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DATELINE:

5 YEARS AGO
IN DOCUMENTATION

BY PERILYN OLSON DC MCS-P

4-Quick Steps to Improve Your Chiropractic E/M Documentation and Get Paid Better!

As a medical compliance specialist who works with chiropractors to help them improve their chiropractic documentation, I often see a common mistake that chiropractors make when it comes to documenting their chiropractic E/M visits.

Macros Can Benefit or Burn Your Chiropractic Documentation

Most EHR systems have some preprogrammed macros, and they are often useless. This is because most macros are written by computer coders, not medical compliance or chiropractic documentation specialists. As a result, what should be included in most documentation macros is often missing. Here is a short list of questions to answer when you are evaluating your patients and most importantly, creating your chiropractic E/M documentation.

This Short List Will Strengthen Your Documentation, Improve Your Doctoring Skills and Boost Your Bottom Line

As chiropractors we are experts at evaluating our patients using range of motion, orthopedic, neurological, and special testing.  All of this is important in an evaluation for treatment, but don’t overlook the following “easy to document” bullets that “count” just as much as your physical findings upon E/M Auditing. Be sure to answer the following questions in your written documentation of your chiropractic E/M documentation:

  • Is your patient oriented to the time, place, and person? This is a single statement that evaluates the mental status of a patient. Did the patient drive themselves to the appointment? Did they fill out paperwork? How did they navigate through the office?
  • What is your patient’s mood and affect? This is an evaluation of the patient’s mental status and attitude. Are they calm, depressed, agitated, or nervous?
  • How does your patient appear? How do they physically look to you? Is the patient normal, thin, overweight, fit, disheveled, unkempt? What is their stature and habitus? This is not meant to be critical, but is an evaluation of their physical appearance. Their general appearance may provide diagnostic clues to their illness, severity of disease, as well as their values, social status, and personality.
  • What about your patient’s gate and station? Really, what chiropractor doesn’t watch their patient walk into the office or down a hall?  Is it normal or antalgic? Did they use a cane or walker? Is there foot-flare or obvious pronation?

Remember, for the exam portion of an E/M code of 99202 only six bullets are required. Add ROM and inspection of spine, and you are there. For 99203, 12 exam bullets are required and these four can easily help a practitioner to acquire that level of examination quickly and effectively.

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