Better Documentation,
Better Reimbursement

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:    Frankp@chiro.org

Thanks to Today's Chiropractic Dec 2002 for permission to reproduce this article!

By Craig Berko, D.C.

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You don’t have to file forms in triplicate, but proper documentation creates proper reimbursement, giving you consistency when it comes time to analyze your profit margins.

Though Shakespeare’s character Hamlet never asked, “To document or not to document?” this question should be answered in your office as soon as possible. And here are two reasons why: Can you say “medical necessity” and “over utilization”?

Here’s another question to ask yourself, “Do you have a compliance program in your office?” Such words are the chosen language of the new millennium. If you haven’t started a compliance program in your office yet, now is the time. A program of self-monitoring and self-audit works to ensure that federal and state mandated issues are complied with in your office.

Two important compliance issues and reasons for frequent third-party review and possible audit are proper documentation and proper coding. I will share with you below why and how to initiate a compliance program properly and begin a new era of business in your practice.

Recently I visited a chiropractor who, like many D.C.s, was being audited by a major insurer and had realized that the “travel card”—the 1970s version of “documentation”—was insufficient to verify necessity of chiropractic care.

Many of you may be asking, “What’s with having to prove medical necessity when I went to school to become a chiropractor?” Here’s a “mindset” tip: Simply substitute the word “chiropractic” for the word medical, but understand that you still must prove necessity of care for the third-party payer. Don’t get emotional—get smart!

Due to insufficient and improper documentation, the audited D.C. was charged with practicing under the standard of care and “over utilization,” the buzz phrase of the late 1990s. The next step in the audit process was a reimbursement, this time by the D.C. back to the insurance company for all those so-called unnecessary visits. This occurred because insufficient notes did not back up necessity. Making matters worse, the insurer then advised the Agency for Health Care Administration (AHCA), which notified the state Board of Chiropractic, who then charged the doctor with improper documentation according to state laws and rules.

Here’s an immediate suggestion: Designate travel cards for internal use only. You should have a system in place that allows a more complete documentation of what took place on each visit. We suggest a full narrative for that first report in complete detail, whether the patient was involved in a trauma or not. Make sure that if you also take X-rays, that the narrative also includes complete details of your radiological findings. If you take a single X-ray, do not just write down subluxation listings on the travel card and call that your report.

Being compliant in your office in regard to documentation basically says that no matter how the patient is paying for care, complete and proper documentation will take place. It’s not to say some travel cards are not sufficient; perhaps some may be provide more in-depth data than others. Here’s the rule: Patient care and proper documentation go hand in hand.

Your first step is to exchange some of your old techniques with some updated ones. You can still make use of the SOAP notes format, but those abbreviations and making circles and check marks have to go, unless they are for internal use only and more complete notes are being recorded to bring your office up to compliance.

There is an interesting note on the use of the travel card. What it was designed for and what it has turned out to be are entirely different things, and it is perhaps the most outdated procedure in chiropractic. Are you still using the same travel card copied from the D.C. who inspired you to pursue a chiropractic career? Do you still make use of the same abbreviated circles and check marks with the capability of 20-25 visits on two sides, and then consider these your notes? In all likelihood, using this system of documentation can only lead to a red flag and a 30-yard penalty!

The travel card used in the above way is as outdated as purchasing a steel square lunch box for your child’s upcoming school year. In the “old days,” the travel card had a different purpose. Chiropractors provided their patients with a small card, the perfect size to be placed into the pocket (especially when traveling) and on it were the patient’s X-ray listings. Another D.C. in a distant town could refer to this small card, thus allowing a patient to receive care from a chiropractor wherever they were.

Then came the super duper version of the travel cards, probably brought on by third-party insurance and the beginnings of documentation. This card had all those abbreviations where you circled either 1, 2, 3 or 4 for the amount of pain the patient is in, not taking into consideration whether it was pain down the arm or a burning sensation in the lower back. All subjective symptoms had no names or description; they were simply numbers 1, 2, 3 or 4. Now we know what it must feel like to be salami waiting to be called upon at the local supermarket. And then you simply circled Y or N on whether the patient was treated during their visit. Forget what procedures were performed. The main thing was that something was done on that visit.

The point is that if there’s no key explaining every abbreviation, initial, circle, check mark or number, and your chiropractic assistant can’t understand it, can you imagine what thoughts an insurance adjuster might have? How about your state Board of Chiropractic, or worse, a plaintiff attorney in a malpractice case against you?

Here’s the problem: If you were audited by your state board and asked to review your file on a particular patient, that file would be incomplete and “non-compliant” in regard to medical necessity and proper documentation with the use of an inadequate travel card. Without proper documentation backing the necessity to see the patient and use procedures on the patient, it would be deemed “over utilization,” a phrase that you do not wish to hear from an insurance company or your State Board of Chiropractic.

The Office of Inspector General has recommended that all health-care providers create self-audits and self-monitoring procedures. They state that causes of investigation from regulatory boards and third party insurers likely would arise from:

• proper coding and coding;
• services that are reasonable and necessary;
• documentation accuracy; and
• avoidance of inducements and kickbacks.

If you do not wish to take the time to stay code compliant with regard to proper documentation for medical necessity, try calling upon one of the many fine chiropractic suppliers of documentation technology.

Some D.C.s have hired a chiropractic assistant to follow them from room to room to just document a patient’s entire visit. But what about re-exams? Do you have to create documentation for that, too? If you did it, then there must be a report of your findings in your file. Here’s a tip: Your care plan and proper documentation go hand in hand. And no matter how the patients are paying, there must be proper note taking.

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Craig Berko, D.C., is vice president of client relations and compliance at AccuMed Data Management, Inc, a company which specializes in chiropractic insurance reimbursement, billing and collection. If you would like an up-to- date diagnosis chart, please fax your request to (954) 425-4095. For more information, visit accumeddata.com or e-mail cberko@accumeddata.com.

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