to ensure it meets the guidelines presented here. Plan the necessary remedial action if you discover your records are not quite up to snuff.

 

Kathy Mills Chang is the founder of her own chiropractic financial-consulting firm and serves as an insurance advisor for Foot Levelers. She can be reached by e-mail at Kathy@kathymillschang.com or through her Web site at www.kathymillschang.com.