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.

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Patients Over Paperwork-What does it Mean for You?

The Patient Over Paperwork initiative has focused on reducing administrative burden so that physicians could concentrate more on patient care. Stakeholders have found that many aspects of the required E/M documentation are redundant. You probably have heard the rumors – such as, new CPT codes, new fee schedule and less documentation required. This is a quick summary of what we currently know for sure.

What will happen in 2019?

    • No changes in coding (not until 2021)
    • No changes in payment (not until 2021)
  • Eliminate the need to document medical necessity of a home visit in lieu of office visit. Not really applicable in most cases in regard to Doctor of Chiropractic.
  • For the history and exam part of an ESTABLISHED PATIENT office visit, CMS states, “when relevant information is already contained in the medical record, the physician can choose to focus their documentation on what has CHANGED since the last visit or what has NOT CHANGED. The provider does not need to re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed.”
  • For the chief complaint, CMS states, “Chief Compliant and history for new and established patient visits, the practitioners need not re-enter in the medical record information that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.”

Pros and Cons

There are too many unanswered questions to establish a true pros and cons list. For example, what does CMS view as relevant information? What does CMS require as evidence that the provider reviewed the previous information in the medical record; is it a signature or written statement? The term history is referred to often, but does it include the chief complaint (CC), history of present illness (HPI), review of systems (ROS), and pertinent past, family, and/or social history (PFSH) or just parts of history? Does review of systems or chief complaint documented by the beneficiary through intake forms count as information already entered in medical record? How exactly does a provider indicate in the medical record that s/he reviewed and verified the information?

Recently, CMS hosted a webinar in which many questions like the ones listed above were brought forth by different providers. CMS has promised to provide a FAQ to all attendees in response to the inquiries. We will be sure to share this information once we receive it. In the meantime, we encourage you to reach out to your local MAC for additional information on documentation guidelines as these new E/M standards are implemented in 2019.

For now, keep an eye out for updates that may roll out from your contracted payers regarding documentation requirements for E/M codes. Although this change applies to Medicare only claims it appears that some payers are clarifying or creating Reimbursement Policy with their own interpretation of CMS Guidelines. A sample of payer language is listed below.

KMC University Library

Chiropractic Medicare Audits are on the rise! Avoid pre-payment Medicare audits by creating pristine chiropractic documentation as directed by the MACRA legislation. Also learn the specific Medicare billing, coding, and documentation requirements for chiropractors. Learn exactly what is necessary to protect your practice, quickly, and easily.

And it includes monthly webinars (CEUs available!), timely news updates, and our email and live HelpDesk to answer your questions. Remember, you don’t have to know everything when you know the people who do. Let us protect you!

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Posted by nuclearnetworking on Nov 3, 2018

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