The Documentation Section @ Chiro.Org is devoted to a full description of what
is considered “complete” patient file documentation by the Chiropractic Schools,
National Associations, and Third Party payors.
This section was compiled by Frank M. Painter, D.C. Send all comments or additions to:Frankp@chiro.org
If there are terms in these articles you don't understand, you can get a definition from the Merriam Webster Medical Dictionary. If you want information about a specific disease, you can access the Merck Manual. You can also search Pub Med for more abstracts on this, or any other health topic.
This section is devoted to a full description of what is considered “complete” patient file documentation, as described by National Associations and Third party Payors. It is the intention of this page to inform our profession about the most efficient means of communicating patient information, as well as outlining what is considered an “adequate” presentation. It is not the intention of the Documentation Section to create standards – just to clarify them.
Proper documentation in the 21st Century will place an increasing burden upon today's providers. Having a clearer understanding of what information to gather, and how to transmit it to other interested parties, may help to reduce that burden.
There are a variety of reasons why a patient file should be clear and complete:
It captures the clinician's thought processes;
It captures patient progress since care was initiated;
Benefit determinations by Third-Party Payors are heavily influenced by record review;
and, malpractice actions are based on what is documented, not on recollections after-the-fact.
This page will continue to develop. I would like to add a complete section on office forms which will focus our exam and simplify reporting those findings.
Explore the shift from Guidelines, often containing numbers/ suggested treatment time frames, to “Best Practices”, which are clinical decisions informed by the best evidence available, and balanced by patient complexity and provider experience.
Our original Guidelines section contains a compendium of Guidelines from around the World, as well as a selection of articles about the need for, and frequent misuse of these Guidelines.
The SOAP Notes Page
A Chiro.Org article collection
The SOAP Notes Page contains articles about using daily notes more effectively.
What is Medical Necessity?
A Chiro.Org Editorial
Medicare defines “medical necessity” as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. From an Insurers standpoint, this is why documentation of the patient encounter is so important. The standard note taking format for every patient encounter is the SOAP note. Medical (chiropractic) necessity is defined by your own notes. Let's review what actually defines reasonable and necessary in the SOAP note.
Medicare Documentation Requirements:
The Hurdle That Continues to Block Our Progress
Dynamic Chiropractic ~ January 26, 2010 ~ FULL TEXT
The rules for Medicare are spelled out in section 240 of chapter 15 of the Medicare Benefit Policy Manual  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.
The Differences Between ICD-9 and ICD-10 CodingPDF
American Medical Association Fact Sheet #2 ~ FULL TEXT
This is the second fact sheet in a series and is focused on the differences between the ICD-9 and ICD-10 code sets. Collectively, the fact sheets will provide information, guidance, and checklists to assist you with understanding what you need to do to implement the ICD-10 code set. The ICD-10 code sets are not a simple update of the ICD-9 code set. The ICD-10 code sets have fundamental changes in structure and concepts that make them very different from ICD-9. Because of these differences, it is important to develop a preliminary understanding of the changes from ICD-9 to ICD-10.
Documentation for the Pediatric Practice
By Claudia Anrig, D.C. ~ FULL TEXT
Over the years, each chiropractic office usually develops its own style of documentation for rendering care to the pediatric patient. The intent of this article is not to set a standard that should be universal, but rather to provide an opportunity for family chiropractors to re-evaluate their documentation protocols and to possibly invite new ideas to their procedures.
Documentation for the Pediatric Practice: Part II
By Claudia Anrig, D.C. ~ FULL TEXT
This article updates information I provided in an article several years ago (Nov. 18, 2004 DC), in the hope that I can shed additional light on ways to improve this overlooked area of practice. The intent of this article is not to set a standard that should be universal, but to provide an opportunity for family chiropractors to re-evaluate their documentation protocols and possibly invite new ideas to their procedures.
Surviving the Scrutiny: New Efforts to Expose Fraud and Recover
Overpayments Puts Health Care Providers Under the Magnifying Glass
ACAnews June 2006 ~ FULL TEXT
If your documentation and coding are in order, experts advise that a file review shouldn’t pose a problem. The 2005 HHS Office of the Inspector General (OIG) report, however, warned that 94 percent of chiropractic records are missing or inadequately present some key elements — evaluation, a treatment plan, medical necessity, and/or contraindications to treatment. Thanks to Nataliya Schetchikova, PhD and the ACA News, newspaper of the American Chiropractic Association, for permission to reproduce this article exclusively at Chiro.Org!
Colossus and Clinical Documentation
There is a computer program called Colossus which is being used to determine what is reasonable and necessary treatment, especially in personal injury claims. Let's review what aspects of documentation are improtant to track over time.
Documentation Requirements ~ Understanding Medicare PDF
The Association of Chiropractic Colleges
This 8-page Adobe PDF file first reviews common misinformation about Medicare coverage, then reviews the essentials of proper file documentation, and then covers the proper way to fill out the HCFA form.
Bulletproof Your Coding, Fees, and Documentation
The cause of low reimbursement doesn’t always lie with the payer, however. It may be the result of improper coding and documentation by the provider. By understanding how the coding process works, we can more easily develop our coding and fee schedule for our office to assure maximum reimbursement. Let’s address the three major points your office must be aware of in order to assure proper reimbursement. You may also want to review our Chiropractic Assistant Section.
Documentation Protocols for Chiropractic Office Visits
More than ever, adequate documentation of patient encounters is an essential part of patient care. Here are some guidelines for record keeping which may serve to focus your attention on this important aspect of practice.
How Insurance Companies Define Medical Necessity NJ Division of Insurance
This FULL TEXT article describes terms like
“Clinically supported”, “Eligible charge”, and the ever popular “Medically necessary” or
“medical necessity”. If you have had your charges reduced for failing to demonstrate medical necessity, then the Documentation Section is for you!!!
How Do I Justify the Medical Necessity of My Care? Part I: Overview
Dynamic Chiropractic ~ May 17, 1999 ~ FULL TEXT
Today, managed care organizations (MCOs) attempt to contain costs. This puts great strain on the ability of health care providers to get reimbursed for what they feel is reasonable and necessary care. This article describes how to identify what is reasonable and necessary care and how to justify appropriate reimbursement.
Part II: The Roland-Morris Questionnaire
Dynamic Chiropractic ~ June 14, 1999 ~ FULL TEXT
This paper will address a simple outcome for use in low back pain patients to document progress over time. It is essential to measure and monitor patient progress with robust outcomes so that the value of our care may be judged by an independent third party. Medical necessity is determined or argued for by this simple process. It is neither time consuming nor expensive. However, the knowledge and skills to implement this do require training.
Utilization Review: How to Win the Insurance Game
As a chiropractor providing peer reviews, let me assure you that it's nothing personal. From the insurance industry's standpoint, it's merely a means to an end; question enough doctors and eventually you will find someone providing improper treatment. In the quest to "manage care," insurance companies are now becoming faster at ordering independent reviews to determine necessity.
Documentation Challenges in Peer/Utilization Review
Dynamic Chiropractic ~ March 8, 1999
It is difficult to provide adequate documentation when a doctors has a high volume practice. This was the reason that travel cards were born and continues to be one of the primary reasons cases are denied. That a doctor can't get the appropriate documentation down on paper is no rationale for arguing with a reviewer. I have the answer: dictation! The quality and thoroughness of dictation far outweigh travel cards, check-off systems, computer-generated notes and handwritten entries. It is legible, pertinent and easy to do.
Improving Medical Documentation PDF
Medicare Part B Bulletin -- November 2000
This Adobe PDF page describes Medicare's efforts to improve the use of E&M codes, and has some interesting comments on the quality of medical documentation. Enjoy!
Selected Errors in Documentation Reporting
Dynamic Chiropractic ~ November 7, 1990
Contrary to perceptions regarding the review of claims, it is seldom that any insurance company intentionally sets out to cut benefits to either the practitioner or the patient/customer. What is sought is the appropriate expenditure of benefits for services appropriately provided, under the terms of the insurance contract.
Documentation of Physical Capacity: It's Purpose in Rehabilitation
Dynamic Chiropractic ~ April 3, 2000
Patients need clear goals to change behavior. Workers' compensation case managers also want to see a clearly expressed goal of care. Alongside identification of activity intolerances from functional questionnaires (e.g. Oswestry), examination of physical capacity deficits provides objective, quantifiable data from which realistic end points or goals of care can be established.
This section reviews guidelines for proper Record Keeping from various State and National Associations.
The Initial Exam
This section reviews guidelines for Initial Examinations from various State and National Associations.
This section reviews guidelines for documenting Patient Progress from various State and National Associations.
Clinical Documentation The American Chiropractic Association
Representatives from 13 of the largest insurers in the United States met with ACA representatives during the second meeting of the ACA-sponsored Claim Solutions Work Group. Based on the suggestions made during this meeting and on recent trends, ACA recommends certain basic requirements be considered as appropriate clinical documentation in patient record keeping. Some of the insurers present at the meeting agreed that using these practices will also reduce clinical record requests by 50 percent.
Medicare Documentation Guidelines (PDF format) The American Chiropractic Association The ACA defines the Medicare PART documentation guidelines in this file. These are Centers for Medicare and Medicaid Services (CMS) guidelines that apply to Medicare only. However, since these guidelines describe “medical necessity” for Medicare, they would easily apply to any other insurer's requirements.
The GUIDELINES Section
A Chiro.Org article collection
This section reviews a variety of Guidelines from State, National, and International Associations covering all aspects of care and documentation.
Useful Tools for Documentation
Letters For Improving Insurance Cooperation
The following copyrighted letters are provided as a service to health-care professionals. You are welcome to use these letters in your office, to communicate with Insurers. However, they may not be sold, reproduced online, or in publications, or used in any group or commercial venture without the written permission of the copyright holder.
Initial and Progress Insurance Letters (Word format)
First Insurance Letter (Word .doc)
This is the letter we send when we open a Med-Pay claim with a newly injured person. You should review your State's Insurance laws to rephrase the paragraph about Insurance Law and Interest Charges for late payment.
Initial and Progress Report Templates (Word format)
Initial Report Template (Word .doc)
We advise Insurers in the first letter that we do not generate Initial or Progress Reports unless they are paid for in advance. This is the template for the Initial Narrative Report. You may also want to review theInitial Report Outline.
Records Request Slip (Word .doc)
We advise Insurers in the first letter that we do not send copies of the patient file unless they are paid for in advance. This is the form we send.
Care Plans (Word .doc)
Finally, along with the first letter we also send a Care Plan that most closely describes the patient's status and intended care. These 11 plans we developed by Robert Mootz, D.C. in his article "Chiropractic Care for Common Industrial Low Back Conditions". They are formatted so that you can print them onto your own letterhead.
Reduced Charges Agreement (Word .doc)
In the case of financial hardship, you may have a patient who will not comply with your care plan because of the cumulative cost (and frequency) of the first month's care. In that case, during the report of findings, I use this form. I ask, "Knowing that we will need to see you between 9 or 12 times during the first month, (and already knowing how much I charge for each service), how much can you afford to pay for these visits, such that you will actually comply with the care plan?" Often people say "Oh, 45 per visit is fine". Then we document that and they sign the form.
<-- End of Letters Section -->
The Chiro.Org FORMS Section
Online forms for the Doctor of Chiropractic are located here. Check out the automated Auto Accident Forms, with narrative reports created “on the fly”, the X-Ray reports, also generated “on the fly”, and browse a variety of examination forms, insurance information forms, and other report forms. Thanks to Joe Garolis, D.C. for maintaining this section!
Patient's Report of an IME
Here' a form donated by Stephen Savoie, D.C. to share with patients who are being sent out for an “Independent Medical Examination” (IME). This form helps the patient to record what happened at the IME. Dr. Savoie said “It has been very helpful when an attorney tells me there is a 12 page IME report stating my patient is perfect, and I tell the attorney (that) the exam lasted 3 minutes.”