Patient Intake and Documentation Compliance

Being Intentional About the Intake Process

Patient intake involves welcoming patients into your office, taking their names and number, and asking where it hurts. But this is only the beginning of gathering information! In our current highly regulated healthcare system, being intentional about the intake process is no longer an option. If key pieces of information are missing, offices can fail a records review or audit.

Specific Documentation Guidelines

Medicare has available tools through published materials and training to educate the chiropractic profession regarding requirements for initial documentation. One of the best resources is the Local Coverage Determination (LCD) or Local Coverage Article (LCA) documents on the Medicare Administrative Contractor’s (MAC) website for each region. Medicare clearly states and sets forth its requirements, but many offices remain unaware of what is required or that these documents even exist!

Keep in mind that Medicare is not the only payer that has specific guidelines regarding documentation. Many other payers have similar, or even more stringent requirements. For this reason, it is necessary to become well acquainted with the requirements and policies of all payers to whom you submit claims in order to lower the risk of non-compliant documentation. Don’t forget to locate your state documentation requirements as well!

WHAT YOU NEED TO KNOW:

Whether you are treating a new patient or simply beginning a new episode of care, make certain that your intake paperwork and/or electronic documentation software prompts you with the following questions and details:

First, what symptoms caused the patient to seek treatment

Second, is there any relevant family history

Third, general overview of past health history:

• General health
• Prior illness
• Past injuries
• Routine medications
• Hospitalizations
• Surgeries

Fourth, mechanism of injury or trauma

Fifth, quality and character of symptom(s) and/or problem(s)

Sixth, symptom details:

• Onset
• Duration
• Intensity
• Frequency
• Location
• Radiation

Seventh, aggravating and Relieving Factors

Eighth, secondary Complaints and Prior Episodes:

• Intervention
• Treatment
• Medication

Remember, just because you receive reimbursement does not mean all is well. If suddenly targeted for an audit, you will likely have to reimburse the insurance carrier for monies paid unless all required documentation has been provided.

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.