September 2019

September 2019

 A+ Documentation

Once chiropractic school is over, you assume you are finished with the homework and tests, right?  Think again.  Sometimes doctors must put in extra time outside of patient hours to complete their documentation. While you shouldn’t have to pull all-nighters to get your notes finished, it doesn’t hurt to double-check your records to ensure they are both complete and compliant. After all, insurance companies can request to review them, and you better believe that they are grading you. Do well, and they will reimburse you for the claims that you submit. If you are missing critical components to your documentation, expect that they are going to further scrutinize and maybe even ask you to pay back the money. 

At one time, the HHS Office of Inspector General (OIG) reported that as many as 94 percent of chiropractic records were missing or inadequately presenting key elements. That statistic has remained steady over the past several years. Many doctors believe that their documentation is “fine” but is it enough to put them in the top 6%? Here are some tips to get you to the head of the class in Documentation 101:

Cut Back on Your SALT

It can be very tempting to copy and paste notes or just use the phrase “Same as Last Time,” especially if the patient is seen multiple times per week for a commonly treated condition. This can make it very difficult for third-party payers to determine the medical necessity of the services that were provided. Your daily visit notes should include information about the patient’s progress toward functional goals. Use all 4 parts of the note (Subjective, Objective, Assessment, and Plan) to make the note encounter specific as it tells the patient’s story. 

Code and Bill What You Document

Your documentation needs to be detailed enough to support the services that you provided. The chiropractic manipulation codes 98940-98942 are based on the number of spinal regions that were treated for a medically necessary complaint. The specific spinal levels that were treated should be listed in order to be considered for reimbursement.  When billing for timed therapy codes, indicate how many minutes the service was performed and what exercises or muscle work was done. And don’t forget to properly document E/M services. The CPT code you use depends on how detailed the history, exam, and medical decision-making process was. When any of this vital information is missing from the documentation, you may be inadvertently upcoding, down coding, or omitting billable services. If you bill for more services that you can prove in your notes, expect to have to repay some of that money if you are selected for a post-payment audit review. Billing a lower level service than what was provided is also a red flag to insurance companies.  Either way, you will be cheating yourself out of your hard-earned money. 

Have a Plan

As they say, “You can’t reach your goals if you don’t have a plan.” This is why it is crucial to maintain a written treatment plan for all patients. It should list specific, measurable, functional goals and outline what services will be needed as well as the estimated time frame that it will take to accomplish them. Both short term and long-term goals are important to ensure that the patient is staying on track. There are times when patients don’t meet the expected goals and that’s ok.  Unforeseen setbacks and poor patient compliance are just some of the reasons a patient’s progress may have stalled.  These issues need to be explained in the notes and re-evaluations. If the prescribed treatment seems to be ineffective dig a little deeper to find out whether a change in diagnosis or treatment protocols is needed. There is no sense in doing something over and over if it isn’t working. When a third-party payer sees that the patient is no longer improving, they may consider the services not medically necessary and stop paying for them.

Check Your Homework

It is a hundred times better for you to find your own mistakes and correct them than to have it discovered after a records request from the patient’s insurance. If errors are discovered in one patient’s chart, it will be assumed that other patient files have errors. You become an easy target for a large post-payment audit. To help prevent a major headache and blow to your pocketbook, perform self-audits in your office to review your documentation, billing, and coding. Not only is this a good idea to help give you some peace of mind, it is a required part of your office’s OIG compliance program.

Making the Honor Roll

Could your documentation pass the test?  Keep in mind that documentation is a group project. The treating doctor may be the one that understands the patient’s condition and the rationale for treatment, however, scribes, chiropractic assistants, and billing staff can all help to make sure that the documentation is organized and accurate. If you find areas where you need improvement, practice makes perfect. Keep trying and keep learning. Your efforts will earn you a gold star before you know it.


Dr. Karen Sedore has over 10 years of experience working in the chiropractic profession. She began as a manager specializing in billing and medical necessity as well as taking on chiropractic assistant responsibilities so that she could be more involved with patient care. She also has experience with income tax preparation and has helped hundreds of families and small businesses with tax planning. In 2016, Dr. Sedore received her doctorate in Chiropractic from National University of Health Sciences. She joined KMC University in 2017 and assists doctors and their staff in her current role as an Membership Advisor.

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