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Chiropractic documentation gap analysis

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Img banner 2Keeping patients safe and healthy is a top priority for all doctors.

It is very easy to fall into a routine with patients’ treatment plans. Regularly scheduled visits can turn out to be more involved when the patient relates something unusual that may impact their treatment. Whether they complain of a sudden worsening of their condition or mention an accident they were involved in, it is the doctor’s responsibility to document the situation and act accordingly.

“Worst Ever”

Many serious health issues can easily mimic neuromusculoskeletal conditions since they cause referral pain in the spine and extremities. A heart attack may present initially as shoulder or jaw pain. Cholecystitis, commonly called a gallbladder attack, can also create shoulder pain.  Sudden, severe pain in the low back may be caused by an abdominal aortic aneurysm or kidney stones. Patients might present to the office with these complaints and try to dismiss them saying they “slept wrong,” or blame it on stress, or something they ate. A trained healthcare professional’s ears should perk up whenever they hear a patient say their pain is the worst they have ever felt.

Whenever a patient complains of unusual or severe pain, further evaluation is needed to determine if it is safe to continue the patient’s care on that visit. If the pain cannot be reproduced with orthopedic tests and there is no known mechanism of injury or reason for the worsening of the patient’s condition, it may be better for the patient to go to the emergency room or urgent care to rule out anything that is life-threatening. This decision may need to be made before the doctor can complete a full exam or the examination may be limited due to the doctor’s scope of practice. It is extremely important to document everything that occurred during the visit.

Important details to record include:

  • What symptoms did the patient present with? When did it start?
  • What did the doctor and other staff members hear and observe?
  • What exams or tests were performed? Both positive and negative findings are important.
  • What advice was the patient given? Did they follow it?
  • Did the doctor follow up with the patient to check on their condition? What was the outcome?

“No Big Deal”

There may also be times when a patient casually mentions that they were involved in some type of accident. The incident may have been work-related, an auto accident, or even in their own home like slipping in the bathtub. Not all patients feel that treatment is necessary for their injuries depending on the severity. Nevertheless, the doctor is the only person qualified to assess the patient’s condition. As many people know first-hand, the full effect of some injuries is not felt until several days later. Even if the symptoms are initially mild, the accident may result in negative changes to a patient’s outcome assessment tools, exam findings, or ability to perform their normal activities of daily living. If the accident is not reported in the patient’s chart, it can appear that the patient is getting worse, and that the doctor’s treatment is not working. This may make it more difficult to establish the medical necessity of care and result in insurance denials.

The patient is not required to file an auto accident or Worker’s Compensation claim; however, third-party payers typically deny claims that are accident related and the patient may ultimately be responsible for payment. From a case management perspective, the doctor should determine the necessary level of evaluation that is required and document the history and physical findings in the patient’s chart regardless of who will be billed for the services.

Documentation is Required for More Than Just Reimbursement

Cash and insurance-based practices are both held to the same standards of documentation requirements based on state regulations. Emphasis is placed on proving the medical necessity of services to receive insurance reimbursement; however, it is just as important to properly document all patient interactions from a risk management perspective. Patients’ charts are their health history; it is crucial that they are as complete and accurate as possible. To ensure that situations such as those mentioned above are properly assessed, encourage patients to be open and honest about any symptoms or injuries they may have. It is also important to enlist the staff’s help to always ask patients questions such as, “Are there any changes to your condition or new issues that you would like to make the doctor aware of today?”

Good communication will enhance the doctor-patient relationship. Keep your ears open to hear how you can best help your patients.

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.


Posted by Team KMCU on Dec 8, 2023

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