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Chiropractic documentation gap analysis

Recognize what’s missing to master your reimbursement and collections!

This Documentation Gap Analysis allows us to evaluate the significant components of your current Documentation program. It should take less than 5 minutes to complete.

Take The Billing GAP Analysis
Telemedicine

Need more guided help? Work with a KMC coach 1-on-1

Sometimes you need more than a self-service, on-demand program and need an expert to analyze your issues, train the corrections, and help you implement the changes, so they stick

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Dr Alan Sokoloff 1

New Course Available!

This course explains the significant role chiropractic care can play in the sports industry and how a DC can succeed as a Sports Chiropractor. Start your steps to success here!

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OIG

There's no need to fear the OIG. We've got your back!

The most effective chiropractic OIG compliance programs are scaled according to the size of the practice!

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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.

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I just wanted to touch base and let you know how much you have helped my daily routine. I just can't tell you how much time and effort I have put in trying to figure out and correct the modifiers on our claims. We have been putting those in by hand and as you can well imagine there were many errors and many times our claims were stopped or just not paid. It seems to me half my life was spent trying to figure out just why we weren't getting paid. I am in awe of how you just clicked buttons and made my life so much easier. I can't thank you enough. I have a pile of old corrections to fix and after that I am done with this issue for good. I am working hard on my homework and although it is extremely difficult and tedious I do see light at the end of the tunnel. Just want you to know I appreciate more than you will ever know. Thanks again.

Peggy Mitchell