Initial Visit Foundational Documentation

Make Time for the Details

For many doctors, documentation can be a daunting and cumbersome chore. After all, who has time for all these details when there are patients to treat? However, annoying as it may seem, documentation is a facet of your practice that you must embrace and be proficient in. Ideally, the initial visit documentation should lay the groundwork for the successful execution of your treatment plan.

The initial visit is the foundation of an episode of care, whether for a new patient or an established patient returning for a new episode.

Initial Visit Requirements are generally categorized as:

• History of patient’s condition with detailed description of the present complaints:
  • Mechanism of injury
  • Details of any previous episodes
• Examination and evaluation of the musculoskeletal and nervous system
• Assessment with Medical Decision-Making language to support the recommended care and the level of Evaluation and Management (E/M) service, as well as relevant complicating factors
• Diagnosis codes for all areas to be treated
• Treatment Plan to include
  • Start and anticipated end date
  • Recommended duration and frequency of visits
  • Specific short and long-term treatment goals
  • Recommended services to be performed during the treatment plan with appropriate rationale
  • Treatment Effectiveness via Outcome Assessment Tools (OATs) scores
• Separately documented treatment rendered during the initial visit

Locating All Documentation Guidelines

Requirements vary from state board to state board and from Medicare to insurance carriers. Be sure you know the rules you’re following by locating all documentation guidelines applicable to your practice. Your documentation also provides a means of communication with other health care providers. There are standards of care and compliance that you are obligated to meet, even when operating a cash-based practice.

Determine If They Meet These Requirements

Review some examples of your documentation to determine if they meet these requirements. While reviewing your documentation, it should be easy to identify medical necessity for all services performed. Nervous about the threat of a Post Payment Audit? Then you likely know that your documentation system needs an upgrade.

The information you submit to third-party payers via your procedure codes must be supported in your documentation, beginning with the vitally important foundation of an initial visit.

Need more help? Schedule a Proactive Chart Review and one of out certified specialists can assist you in a friendly internal audit!

Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and practiced for over 20 years. Her interest in Medical Compliance began when she earned the 100-hour Insurance Consultant/Peer Review certification from Logan University in 2015. She has been a certified Medical Compliance Specialist-Physician since 2016. In November 2020, Dr. Auchenbach joined the excellent team at KMC University as a Specialist and, as part of this dedicated team, is determined to bring you accurate, current, reliable information. You may reach her by email at info@kmcuniversity.com or by calling (855) 832-6562.