February 2019

February 2019

Patient Intake - 8 Essentials You Must Include

Gone are the days when patient intake involved simply welcoming the patient to your office, taking their name and number, and asking where it hurts. During recent audits in the state of Florida, there were key pieces of information found to be missing causing many offices to fail…miserably.

Medicare has attempted to educate the chiropractic profession regarding requirements for initial and subsequent documentation through published materials and trainings.  One of the best resources is found in the Local Coverage Determination (LCD) document on the Medicare Administrative Contractor’s (MAC) website. Although Medicare clearly states and sets forth their requirements, many offices remain unaware of what is required.

Keep in mind that Medicare is not the only payer that has specific guidelines regarding documentation. Many other payers have similar, or even more stringent requirements. For this reason, becoming very acquainted with the requirements/policies of any payers that you submit claims to is a smart strategy.

What You Need to Know:

Whether you are treating a new patient, or simply beginning a new episode of care, you should make certain that your intake paperwork, or electronic documentation software is prompting you with the following questions and details:

  1. What symptoms are causing the patient to seek treatment?

  2. Is there any relevant family history?

  3. General overview of past health history:

    • General health

    • Prior illness

    • Past injuries

    • Routine medications

    • Hospitalizations

    • Surgeries

  4. Mechanism of trauma

  5. Quality and character of symptom(s)/problem(s)

  6. Symptom details:

    • Onset

    • Duration

    • Intensity

    • Frequency

    • Location

    • Radiation

  7. Aggravating/Relieving Factors

  8. Secondary Complaints, and Prior:

  • Intervention

  • Treatment

  • Medication

Remember, just because you are receiving reimbursement does not mean all is well. If suddenly targeted for an audit, you will very likely have to reimburse the insurance carrier for those funds unless proper requirements are met, and you are supplying carriers with the information they require.

If you’re in need of a detailed Patient Intake paperwork system, The Paperwork Project has exactly what you need!