Documentation & Coding

There are many valid reasons to document the encounter between you and your patient. It is essential to the practice for accurate record-keeping; it is valuable to the patient to have their medical history recorded for any future need, and it is required by the payer to indicate that the services that were billed were performed and coded correctly.

Reflect and Examine your Chiropractic Practice’s Status We tend to think of summer as a time for outdoor activities, vacations, and lounging in the…

For most of us, the demands of school left little time to think about running a practice - how every decision is the practice owners, what forms and EHR to use, which insurance companies to contract with, what services to offer, etc.

It can be a red flag if every daily visit note looks exactly like the one from the previous encounter. And this is often the case with the use of electronic health records (EHR).

When you’re unwilling or unable to formally discharge a patient from active symptomatic care, you inadvertently create one of the more common audit triggers - seemingly ongoing active care that does not reflect the various phases of care available in your practice.

There has been an abundance of records requests since the beginning of this year. I would imagine the providers that are receiving these requests wish they had initiated a chart review themselves before someone else asked to see how their documentation stood up to expectations.

When we talk about documentation platforms, it is assumed that we are talking about Electronic Health Records (EHR). However, many practices use paper medical records to document their interactions with patients.

The terms telehealth and telemedicine are used interchangeably and are the all-encompassing administration of healthcare services via required real-time telephone or video conferencing. The patient must consent to the service before or at the time it takes place.

The term “Routine Office Visit” describes treatment visits where the patient is being seen for the execution of the written treatment plan at the beginning of the Episode of Care. The documentation of these visits contains the details of patients’ progress, or lack thereof, as they advance through the stated plan.

Now that we've had a month to settle into the new Evaluation and Management (E/M) coding rules that went into effect at the beginning of the year, the questions are getting more specific and refined.