Our No. 1 Medicare Documentation Error
SOURCE: Dynamic Chiropractic ~ January 15, 2014
By Susan McClelland
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.
Medicare regulations require that we create a treatment plan when treating Medicare beneficiaries.
This treatment plan must include three elements or it will fail review:
1) recommended level of care
(duration and frequency of visits);
2) specific treatment goals;
3) objective measures to evaluate treatment effectiveness.
To repeat, the treatment plan must include all three of these elements or it will fail review.
Unfortunately, many doctors of chiropractic are not creating treatment plans at all. For those who do, the plans generally include the recommended level of care (e.g., “Two times a week for two weeks followed by once a week for two weeks. To be re-evaluated for further care at that time”). We generally fall short when it comes to the second and third elements.
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