Documentation: 8 easy ways to keep your claims on track
Chiropractic Coding & Compliance Alert
Documentation:
8 easy ways to keep your claims on track
Published on Tue Sep 23, 2014
Document the specific level of subluxation and areas of manual therapy on every visit.
Ensure that you report objective, measurable functional improvement on every visit.
Use functional outcome assessments to further quantify the necessity and progress of the care plan (CMS makes the use of outcome measures mandatory from 2015 under PQRS reporting).
Your notes should demonstrate functional improvement and a discharge decision when maximum benefit is accrued.
Chronic conditions such as degeneration and displaced discs (the 722 series) require longer care and therefore should be documented whenever you come across one.
In keeping with the need for mainstreaming the patient, your plan should also focus on active care and rehabilitation.
Keep the notes legible: they will defend your work and claim only if the auditor can read them.