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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.
  • Remember to sign all the patient notes. 

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