Is your paperwork or electronic documentation software prompting you with these questions for your initial visit documentation, whether a new patient or a new episode of care? Are you including these details?
1. Symptoms causing the patient to seek treatment
2. Family history if relevant
3. Past health history (general health, prior illness, injuries, or hospitalizations medications, surgical history)
4. Mechanism of trauma
5. Quality and character of symptoms/problem
6. Onset, duration, intensity, frequency, location and radiation of symptoms
7. Aggravating or relieving factors
8. Prior interventions, treatments, medications, secondary complaints
Are you supplying the information that carriers want?
Reimbursement checks may still be showing up in the mail, but realize that when they target you for an audit, if you haven't hit the marks above, you may have to give some of the money back.
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