Ensure coding accuracy, billing integrity and medical necessity
METICULOUS DOCUMENTATION IS NOT JUST A FORMALITY in health care; it’s a fundamental practice ensuring patient care quality, legal compliance and effective communication among health care providers. Chiropractic documentation and care is no exception to this rule. Chiropractors must maintain accurate and comprehensive records of their patients’ assessments, treatments and progress. The tools available for documentation, including both traditional manual methods and modern electronic health records (EHR) systems, are wide and varied. This article illustrates the significance of self-auditing your chiropractic documentation and coding, and discusses the benefits of both digital and manual methods to evaluate coding accuracy, billing integrity and medical necessity, to keep your practice safer.
Documentation: The foundation of effective chiropractic care
Documentation is a cornerstone of effective chiropractic care. It’s not merely about meeting regulatory requirements; rather, it’s about providing a clear, thorough and chronological record of patient encounters. Proper documentation ensures continuity of care across different visits, aids in clinical decision-making and supports accurate billing. More importantly, it facilitates collaboration between chiropractors and other health care professionals, contributing to a holistic approach to patient well-being.
Self-auditing: A pillar of risk management
The Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) provides guidance to individual and small group practices about the implementation of a compliance program. This important facet of the business side of practice includes a mandate to continuously self-audit to ensure billing for chiropractic services is accurate. Self-auditing involves reviewing one’s own documentation practices to ensure accuracy, compliance and consistency. By proactively identifying errors or inconsistencies, chiropractors can rectify issues before they escalate into more significant problems. Medicare requires this self-auditing, but when implementing a self-auditing process, it applies across the board for all documentation. Additionally, semi-annual coding audits are also strongly recommended.
The digital approach: electronic health records audits
In recent years, electronic health records (EHRs) have revolutionized health care documentation. EHRs offer a myriad of advantages, including streamlined data entry, enhanced accessibility and integration with other health care systems. Auditing EHRs digitally is a contemporary approach offering unparalleled efficiency and accuracy. When I’m auditing a full patient chart or episode of care, I prefer to have it scanned as one document, to include all the ancillary paperwork completed as well as the EHR file. It’s always best to organize it in chronological order. Then the digital audit can take place without all the printed paper.
Benefits of digital auditing
Efficiency: Auditing EHRs digitally saves considerable time compared to manual methods. Advanced search functionalities allow chiropractors to quickly locate specific records, making the auditing process smoother and more time-effective. Even using a PDF version of the digital file allows for the “search” feature of “Ctrl-F” to find what you are looking for in the audit.
Data integrity: EHR systems often incorporate built-in safeguards against errors and inconsistencies, such as mandatory fields and data validation checks. This reduces the likelihood of mistakes and enhances the accuracy of the documentation.
Accessibility: Digital records are easily accessible from various devices and locations, enabling chiropractors to review documentation remotely. This accessibility proves valuable in urgent situations or when collaborating with other health care professionals.
Automation: Many EHRs have features that automatically generate alerts for missing or incomplete documentation. These automated reminders help chiropractors promptly address gaps in their records.
Analytics: EHR systems can provide insights into documentation patterns and trends, allowing chiropractors to identify areas of improvement and adjust their practices accordingly.
The manual approach: handwritten audits
While digital methods offer undeniable advantages, manual audits of chiropractic documentation have their own merits, particularly for those who prefer a tactile approach or operate in settings with limited technological resources.
Benefits of manual auditing
Thoroughness: Handwritten audits encourage a more detailed review of patient records, as the process often involves physically reading through each entry. This meticulous examination can uncover subtle inconsistencies that might be missed in a quick digital scan. And it also allows for highlighting and note-taking right on the documents.
Personalization: Some chiropractors find manually reviewing records allows for a deeper connection with their patients’ journeys, potentially leading to insights that could enhance patient care.
Low-tech settings: In environments with limited technological infrastructure, manual audits remain a viable option. They require no specialized software or hardware, ensuring accessibility to all chiropractors, regardless of their resources.
Mindfulness: Manual audits demand focused attention, potentially fostering greater awareness and attentiveness to detail during the review process.
Mitigating risk through self-auditing
Regardless of the chosen approach — digital or manual — self-auditing plays a critical role in risk management for chiropractors, particularly in the domains of coding accuracy, billing integrity and medical necessity.
Coding accuracy: Chiropractic care involves specific coding to accurately represent the procedures performed. Self-auditing ensures the assigned codes align with the documented treatments, reducing the risk of coding errors that could lead to under- or over-billing. We urge including “spot check audits” multiple times per month to compare the code selected to the documentation. Ensure whoever selects the original code gets support from another team member in reviewing so that more eyes on the document present a more comprehensive approach.
Billing integrity: Accurate billing is contingent on comprehensive documentation. Self-auditing confirms the billed services correspond to the treatments administered, mitigating the risk of financial penalties or accusations of fraudulent billing. Again, we always recommend a different team member perform the “spot check audits” so fresh eyes can contribute to the review. We suggest collecting a random number of claims per month to compare coding and billing to the documentation.
Medical necessity: Chiropractic care must be medically necessary to ensure optimal patient outcomes and reimbursement. Through self-auditing, chiropractors can assess if their documentation sufficiently justifies the medical necessity of the treatments provided, reducing potential denials from insurance companies.
Legal compliance: Self-auditing ensures all documentation adheres to legal and regulatory standards, safeguarding chiropractors against potential legal actions stemming from non-compliance. If you are not up to speed on all the regulations and guidelines, seek assistance from certified compliance professionals to train or help you in the auditing process. The Centers for Medicare and Medicaid Services (CMS) has suggested all audits should be conducted by an impartial third party whenever possible.
Patient safety: Incomplete or inaccurate documentation could lead to misunderstandings or misinterpretations of a patient’s condition or treatment plan. Self-auditing helps prevent such discrepancies, ensuring patient safety and well-being.
Professional reputation: Meticulous documentation reflects a chiropractor’s commitment to excellence. By consistently auditing their records, chiropractors uphold their professional reputation and instill trust in both patients and peers. And when the profession at large embraces this practice, all documentation will improve, as should our reputation with government entities and payers.
The importance of self-auditing in chiropractic coding documentation cannot be overstated. Whether opting for the efficiency of digital audits, the thoroughness of manual reviews or the hybrid of the manual review within a digital document, chiropractors must embrace self-auditing as an integral part of their practice. This proactive approach to risk management not only ensures compliance and accuracy but also upholds the integrity of chiropractic care. As technology continues to advance, chiropractors can choose the method that best aligns with their preferences and resources, all while safeguarding their patients and practice. It’s good for everyone!
KATHY WEIDNER, MCS-P, CPCO, CCPC, CCCA, better known professionally as Kathy Mills Chang, is a Certified Medical Compliance Specialist (MCS-P), a Certified Professional Compliance Officer (CPCO) and a Certified Chiropractic Professional Coder (CCPC). Since 1983, she has been providing chiropractors with reimbursement and compliance training, advice and tools to improve the financial performance of their practices. This year celebrating 40 years of service to chiropractic, Kathy leads the largest team of certified specialists under one roof in the profession at KMC University, and is known as one of chiropractic’s foremost experts on Medicare and documentation. She or any of her team members can be reached at 855-TEAM KMC or info@KMCUniversity.com.