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Our No. 1 Medicare Documentation Error

Chiro.Org Blog: We have all heard that chiropractic documentation is being reviewed by multiple Medicare contractors and that we are failing these reviews miserably. So, where are we going wrong? In this and subsequent articles, let’s address the top reasons we are failing review, starting with the No. 1 reason – our treatment plan documentation. […]

Keep Your Records Clean With SOAP

Chiro.Org Blog: There are many systems used by health care professionals to track patients’ progress, but SOAP is probably the most common format for maintaining progress notes. Using SOAP to keep clear, complete, concise, accurate, patient- and encounter- specific records is not just for medical doctors. It’s one of the best ways for the doctor of chiropractic to monitor patients’ progress, as well as to maintain complete records that can be used as a defense in third-party audits or malpractice suits. […]

Bulletproof Your Documentation

Chiro.Org Blog: A recent survey of 80 chiropractors revealed that 72 percent of them collected paperwork for their clinic from various sources, creating a patchwork effect. Because very few utilized an actual system of paperwork, they admitted concern that some documentation could fall through the cracks. So, what paperwork should you have in your office? […]

MEDICARE INFO: Cross-Referencing Regions of Complaint, PART Findings, Diagnoses and CPT Codes

Chiro.Org Blog: In 2012 the Centers for Medicare and Medicaid Services and CMS-contracted reviewers performed chiropractic Medicare reviews nationwide. The results of their efforts were not good news for the chiropractic profession. Volumes have already been written about this concern. Here, I offer a set of questions to help guide doctors in documenting the number of patient complaints, subluxations, diagnoses, regions adjusted and the appropriate billing codes. This series of questions is accompanied by comments and tables to clarify the importance of each question. […]

SOAP Notes: A Chiropractic Perspective

Chiro.Org Blog: S.O.A.P: We all learned it in school and we all do our best to follow it in our daily charting of patient encounters. My good friend Dr. Mario Fucinari expresses it as a formula: S+O=A yields P. Your subjective findings plus your objective observations equal your assessment, which leads to your plan. Simple. Easy to understand. […]

SOAP Notes: Is It Time for a Cleaning?

Chiro.Org Blog: I have been planning for some time to write an article about how traditional SOAP notes do not fit chiropractic practice, and the unfairness of holding DCs to a model clearly created for and primarily applicable to medical physicians. But Dr. Ronald Short beat me to the punch with his outstanding article, “SOAP: A Chiropractic Perspective” [March 1, 2013 issue], in which he masterfully illustrated the problem. […]

Medical Documentation Falls Short of ICD-10 Coding Demands

Chiro.Org Blog: Nearly 65% of clinical documentation doesn’t contain enough information for coders to use for billing under the upcoming ICD-10 coding system, a coding expert said here at the American College of Physicians annual meeting […]

Medicare Documentation Requirements: The Hurdle That Continues to Block Our Progress

Chiro.Org Blog: The rules for Medicare are spelled out in section 240 of chapter 15 of the Medicare Benefit Policy Manual [3] and in your local carrier’s or administrator’s Local Coverage Determination (LCD). The terminology is generally consistent; however, it can be confusing based on how the language is misinterpreted by chiropractors and those who teach documentation and coding seminars. Contrary to what many believe, Medicare documentation is not subluxation-based, even though parts of section 240 can mislead one in this direction. Why do we say this? Because “subluxation-based” to chiropractors is a different concept compared to subluxation-based to Medicare, and this fact is clearly spelled out in the rules. […]

A Critical Piece of Quality Documentation: Outcomes Assessment

A Critical Piece of Quality Documentation: Outcomes Assessment

The Chiro.Org Blog

SOURCE:   American Chiropractor 2011 (May) 33 (5): 28-34 by Steven Yeomans, D.C.

Today more than ever, chiropractors are faced with the challenge of running a busy practice and, at the same time, juggling the documenting requirements in light of Medicare audits, proving […]

Chiropractic Reaches Consensus On Terminology For Stages Of Care

Chiropractic Reaches Consensus On Terminology For Stages Of Care

The Chiro.Org Blog

SOURCE:   ACAnews ~ November 2010 By Nataliya V. Schetchikova, PhD

This article reports on the JMPT study titled:

Consensus Terminology for Stages of Care: Acute, Chronic, Recurrent, and Wellness J Manipulative Physiol Ther 2010 (Jul);   31 (9):   651–658

For […]

Alteration of Motion Segment Integrity

Alteration of Motion Segment Integrity

The Chiro.Org Blog

SOURCE:   Dynamic Chiropractic By Jeffrey Cronk, DC, CICE

Sometimes the internal discourse that is common in our profession seems to get in the way of our acceptance of real help so that we can expand our profession and better serve our patients. Alteration of motion […]

The RAND 36-Item Health Survey 1.0 (SF 36)

The RAND 36-Item Health Survey 1.0 (SF 36)

The Chiro.Org Blog

SOURCE:   Chiro.Org’s Outcome Assessment Questionnaire Page

Patient self-perception of the health care experience is becoming an important component of clinical outcomes assessment. In light of the progression toward a more closely managed health care system, chiropractors are being expected to document and […]

Details Of The Chief Complaint

Details Of The Chief Complaint

The Chiro.Org Blog

SOURCE:   A Chiro.Org Editorial By Paul D. Mullin, D.C.

Before we examine any new patient, we need to gather a detailed history, particularly of the current complaint(s). I want to thank Paul D. Mullin, D.C. of Palmer College for suggesting these 18 questions, to help […]

Writing Initial Reports

Writing Initial Reports

The Chiro.Org Blog

Do you write Initial and Follow-up Reports for Third Parties?

My office does, IF they are paid for in advance by the requester.

You may find value in reviewing templates of these reports.

Initial Report: An Outline for the D.C.

[…]

Hidden Malpractice Dangers in EMRs

Source Medscape Steven I. Kern, Esq.

An estimated 85,000 medical lawsuits are filed annually, which include those against hospitals and individual physicians. One of the highly-touted benefits of electronic medical records (EMRs) is the potential to help prevent malpractice incidents and medical errors. By providing better documentation, automatically checking for medication errors and drug interactions, […]