"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 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.
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%.
Here's how you can transform your documentation:
Differentiate between active treatment and maintenance care records. Utilize templates and macros to ensure essential elements are captured for each treatment type.
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Initial visits should have detailed history, exam, initial assessment, diagnosis, and treatment plan to lay the foundation for medical necessity.
Conduct periodic documentation audits to meet statutory requirements, detect fraud, and ensure continuous improvement.
Understand the definitions of medical necessity as stipulated by payers to ensure compliance.
Ensure your billing codes match the treatment documentation to avoid red flags during audits.
Avoid "same as last visit" documentation. Each treatment should be encounter-specific.
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!