Bulletproof Your Documentation

This section is compiled by Frank M. Painter, D.C.
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Thanks to Chiropractic Economics for access to this article!

By Kathy Mills Chang

Part 1: Ensure your admitting and ongoing paperwork isnít slipping through the cracks

Because of the many different techniques and philosophies involved in chiropractic, you can be assured different doctors utilize different admitting and ongoing paperwork.

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?


Most state chiropractic boards that have a standard of care for patients include taking patient history. If one were to follow the evaluation and management documentation guidelines, history is a significant portion of the value.

Because the requirements entail collecting information about the chief complaint; the history of the present illness; a review of systems; and the patientís past, family, and social history, there is a substantial amount of information that can and should come from the patient.

Having information laid out in a clear fashion on your admitting paperwork allows the patient to answer the majority of the essential initial consultation questions. Using your admitting paperwork as a template allows you to ensure the required bullet points will be answered by the patient and reviewed by the physician.

A simple review of the evaluation and management requirements for the history section should allow you to compare your existing initial paperwork to be ideal. Make sure you have ample space available within your questions to make physician notes, as these become part of your permanent record.

Some doctors prefer to have a separate consultation sheet to review this information. Others prefer to have space available within the patient history to save time and create efficiency in the consultation process.

Guidelines for the requirement of initial patient history can be found in the Center for Medicare and Medicaid Services (CMS) Evaluation and Management Documentation Guidelines, your state board of chiropractic examiners documentation rules, or medical review policy from individual insurance carriers you participate with.

In order to ensure your history meets all of the requirements, gather all of these and compare your initial admitting and follow-up paperwork to be sure yours pass muster.

Additionally, many doctors hoping to improve their documentation and recordkeeping choose to include in the history questions related to the patientís activities of daily living deficits. When selecting functional goals in your treatment plan, this information is invaluable.


The clinical examination is the doctorís opportunity to expand upon objective findings discovered in the initial or follow-up visits. Your examination form should be complete with all major tests expected to meet the standard of care required in your examination.

A thorough understanding of the CMS Evaluation and Management Guidelines assists in knowing minimum requirements for the various levels of coding used in the office.

While it is important to list all possible tests that could be performed, remember that a form listing every test in the chiropractic profession could cause problems should you find yourself on the witness stand or in an audit.

If you elect not to perform a particular orthopedic or neurological test on the list on the patient, you must indicate on your record, ďNot performed,Ē or, N. P. ó then you must prepare yourself to be asked why you elected not to perform that test.

Because periodic follow-up examinations performed within the same round of episodic care require the doctor to repeat positive tests from the first exam, itís often helpful to have subsequent examinations listed on the same form. This makes it easy to review your initial exam and follow up what is necessary at the periodic re-evaluation.

However, should the patient return for care for a new episode, it would be prudent to utilize your initial exam form again and start from scratch.

If you feel you need a review of the most common orthopedic and neurological tests performed, the book, ďPractical Assessment of the Chiropractic Patient,Ē by K. Jeffrey Miller, DC, DABCO, is recommended.

Or, you can review Schafer's

Orthopedic and Neurologic Procedures in Chiropractic

The CMS Evaluation and Management Guidelines layout an explanation of what is expected in the examination portion of your evaluation and management service. These guidelines indicate the recognized body systems that should be included in the exam as well as the recognized body areas.

For example: It is often a surprise to chiropractors that the six body areas recognized are listed as follows: head and neck; spine, ribs, and pelvis; right upper extremity; left upper extremity; right lower extremity; and left lower extremity.

Based on a typical examination that would include the head, neck, spine, ribs, and pelvis, a doctor would only have met the requirement for two body areas. This may be far more limiting to your ability to code appropriately than you may realize. Be sure you collect the evaluation and management guidelines and compare with your existing examination form.

Remember, this examination carries tremendous weight in establishing medical necessity. Therefore, make sure your form meets all of the requirements.


There are many ways doctors choose to list the diagnosis that is part of the treatment record. The diagnosis goes along with the entire treatment episode so itís important to list all of the appropriate diagnosis codes.

If the doctor chooses to include massage in the plan, a muscle-related diagnosis is necessary. Likewise, disc-related treatment should be warranted by a disc diagnosis code.

One of the easiest ways to accomplish this, not only to make it easy on the doctors, but also creating ease for the staff, is to have a master diagnosis sheet. This diagnosis sheet would contain all of the potential diagnosis codes you would typically use and be available as part of the record.

Ideally, these diagnosis codes would be divided and categorized. For example: Muscle-related diagnosis codes, disc-related diagnosis codes, and other tissue-specific diagnoses would be grouped together.

Itís important to review all of the diagnosis codes you use on a periodic basis. Because changes occur almost every year, itís also important to get a diagnosis reference manual and update your form periodically.

The beauty of having a diagnosis sheet is they can become part of the record and be placed together with other paperwork grouped by episode of care. In a paperwork system, these various forms, including the diagnosis sheet, could be color-coded. That way, the beginning, middle, and end of an episode could be obvious in your patientís chart.

Remember, just because you hand the diagnosis codes to your team to enter into your practice management software, does not mean the patientís record contains the diagnosis, which is a requirement. Use of a diagnosis sheet alleviates these concerns.

This review is only effective if you use it to compare it with what you already have. If you feel your paperwork could use a tune up, there are many options.

For example: Many practice management companies have put together systems of paperwork. Companies, such as Parker Share, have paperwork available for purchase. You can also check out www.newpatientpaperwork.com to read about a complete paper documentation system now available for doctors in the profession.

Part 2: From treatment plan to discharge, is the rest of your documentation good to go?

In the previous issue, the first three items recommended for bulletproofing documentation were discussed: history, examination, and the diagnosis paperwork.

The remaining paperwork necessary to bulletproof your documentation includes the treatment plan, functional daily notes, the re-evaluation, and the discharge.

Treatment plan

Doctors of chiropractic have a wide and varied view of what constitutes a proper treatment plan. It is not unusual to describe your treatment plan with what is actually a care plan.

The purpose of a treatment plan is to identify everything you intend to do with the patient and why. The definition of a care plan is more than likely the number of visits you expect your patient to come in for care.

Because the treatment plan goes a long way toward establishing medical necessity for the care you wish to render, it is important to include everything you may decide to do. It is recommended you include all the possible care you may wish to render as a template, and then customize it for each individual patient.

A properly written treatment plan includes a variety of components.   Medicare discusses a minimum of the following four components:

  1. Frequency and duration:   The length of time you expect to see the patient.

  2. Active goals:   The short- and long-term functional goals you hope the patient reaches.

  3. Measurable tools:   The objective tools you will use to evaluate treatment effectiveness.

  4. Initial date of treatment:   The indication of what date this treatment plan began.

If you are creating paperwork to assist you with documenting medical necessity and recording your documentation, it makes sense to let the paperwork do the majority of the heavy lifting. This means the paperwork will act as a template reminding you of those things you need to fill in.

The treatment plan is one of the most important components of your documentation. Nothing goes as far to establish medical necessity as your plan of care.

It is helpful to think of laying out your treatment plan in a way the reader can easily discern not only your plan, but also why you intend to do it.

The following is a model for laying out your treatment plan.

For each of the chief complaints your patient has, complete the following: the patient has (list complaint), creating (which) functional deficits, causing me to diagnose (insert diagnosis), and recommend treatment of (list each specific treatment you wish to render), with , with frequency and duration of (list the frequency and duration for each treatment), until we reach the following short-term or long-term goal (add short-term and long-term functional goal).

Functional daily notes

The paperwork required to formulate excellent daily notes does not have to be difficult to complete. In fact, if youíve done a great job establishing your case in items one through four, keeping functional daily notes will not be difficult.

It is often best to make the notes you use something that fits with the flow of your practice. Because certain requirements must be included on a daily basis, make sure your paperwork lists each one in detail.

For example: A requirement of daily notes is to address the patientís history. This means you should review each chief complaint and determine if the patient is doing better, worse, or staying the same.

Additionally, there should be an examination in each area you have a diagnosis. These are factors that assist you in determining an evaluation of the effectiveness of the treatment. You must always indicate, especially for Medicare, the segments you adjusted.

Many daily notes templates will have all of the segments listed from C1 through the sacrum. Each segment adjusted can easily be circled.

Be sure to review any documentation requirements set forth by carriers with whom you participate on contracts. A review of your state board requirements, these contracts, and other medical necessity guidelines can assist you in knowing whatís required on a daily basis.

It makes the most sense to configure your daily notes paperwork so each item required can easily be answered in an efficient manner during a patient encounter.


Because so many carriers require you show progress within two to four weeks to establish medical necessity, itís vital that appropriate re-evaluations are conducted at periodic intervals.

In order to address any positive findings from the initial examination, have appropriate paperwork that allows you to review these findings with ease. Many offices choose to list more than one exam on the same form. Because of this, the doctor is able to review the initial examination findings and repeat only those tests that were positive the first time. Having them aligned side-by-side allows the doctor an efficient manner for performing the required tests.

Because an evaluation and management service can also include a history component, readdress historical information at the time of the re-evaluation.

These questions should include items such as percent of improvement since the initial exam, any new injuries or incidents since the original examination, and the patientís assessment of his or her progress.

For that reason, many offices choose to have paperwork that will ask specific questions from the patient immediately prior to this re-evaluation.

Additionally, if you use outcome assessment tools, this is a great time to recheck those values and score them to determine the objective percent of improvement.


While a form may not be necessary to discharge a patient, it is helpful to lay out all of the reasons why the patient may be discharged so you are able to check off the appropriate option.

Remember, when you come to the end of the treatment plan and the patient has met his functional goals, itís appropriate to discharge him from active care.

Another advantage in having a system of paperwork beginning with initial history and ending with the discharge is that it is easy to discern the beginning, middle, and end of the treatment episode.

Laying out all of the reasons a patient may be discharged from care is easy to do. Whether the patient is discharged because the functional goals are met or whether itís administratively because he or she dropped out of care, indicating this allows the reader to see the episode of care has ended.

This review of paperwork in the system is most effective if you use it to compare with what you already have. If you want to tune-up your paperwork system and have forms that are integrated and work together to assist you with reporting medical necessity, look for something with a common look and feel.

If your paperwork system is easy to use, documentation will not feel like such a chore. Make sure your system of paperwork works for your practice and with your personality.

Knowing your paperwork assists you in meeting all of the requirements of documentation will allow you to be in present-time consciousness with the patient.

You can sleep well knowing your documentation is all that it can be!

Kathy Mills Chang is the founder of her own consulting firm, assisting doctors with finding financial and reimbursement ease in practice. She also serves as Foot Levelersí insurance advisor. She can be reached at info@kmcuniversity.com or through www.kathymillschang.com.


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