KMC University on Documentation

Medically necessary care

As you already know, Medicare, your chiropractic board, and other third-party payers have specific requirements for documentation of the first and any subsequent chiropractic visits. The bottom line: in order for you to be reimbursed, your documentation needs to support medically necessary, episodic care, i.e., care that has a beginning, a middle, and an end. Can you see that patient again after treatment has “ended?”” You can provide and document all the clinically appropriate care you see fit, document it according to your state’s requirements, and collect from your patients. Want to file more claims for reimbursement? Sure you can; as long as you document a new episode of care.

Medicare documentation requirements

Because third-party carriers don’t usually ask to see your documentation before they pay, they trust that you’ve met all the guidelines and that your notes say what they’re supposed to in order to support reimbursement. They have a mandate to periodically check documentation on a post-payment basis. If your documentation isn’t complete, legible, and coherent, it could get kicked right back to you along with a request for return of monies paid. Worse, ongoing inadequate, illegible, or sloppy documentation can land you under an auditor’s magnifying glass. As far as third-party payers are concerned, if you didn’t document care correctly, it may as well never have happened. Medicare has published documentation requirements that are an excellent standard to adopt for your practice.

Bulletproof documentation

At KMC University, we help our customers and clients with forms and processes that result in consistent, defensible, reimbursable documentation. One process, for instance, might involve “translating” the third-party payer required intake information into the questions that would reflexively come up for you. The Evaluation and Management Documentation Guidelines are clear about what is required. Even if they are not in “chiropractic English.”

For example:

• Symptoms causing the patient to seek treatment = Why is my patient seeking my care? What is the chief complaint among all the aches and pains they’re reporting today?
• Mechanism of onset = How did my patient’s condition or injury happen?
• Aggravating/relieving factors = What makes my patient feel better or worse?
• Functional deficits = What activities of daily living, like sitting, sleeping and walking, are affected by this condition and causing my patient’s decreased functional performance?

Additionally, Medicare’s PART Documentation guidance is a guideline that provides straightforward direction for you to ensure that you meet your documentation obligations with ease.

Streamline your documentation and your procedures

All kinds of things can get in the way of complete and detailed documentation, from you or your staff misunderstanding the requirements to everybody simply wanting to leave at the end of a long day and relax with their families, even if all the charts are not caught up. KMC University can help you streamline your documentation procedures so that this is as seamless and painless a process as possible—and so that you get home in time for dinner.