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Approximately 50 percent of the chiropractic profession has adopted an Electronic Health Record (EHR) system.
Many EHR vendors have chosen the approach of letting the doctor develop their own individualized documentation mostly without parameters. This places the burden on the doctor to be confident that they know, understand and can apply the rules of documentation requirements without the benefit of a system that will guide them.
The Centers for Medicare and Medicaid Services (CMS) have policy accessible with more details regarding CMS chiropractic documentation requirements.
Documentation requirements for the initial patient visit
The following documentation requirements apply whether the subluxation is demonstrated by X-ray or by physical examination:
Documenting the symptoms causing the patient to seek treatment, the family history, past health history including their general health, prior illness, injuries, or hospitalizations, medications, surgical history is relevant. Other aspects of the history include: quality and character of symptoms or problem, onset, duration, intensity, frequency, location, and radiation of symptoms, aggravating or relieving factors, prior interventions, treatments, medications, secondary complaints, and the symptoms causing patient to seek treatment.
2. Description of the present illness including
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 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.”
3. Evaluation of musculoskeletal and nervous system through physical examination
Performing a routine physical examination consists of vitals, spinal evaluation, neurological and orthopedic evaluation. Including P.A.R.T. components of the examination is essential.
The primary diagnosis must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation. (Note: with ICD-10 acceptable code is M99.0_ segmental and somatic dysfunction)
5. Treatment Plan:
The treatment plan should include a recommended level of care (duration and frequency of visits). When discussing duration of care, Medicare is asking for the episode of care, which is characterized by a beginning and an end of care. This is different than with most third party payers. This can be stated in weeks, visits, or both. This is difficult for many DC’s because they will say I do not have a crystal ball. The fact is, as a clinician, you need to base your end point of care on your experience and the patient’s condition.
Medicare wants to know when you project you will be done with active treatment. It may be difficult to estimate, but do the best you can. Many DC’s will list three times per week for 2-4 weeks and then reevaluate. This does not describe the duration of the episode and that care has been completed. For example: the duration of care is estimated at 8-10 weeks and 24 visits. Initially, the frequency of care will be 3-4 times per week. A re-evaluation will be in approximately 12 visits to determine the patient’s future course of care.
In addition, specific treatment goals are critical to determining what your treatment plan is addressing. Treatment goals need to be patient specific functional goals. Reviewers are fatigued with seeing “20 percent reduction in Oswestry”. This is not a patient specific functional goal. A patient specific functional goal can be established by quantifying functional activity. Objective measures are necessary to evaluate treatment effectiveness.
There are many ways to do this. Think about this as using time (hours or minutes), a patient specific pain scale (0-10 or 0-100) when performing an ADL or measuring something such as range of motion or a straight leg raise. For example: The patient stated that prior to this incident she could sit for three hours without pain. The patient specific goal is to return her to her pre-incident status of sitting for three hours without pain.
6. Date of the initial treatment.
The initial date of treatment is an important date to document when a patient begins care.
How can I keep on track with each patient note?
It can save the provider hundreds of hours by purchasing an EHR system that already has much of the requirements already installed in the system. From there, it is important to train the provider to personalize the system by adding to the note with their individual terminology.
Timothy S. Wakefield DC, DACBSP, CSCS, CCST, eChiroEHR Director of Development for Best Practices Academy, has been in full time clinical practice for 27+ years. He has assisted with clinical content development for EHR systems and has taught multiple programs and written books and manuals on chiropractic clinical procedures, clinical documentation, CPT coding, sports injuries, physical fitness and other health related topics. He enjoys researching and learning about the new demands of healthcare and then developing systems and procedures to increase efficiency and profitability for the entire chiropractic profession. He can be contacted through bestpracticesacademy.com or 877-788-2883.
About Best Practices Academy
Providing leadership in practice growth, risk management, quality performance, and certified EHR systems since 2006. Best Practices Academy (BPA) will be sure your practice is ready to migrate from fee-for-service-based to a value-based system, and help you grow the practice of your dreams. BPA studies your practice’s statistics such as CPT codes being utilized, most common ICD-10 code selections, random review of documentation, capacity analysis, and financial account reports to determine if the practice is healthy or sick.
Best Practices Academy prides itself in having some of the best people in the industry to evaluate practices. A team approach is taken to find out what areas of concern are. This is usually an eye opener for many DCs.