Lean Into Stellar Documentation

Once chiropractic school is over, you assume you are finished with the homework and tests, right?  Think again.

Sometimes doctors must put in extra time outside of patient hours to complete their documentation. While you shouldn’t have to pull all-nighters to get your notes finished, it doesn’t hurt to double-check your records to ensure they are both complete and compliant. After all, insurance companies can request to review them, and you better believe that they are grading you. Do well, and they will reimburse you for the claims that you submit. If you are missing critical components to your documentation, expect that they are going to further scrutinize and maybe even ask you to pay back the money.

When looking at proactive chart reviews, a high number of chiropractic records are missing or inadequately presenting key elements which leads to error rates of much more than the compliant ten percent. Many doctors believe that their documentation is “fine” or that because they are getting paid there is nothing to improve. Here are some tips to raise your level of documentation and reduce your risk of finding out the hard way that your documentation does not rise to the level necessary to pass a third-party payer audit.

Be Disciplined with Your SALT🧂

It can be very tempting to copy and paste notes or just use the phrase “Same as Last Time” (SALT), especially if the patient is seen multiple times per week for a commonly treated condition. This can make it very difficult for third-party payers to determine the medical necessity of the services that were provided, as every note looks like every other note. Your daily visit notes should include information about the patient’s complaints, changes in objective findings, and progress toward functional goals. Use all four parts of the note (Subjective, Objective, Assessment, and Plan) to make the note encounter specific as it tells the patient’s story.

Code and Bill What You Document🔢

Your documentation needs to be detailed enough to support the services that you provide. The chiropractic manipulation codes 98940-98942 are based on the number of spinal regions that were treated for a medically necessary complaint. The specific spinal levels that were treated should be listed to be considered for reimbursement. For accurate coding, there should be a separation between the regions treated as medically necessary and the compensatory regions. When billing for timed therapy codes, indicate how many minutes the service was performed and what exercises or muscle work was done. And don’t forget to properly document Evaluation and Management (E/M) services. The E/M code you use depends on a clinically appropriate history and exam, as well as medical decision-making or time.

When any of this vital information is missing from the documentation, you may be inadvertently upcoding, down coding, or omitting billable services. If you bill for more services that you can prove in your notes, expect to have to repay some of that money if you are selected for a post-payment audit review. Billing a lower-level service than what was provided or not billing for the service at all, is also a red flag and could be considered an inducement violation. Either way, you will be cheating yourself out of your hard-earned money.

Have a Plan📝

As they say, “You can’t reach your goals if you don’t have a plan.” This is why it is crucial to maintain a written treatment plan for all patients. It should list specific, measurable, functional goals and outline what services will be needed as well as the estimated time frame that it will take to accomplish them. Both short term and long-term goals are important to ensure that the patient stays on track.

There are times when patients don’t meet the expected goals and that is expected. Unforeseen setbacks and poor patient compliance are just some of the reasons a patient’s progress may have stalled. These issues need to be explained in the notes and updated during re-evaluations. If the recommended treatment seems to be ineffective dig a little deeper to find out whether further testing or a change in treatment protocols is needed. There is no sense in doing something over and over if it is not working. When a third-party payer sees that the patient is no longer improving, they will consider the services not medically necessary and stop paying for them.

Check Your Homework✔️

It is a hundred times better for you to find your own mistakes and correct them than to have them discovered after a records request from the patient’s insurance. If errors are discovered in one patient’s chart, it will be assumed that other patient files have errors. You become an easy target for a large post-payment audit. To help prevent the stress and consequences of unfavorable results, perform self-audits in your office to review your documentation, billing, and coding. Not only is this a good idea to lower your risk, but it is also a required part of your office’s OIG compliance program.

Shoot for the Stars💫

Does your documentation pass the test? Find out about how your documentation measures up HERE. Keep in mind that documentation is a group project. The treating doctor may be the one that understands the patient’s condition and the rationale for treatment, however, scribes, chiropractic assistants, and billing staff can all help to make sure that the documentation is organized and accurate. If you find areas where you need improvement, practice makes perfect. Keep trying and keep learning. Be more compliant this year than you were last year. Your efforts will earn you a gold star and more importantly peace of mind!

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.