Welcome to the Documentation Section @ Chiro.Org! This section 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 is updated frequently.
Clinical Documentation
This section was compiled by Frank M. Painter, D.C. Make comments or suggestions at the Contact Us Page
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Introduction
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 want to add a complete section on office forms which will focus our exam and simplify reporting those findings. If you have developed forms which you would like to share with our profession, please contact me at Frankp@chiro.org You may also find useful information in our Guidelines Section or the Outcome Assessment Section
Articles About Documentation
Documentation for the Pediatric Practice II
By Claudia Anrig, D.C.
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
The Association of Chiropractic Colleges
This 8-page Adobe Acrobat 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 for the Pediatric Practice
By Claudia Anrig, D.C.
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.
Applying Outcomes Management into Clinical Practice
J Neuromusculoskeletal System 1997 (Summer); 5 (2): 1-14 ~ FULL TEXT
The paradigm shift in health care from case management to cost contained, outcomes management (OM) has vaulted the study and use of valid and reliable outcomes tools . OM, when used appropriately, can measure progress, or the lack thereof, in three critical areas which include pain management, physical capacity (impairment), and disability.
The Evidence-based Practice Page
This page provides information on how to interpret the various statistical tests utilized in many journal articles, and also provides articles about Evidence-based Practice. You may also enjoy the new “Best Practice” Initiative Page.
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.
What is Medical Necessity?
Physician's News Digest August 2002
There are almost as many definitions of medical necessity as there are payors, laws and courts to interpret them. Generally speaking, though, most definitions incorporate the principle of providing services which are “reasonable and necessary” or
“appropriate” in light of clinical standards of practice. The lack of objectivity inherent in these terms often leads to widely varying interpretations by physicians and payors, which, in turn, can result in the care provided not meeting the definition. And last, but not least, the decision as to whether the services were medically necessary is typically made by a payor reviewer who didn’t even see the patient.
How Insurance Companies Define Medical Necessity
This FULL TEXT article from the NJ Division of Insurance 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
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.
and
Part II: The Roland-Morris Questionnaire
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
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
Medicare Part B Bulletin-- November 2000
This Adobe Acrobat 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
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.
Differentiating “As Needed”, “PRN”, and “Supportive” Care
One of the most difficult areas in chiropractic management is recognizing the need for supportive care. Many of us who treat complex soft tissue injuries, including persistent subluxation complexes, understand that these patients may require periodic, ongoing chiropractic treatment.
Documentation of Physical Capacity: It's Purpose in Rehabilitation
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.
Association Recommendations
Record Keeping
This section reviews guidelines for proper Record Keeping.
The Initial Exam
This section reviews guidelines for Initial Examinations.
Outcome Assessment
This section reviews guidelines for documenting Patient Progress.
The GUIDELINES Section
This section reviews a variety of Guidelines from State, National, and International Associations covering all aspects of care and documentation.
Clinical Documentation The American Chiropractic Association
Last year, 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 The American Chiropractic Association
The American Chiropractic Association provides this commentary in order to assist its members to better understand the Medicare PART clinical documentation guidelines. 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.
Recommendations for Chiropractic Documentation Wisconsin Chiropractic Association
This 45 page document from the includes a section on chiropractic “listings”, indicators of chronicity, and an extensive list of commonly used abbreviations.
Useful Tools for Documentation
Letters That Improve Insurance Cooperation
NOTE:
The following copyrighted letters are provided as a service to health-care professionals. You are welcome to use these letters 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
This is the letter we send when we open a Med-Pay claim for 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
We advise Insurers in the first letter that we do not generate a full Initial or Progress Report unless they are paid for in advance. This is a template for the Initial Narrative Report. You may also want to review the Initial Report Outline.
Records Request Slip
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 Request Form we send them.
Care Plans
We also send a Care Plan that most closely describes the patient's status and intended care requirements. These 11 plans we developed by Robert Mootz, D.C. They are formatted so that you can print them onto your own letterhead.
Reduced Charges Agreement
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.
Diagnosis Codes (ICD-9) Commonly Used in the Chiropractic Office
This ia a cross-section of the Dx codes most commonly used. It also includes a cover letter explaining how (and why) a DC uses these codes. The full document is also downloadable as a Word document.
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.”
Medical Shorthand IAND
Medical Shorthand II
Thanks to Dr. Boileve for these 2 documents. These Adobe Acrobat files spell out accepted medical and chiropractic "shorthand" for files.
More useful Tools for the D.C.
Looking for ICD-9 diagnosis codes, chiropractic colleges, search engines, or maps and phonebooks? This is the place to go!
