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Documentation FAQ

Documentation FAQ

Q: My software has a Same As Last Treatment (SALT) feature. Is this okay to use for routine patient visits?

A: Using the SALT feature without making any changes to the record on each individual date can be considered fraudulent record keeping and can put a doctor at risk during an audit or record review.  Cloning notes are under close scrutiny as they could be produced without a physician or patient present. 

The unique information gathered on each patient visit is what determines whether that visit meets the medical necessity guidelines of a payer.  If nothing is noted as being changed from one visit to the next, no progress is noted and care is not supported.

Q: When a staff member is performing a delegated service on behalf of the doctor, who must sign the note?

A: Both the doctor and the staff member.  The staff member should document each detail of the service, sometimes including clock time in and out, exercises performed or techniques used.  The doctor who is supervising the delegated service must countersign the note to indicate the treatment was performed as expected and the patient responded appropriately.

Q: What do I put in Box 14 on the claim form for the Date of Onset if this patient was seen a few months ago for the same or similar condition?

A: The Date of Onset should always be the first date you saw the patient for THIS treatment episode, except in the case of Personal Injury or Workers Compensation Injury which would use the accident date as the Date of Onset.

If the patient was discharged at the end of care the last time you treated them for this condition, then there is an obvious stopping point from before, and starting the new treatment episode should be really distinct with the new date of onset.

A date of onset over 90 days can be a red flag to an insurance carrier that indicates possible maintenance, wellness, or supportive care.  There certainly can be care episodes that last beyond 90 days but the documentation must be present to support the need for the extended care.

Q: How long do I have to complete my notes for a patient visit?

A: CMS expects the documentation to be generated at the time of service or shortly thereafter.

Delayed entries within a reasonable time frame (24 to 48 hours) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.  If changes or new info comes up, you have up to 48 hours to amend the record.

Q: Do all insurance companies require these Functional Outcomes Assessment Questionnaires or just Medicare?

A: These Functional Health Questionnaires/Functional Outcome Assessment Tools (OATs) are useful to substantiate a patient’s functional deficits and gauge the changes throughout care.  These tools help to prove medical necessity and show when Maximum Medical Improvement is being reached in relationship to your goals.  We highly recommend the use of these tools for every patient under active care. 

The use of these Functional Outcome Assessment tools with all insurance carriers is advised as they prove to satisfy the measurable and quantifiable aspects that payors are looking for when trying to determine whether the care was medically necessary as defined by their guidelines. They are a great tool in writing specific and obtainable goals and are very beneficial to the story telling of a phase of care.

You will find that some payors, when seeking authorization for visits, may ask for the scores on these questionnaires to use in their algorithms to approve visits.

Q: What does Medicare need in my documentation in order to establish medical necessity?

A: Medicare’s utilization guidelines for chiropractic services require the following three components in order to establish medical necessity:

  1. Presence of a subluxation that causes a significant neuromusculoskeletal condition. Medicare will not pay for treatment unless it is by manual manipulation of the spine to correct a subluxation. The subluxation must be consistent with the complaint/condition.
  2. Documentation of the Subluxation. A subluxation may be demonstrated by one of two methods: x-ray or physical examination. If documented by physical examination, the PART system must be used.
  3. Documentation of the Initial and Subsequent Visits. Specific documentation requirements apply whether the subluxation is demonstrated by x-ray or by physical examination.