New Year Compliance and Documentation Upgrade

New Year, New Compliance and Documentation Goals

Many of us become reflective and quiet this time of year. Hopefully one of the areas you have considered and thought on is your practice, with focus on goals and clear direction for the new year. As we all commonly set personal resolutions, we should also set professional and business resolutions. One of the best goals you could have for your practice is to become more compliant in the new year. As we work with provider across the country, we hear one of the most common goals is to be able to feel confident with their documentation and to feel secure that what they are noting down and recording in the patient chart will support what is being coded and billed. This is a great place to start!

There are several steps that can be taken to improve your documentation, coding, and compliance and not let your resolution remain unfulfilled.

• Take stock of where your practice currently is.
• Look at your billing patterns. Are you managing your patients with episodic care?
• Locate all payer policies and guidelines. This is one of our best resources for compliant documentation. Make it a point to locate and print every payer’s policy that you are contracted, with including Medicare.
• Use these documents to solidify what each payer expects to be documented to support the services that they cover. Likewise, learn what services they do not cover.
• Take notice of the recurring themes of medical necessity, functional deficit, patient progress, and treatment plan.
• Be sure that the services being rendered in your practice are being reported with the correct procedure codes.
• Coding, billing, and collections all have patterns that tell a story. Identify your patterns.
• Perform or have performed for you a Baseline Audit. Don’t know how? Have us do it for you!
• Implement an OIG Compliance Program! You will be so relieved to have a compliance program that is working in your practice to ensure you are not committing fraud, waste, or abuse.

As Kathy says, strive to be more complaint next year than you are today! To plus that, do one thing this month that allows you to be more compliant next month. And if you want to dial down even further, make every case that you manage, every note that you document, and every code that you assign more compliant than the previous one. Make this the year that you follow through with your resolution to lower your risk of audit and recoupment by upgrading your documentation, coding, and compliance.

Happy 40 years Kathy! Thank you for all you have done for all of us in the Chiropractic Profession!

Dr. Colleen Auchenbach graduated with a Doctor of Chiropractic from Cleveland University Kansas City in December of 1998 and enjoyed practicing 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 and a Certified Professional Medical Auditor since 2022. Dr. Auchenbach joined the excellent team at KMC University as a Specialist in 2020, and as a part of this dedicated team is determined to bring you accurate, current, and reliable information. You may reach her by email through info@kmcuniversity or by calling (855) 832-6562.