Mastering Chiropractic Records: Transforming Documentation From Denial to Dynamic Posted on Sep 28, 2023
Introduction | Chiropractic Online CE Is The Key
CCEDseminars | Continuing Education For Chiropractors!"We've got it covered," many chiropractors say when it comes to documentation. However, statistics and experience tell a different story. Transform your chiropractic records from a weak point to a strong asset in your practice.
The Importance of Accurate Records
The HHS Office of Inspector General (OIG) reports an alarming 94% error rate in chiropractic records. These errors can lead to issues with medical necessity, treatment plans, and even contraindications to treatment, making your practice vulnerable to audits and financial penalties.
Real-life Cases: From Denial to Dynamic Documentation
Even chiropractors confident about their documentation often make errors that can compromise their practice. A client, who came to us for a documentation review, was stunned to find her Medicare documentation error rate was at a staggering 100%.
Turning the Tables: Strategies for Dynamic Documentation
Here's how you can transform your documentation:
D-Distinguish
Differentiate between active treatment and maintenance care records. Utilize templates and macros to ensure essential elements are captured for each treatment type.
Y-Yearly Training
Stay current by connecting to trusted sources like CCEDseminars for continuing education credits in chiropractic online CE, documentation updates, and compliance guidelines. Click HERE for awesome chiropractic online CE resources!
N-New Patient/New Episode
Initial visits should have detailed history, exam, initial assessment, diagnosis, and treatment plan to lay the foundation for medical necessity.
A-Audit Regularly
Conduct periodic documentation audits to meet statutory requirements, detect fraud, and ensure continuous improvement.
M-Master Medical Necessity Definitions
Understand the definitions of medical necessity as stipulated by payers to ensure compliance.
I-Initiate Correct Coding
Ensure your billing codes match the treatment documentation to avoid red flags during audits.
C-Cloned Records – A Thing of the Past
Avoid "same as last visit" documentation. Each treatment should be encounter-specific.
Conclusion
Your documentation practices can greatly influence the success and longevity of your practice. Ensuring that your records are accurate, comprehensive, and compliant is crucial for practice sustainability. Click HERE for even more incredible learning opportunities from medicare to PI!