Chiropractic documentation gap analysis

Recognize what’s missing to master your reimbursement and collections!

This Documentation Gap Analysis allows us to evaluate the significant components of your current Documentation program. It should take less than 5 minutes to complete.

Take The Billing GAP Analysis

Need more guided help? Work with a KMC coach 1-on-1

Sometimes you need more than a self-service, on-demand program and need an expert to analyze your issues, train the corrections, and help you implement the changes, so they stick

Learn More
Dr Alan Sokoloff 1

New Course Available!

This course explains the significant role chiropractic care can play in the sports industry and how a DC can succeed as a Sports Chiropractor. Start your steps to success here!

Learn More

There's no need to fear the OIG. We've got your back!

The most effective chiropractic OIG compliance programs are scaled according to the size of the practice!

Learn More

Examination Should Be Driven by History

Chiropractic Examination Driven by History

The examination of your chiropractic patient must be driven by your patient’s history. As with all stories, it is the starting point that leads to the conclusion which is – in this case – the medical necessity of their chiropractic care.

The Appropriate Chiropractic Documentation of Patient History and Medical Necessity

The reality is recording these crucial patient history elements begins with the collection of the patient’s HPI (History of Present Illness).  The patient’s history drives the examination and ultimately proves the need for chiropractic treatment and is clinically correlated to the condition and its severity.

HPI is taught using the mnemonic acronym OPQRST in which initial letters represent:

  • Onset – What was occurring when the symptoms first occurred? Were the symptoms sudden or gradual onset?
  • Provocation/Palliation – Does anything improve the symptoms or make them worse?
  • Quality – A description of the pain – sharp, stabbing, aching, throbbing, dull, crushing, sharp, etc.
  • Region/Radiation – The location of the pain and its movement to other body parts.
  • Severity – The severity of symptoms on a scale of 1 to 10, 10 being most intense.
  • Time – The time of the symptoms first occurrence.

Following the OPQRST protocol allows the chiropractor to establish medical necessity for a course of treatment, identify complicating factors, and define the duration of chiropractic care needed for your chiropractic patient.

Image Image

The workshop helped us to be better prepared for submitting claims that will not be rejected. Showed us how to find medical review policies and where we could find Medicare resources that tell us exactly how to code a procedure and document.

VHOL Attendee