Minimal Documentation is Basic, Enhanced Documentation is Necessary
While states require minimum documentation requirements for chiropractors, many states require chiropractic-specific details. While it is not recommended that you only do the minimum to scrape by, there might be times when you only need to document to the level of meeting the state requirement. Enhanced documentation is recommended for the level of care you desire to provide to your patients. Better documentation means better patient care and better patient outcomes.
Documentation of Routine Chiropractic Office Visit
In your chiropractic practice, you must attain state specific minimum documentation requirements or greater by establishing standards for documentation defining your policy requirements and your standard operating procedure (SOP). These will include an explanation of the use of your patient’s subjective data, the provider’s objective findings, the assessment, and the treatment rendered.
Back to: Documenting Routine Office Visits
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Since we have been implementing compliance, we noticed that our claims have been processed better with increased collections and decreased denials! The copay collections have improved and asking for the patient responsibility is easier because we know what to ask for, and we can confidently collect while the patient is in the office rather than having to rely on sending out patient statements.