Documentation & Coding

Most providers are unaware of and never look for the red flags in their documentation and coding which could trigger an audit.

SOAP Documentation: Prevent Financial Consequences Many doctors have invested thousands of dollars in an EHR system loaded with templated macros used to create their…

Our recommendation: get proactive, and find out what's really going on in your documentation before an outside auditor does.

As providers create medical records of the encounters between the doctor and the patient, the format for collecting the required information can vary drastically. Practice style, patient population, and personal preference are all considerations when choosing how to gather information from the patient to meet compliance standards.

Successful providers review their coding and documentation and strive to improve accuracy and compliance. Documentation involves far more than just writing down a list of services or copying notes from visit to visit. Likewise, proper coding involves more than just figuring out what codes the payer will accept and billing those.

The definition(s) of medical necessity is one of the most important to you and your practice whether a cash-based practice or one dealing with third-party payers.

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.

It sounds simple, but if it were, a large percent of chiropractic practices wouldn’t be getting it wrong!

There are several steps that can be taken to improve your documentation, coding, and compliance and not let your resolution remain unfulfilled.

According to the Centers of Medicare and Medicaid Services (CMS), there are ten principles to adhere to in the documentation of a medical record. Let’s take a look: