Many chiropractors believe their documentation is rock solid.
But facts don’t bear this out. Recently the HHS Office of Inspector General (OIG) reported that as many as 94% of chiropractic records are missing some key element. Like the vast majority of automobile drivers who believe they are “above average” drivers, documentation audits tell a different story.
Under- and over-coding E/M services
Do you use whatever code “feels” right based on the amount of time you spend? That means you’re guessing, using a code that may be too high or too low. Both over- and (surprisingly) under-coding constitute major red flags. Auditors keep a sharp eye out for those who fall outside normal billing patterns and inspect their records more closely.
Coding and documenting incorrectly
Granted, you should code based on the treatment you provided. But if your documentation doesn’t support the code, it’s another red flag. These are often found in post-payment audit reviews, and can cost you thousands of dollars in repayment. Consider this a heads up to make sure your daily documentation record and billing record precisely match.
Cloning records or rote justification of medical necessity
When documentation is a copy-paste effort and statements like “same as last visit” pepper the daily notes, it’s difficult for a third-party reader to determine the necessity of the visit. Standard guidelines dictate what must be included. Make sure each visit’s documentation is “encounter-specific” and stands on its own.
“Yeah, there must be a lot of messed-up practices out there, but our documentation is fine, after all, we use the XYZ software package.” Careful. Your software is merely a tool. It can help you more quickly fulfill your obligations—or more quickly make costly documentation errors.