“MORE DOCUMENTATION, YES,” said no chiropractor ever. Health record documentation is the most difficult—and unrewarding—part of being a good doctor. However, proper documentation is critical for patient care quality and compliance, especially when defending against audits. This article dives into the most common errors in chiropractic documentation and how to avoid them.
Understanding the difference between clinically appropriate care and medically necessary care is vital. Medically necessary care meets a higher standard and varies based on payer types or even board of examiners. Always ensure your documentation includes all the necessary details to establish medical necessity, from initial intake and history to a well-defined treatment plan. Click HERE for more information!
Your coding should always align with what's in the documentation. Incorrect coding not only leads to audit failures but also negatively impacts the chiropractic profession. For example, treating the full spine when the patient has a complaint only in the neck and billing for multiple spinal regions is incorrect. Always ensure your documentation and coding match.
Failing to document services is an egregious error, and one that can have severe consequences. Always maintain comprehensive records for each patient. Records should be signed and dated, in chronological order, to meet compliance guidelines.
Using techniques and therapies that are considered experimental or investigational by third-party payers can be a tricky area. These require specific documentation and possibly patient consent to proceed. Always check the medical review policy of the payer you're billing to understand these limitations.
An unsigned note is incomplete. Always ensure that all notes are signed by the respective provider to avoid issues later on, especially with electronic health record (EHR) systems.
Documentation may be a challenge, but it's a crucial aspect of a well-functioning chiropractic practice. Being vigilant about avoiding these common documentation errors will not only improve your practice's compliance but will also contribute to better patient care.
For those who are looking to further hone their skills in this area, consider enrolling in chiropractic CE courses that focus on documentation best practices. CCEDseminars offer a range of options to help you stay ahead of the curve and ensure that your practice thrives.
Through comprehensive understanding and constant improvement, you can elevate your documentation practices, improving both compliance and your bottom line. Click HERE for more clinical pearls!