Little Chiropractic Documentation Mistakes That Cause Big Problems (Part 1)
With auditors examining our every move, many chiropractors are growing increasingly concerned about the state of their documentation.
Here's the really bad news: as a Certified Professional Auditor and Professional Coder myself, I have reviewed countless chiropractic records and many DCs have good reason to worry.
Here's the good news: this article will teach you how to avoid surprisingly common and easily overlooked mistakes in your documentation that generally spell big trouble during an audit.
First, why the focus on the little items?Here's why.
Most audit tools used by insurance companies have about 18 items that a chiropractor would need to pass, typically with an 80% score or better.
If you do the math, that means you have to get 15 items "correct" to pass your audit.
Unfortunately, that doesn't leave much room for error.
So you simply can't afford to make mistakes, especially those that are small and easily preventable.
With that in mind, here are the first four of the most common "small" errors that I see chiropractors routinely make:
In other words, your little issues have now created a big problem.
So, don't give auditors or claim examiners more reason to go through your notes with a fine-toothed comb.
Instead, be sure your documentation covers the basics!
Here's the really bad news: as a Certified Professional Auditor and Professional Coder myself, I have reviewed countless chiropractic records and many DCs have good reason to worry.
Here's the good news: this article will teach you how to avoid surprisingly common and easily overlooked mistakes in your documentation that generally spell big trouble during an audit.
First, why the focus on the little items?Here's why.
Most audit tools used by insurance companies have about 18 items that a chiropractor would need to pass, typically with an 80% score or better.
If you do the math, that means you have to get 15 items "correct" to pass your audit.
Unfortunately, that doesn't leave much room for error.
So you simply can't afford to make mistakes, especially those that are small and easily preventable.
With that in mind, here are the first four of the most common "small" errors that I see chiropractors routinely make:
- SLOP (instead of SOAP) - Most chiropractors were trained to document SOAP notes.
You know the drill.
S = Subjective, O=Objective, A=Assessment, P=Plan.
Plain and simple, those are the basic requirements for your notes.
Miss a letter and really all you have is slop that won't justify your care.
Yet, far too many chiropractors do that.
They skip the S or the O or the A or the P.
Sure, we understand your busy.
But there are some corners you just can't cut.
And this is one of them. - Signatures - There are a variety of "acceptable" signatures that Medicare and other payers will permit as standard documentation, but the one signature that is definitely not acceptable is the one that is absent.
Put simply, you are required to sign all daily notes in some way, shape or form (See Medicare Program Integrity Manual, Pub.
100-08, Chapter 3, Section 3.
4.
1.
1 B).
If you are utilizing EMR, you are likely ahead of the game, as this is generated with the push of a button.
If you have delayed using EMR, perhaps the cramp in your hand you get from signing every note will persuade you! - Abbreviations - If you are audited, don't count on a chiropractor reviewing your records who will know what "PR-L" or "ASRA" or even "Sublux" means.
For that matter, even a non-chiropractor may have difficulty with non-specific abbreviations like "PT.
"Did you send the patient for Physical Therapy or part-time work?The auditor is not going to try and translate your abbreviations, especially if a key isn't present that explains them.
A wonderful SOAP note with one unidentifiable abbreviation can cause you to fail your audit.
So, make sure that you are spelling it out clearly (another advantage to EMR, push the button and the word comes out!) or that you provide a key that clearly translates all your abbreviations. - Referrals - As the saying goes, if it isn't documented, it didn't happen.
Sure you may have referred your patient to receive massage therapy, but where is it in the SOAP note?If you are trying to get that massage visit paid, you better be able to track a referral somewhere.
Insurance company denying the necessity of your care? Where is your documentation regarding your patient's visit to the Orthopedic Surgeon whose recommendation was to continue with chiropractic care?You should be documenting all referrals to and from your clinic.
An auditor who looks through your notes and finds none does not conclude that you never refer.
He thinks that he has found a chiropractor who fails to document thoroughly and looks to see what other mistakes he can find.
In other words, your little issues have now created a big problem.
So, don't give auditors or claim examiners more reason to go through your notes with a fine-toothed comb.
Instead, be sure your documentation covers the basics!
