Chiropractic documentation gap analysis

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How do you and your office handle records requests?

If you’re playing ostrich and hoping that if you ignore them, they will somehow go away, you’re setting yourself up for a fall.

Whats your Chiropractic Practices Status

If this is or has been your pattern, first: breathe. You may not be doing anything wrong, and some of these requests from a CERT (Comprehensive Error Rate Testing) contractor, an A/B MAC (Medicare Administrative Contractor), a RAC (Recovery Audit Contractor), or the OIG (Office of the Inspector General) are generated randomly. Always read the request letter for details of why they are requesting records and when the records are due to be submitted.

Non-response is the biggest reason for claim denials

But whether the record’s requests you receive are random or targeted, just about the worst thing you can do is not respond. In fact, non-response is the biggest reason for claim denials. Not only does this cost money, but it also makes you and our profession look bad. Chiropractors already have a reputation for not being willing to follow the rules. Adding fuel to this smoldering fire isn’t in anyone’s best interests, including yours.

When you don’t respond by sending in the requested documentation, the assumption is usually that it’s because you don’t have any. Not only does this pretty much guarantee denial of the claim, but it also draws attention to you, and could lead to financial penalties, additional medical review, or even, eventually, a full-blown audit.

If all your documentation is written and organized promptly, you will be ready to review it for accuracy and completeness, make copies, and send it off.

For the best possible outcome keep the following in mind:

  1. Records should be legible – Handwritten records loaded with abbreviations are hard to read. Often, they are completely illegible. If a reviewer cannot read your records, the claims will be denied. If your records are difficult to read, take the time to transcribe and translate the records (without altering them) before submitting them. Avoid abbreviations; instead, enter the full text. If you must use abbreviations, attach a key to define each one.
  2. Include everything that is asked for (and maybe some things that are not) – A record’s request usually contains the patient’s name, a date range for the visits, and a list of the items wanted for review. The payer may only ask for daily treatment notes or may also want exams, radiology reports, treatment plans, etc. If the start date for the request is in the middle of a patient’s treatment plan, it may make sense to send the preceding exam to show any significant findings that pertain to the treatment the patient received.
  3. Be able to support the medical necessity for the services provided – Most third-party payers (Medicare in particular) use functional improvement as proof of medical necessity. Everything in the patient’s chart should tell the ongoing story of the patient’s condition. Evaluation and Management (E/M) services should be performed at reasonable intervals throughout the patient’s treatment to show physical improvements. Outcome Assessment Tools (OATs) will help support functional gains from a subjective perspective. The treatment plan is used to tie together everything from the patient’s chart and to set short and long-term goals that are specific and measurable. Daily SOAP notes will fill in the gaps from visit to visit. If the doctor feels that additional explanations are required, a narrative report may be written to include additional information.
  4. Keep the records organized – Records should be assembled in chronological and supportive order that explain the treatment as it occurred. Good documentation reads like a story with a beginning, middle, and an end that makes sense to the reviewer. Use a Case Summary Letter if needed to clearly illustrate the case management process.
  5. The doctor should review the documentation before it is submitted – While staff members can prepare the bulk of the information needed to respond to a records request, it is vitally important that the doctor reviews the information before it is submitted. The doctor is ultimately responsible for all documentation. This is his/her last chance to make sure that all amendments and clarifications have been included in the file before it is sent to the requester.
  6. Better yet…have a professional review before you send – If you don’t know what you don’t know, such as why you got that request, consider having a professional review the packet before you send it. You may have an opportunity to include addenda where information may be missing, etc. Those of us who audit daily have a keen eye toward issues that may have prompted the request. An ounce of prevention is worth a pound of cure…or worse yet, an untenable recoupment request.

Many doctors believe that nothing bad will happen if records are not sent. This is not the case! The number one reason claims are denied is that the “provided documentation does not support medical necessity.” Sometimes those findings are because the records were never provided. Failure to respond to a request for records hurts the doctor, the practice, and the chiropractic profession. Even poor documentation is better than nothing. It is important to send the records to prove a service was provided and that billing was not fraudulent. Good documentation can reduce the number of denied claims an office receives and may also reduce the number of records requests the office receives in the future.

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 at or by calling (855) 832-6562.



Posted by Team KMCU on Apr 1, 2024

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