Your Documentation: It’s Time for a Closer Look
Who truly relishes the idea of auditing documentation? Many of us choose to outsource this task to gain a better perspective on how the contents of our patient files may appear to a future auditor, since that documentation is the most crucial piece in proving medical necessity for all the work we do.
KMC University has the largest team of certified compliance specialists in all of chiropractic. This team has performed hundreds of chart reviews, and has identified the most commonly found weakness or missing elements in many files:
- Outcomes Assessment Tools: Critical for documenting a patient’s objective functional improvement regarding activities of daily living and day-to-day function.
- Diagnosis: ICD-10 guidelines require that the patient’s condition be diagnosed to the highest level of specificity. This means that the diagnoses listed should be consistent with the history and the examination findings.
- Functionally-based Subjective Complaint: Not merely referencing the patient’s pain level, but relating their pain to a documented loss of function.
- Assessment that demonstrates “Doctor Thinking”: Perhaps the most misunderstood element of a daily SOAP note, assessments relate to the patient’s progress and HOW you know the patient is improving or not. It allows for the discussion of WHY the patient may need more care.
- Initial Written Treatment Plan: Necessary to keep the patient and the doctor on track regarding scheduled care, long and short-term goals, and progress. A treatment plan is also required for Medicare cases.
While this list is far from complete, these are some of the most common problems found during an audit that could spell trouble for a practice in supporting medical necessity.
KMC University has graciously extended their offer of an insightful one-chart review to identify where the good, the bad, and the OMGs are lurking in your documentation. Through October 31, 2017 you can take advantage of this vital service, regularly $225, for just $29. A written and verbal report is included. There is just no good reason to pass up letting KMC University conduct this audit before someone who you do not choose does!
To receive this offer, visit https://www.kmcuniversity.com/store/one-chart-review and use coupon code 1CR29 at checkout. You can also call 855-832-6562 for more information.