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An Overiview of Clinical Documentation for the Chiropractic Profession

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An Overiview of Clinical Documentation for the Chiropractic Profession AN OVERIVIEW OF CLINICAL DOCUMENTATION FOR THE CHIROPRACTIC PROFESSION Steven G. Yeomans, DC, FACO 404 Eureka Street Ripon, WI 64971-0263 920-748-3644 (Ph) 920-748-3642 (Fax) [email protected] Course Objective: TO BULLET-PROOF YOUR DOCUMENTATION AGAINST AN ADVERSARIAL REVIEW PROCESS Table of Contents Content Page # ACA Recommendations (2001) 3-4 WCA Recommendations (1996) Intro & Acknowledgements ………………………………………………... 5-8 Chapter 1: Documentation recommendations ………………………….….. 9-18 Chapter 2: Commonly used mechanisms of record keeping ……….……… 19-21 Chapter 3: Commonly used outcome assessment measurements …………. 22-24 Chapter 4: A primer on chiropractic listings ……………………….……… 25-26 Chapter 5: Glossary ……………………………………………………….. 27-28 Chapter 6: Commonly used abbreviations ………………………….……… 29-32 Appendix A: HCFA Guidelines for Patient History Level Selection ……… 33 Appendix B: Bibliography ………………………………………………… 34-35 Chart Audit 36 Yellow Flags (psychometrics) 37-38 CPT Codes 39-40 Bibliography 41-44 2 Ref: ACA Today, March 2001 The Newsletter of the American Chiropractic Association CLINICAL DOCUMENTATION KEY TO REIMBURSEMENT FOR CHIROPRACTIC CLAIMS ARLINGTON, VA – During its recent meeting, the American Chiropractic Association (ACA) House of Delegates passed a resolution to assist doctors of chiropractic in successfully being reimbursed for necessary patient care by insurance companies. ACA is now committed to disseminating the recommendations contained in the resolution to doctors of chiropractic, chiropractic organizations and chiropractic colleges nationwide. 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. “The mutual goal of the insurers and doctors of chiropractic at this meeting was to simplify the claims process,” explained Pat Jackson, vice president of professional development for ACA. “This way, chiropractors can reduce administrative costs and get paid for more covered claims, and insurers can reduce claims expenses.” According to Ms. Jackson, many insurers are already adopting the recommended guidelines resulting from the meeting in order to educate their claim personnel on appropriate requests for chiropractic clinical documentation. The ACA also contends that a concerted effort by the chiropractic profession to standardize clinical documentation will improve reimbursement experience exponentially for doctors of chiropractic. For this reason, a special effort will be made to share this information with chiropractic colleges so it can be incorporated into the curricula. ACA recommends the following documentation procedures: 1. The nationally accepted HCFA billing 1500 form must be completed in detail. This means all required fields must be completed. 2. Subjective, objective, and treatment (if rendered) components should be incorporated into patient records on each visit. A customized format is not needed but these elements must exist consistently. Any significant changes in the clinical picture (e.g. significant patient improvement or regression) should be noted. 3 3. All ICD-9-CM diagnosis codes and CPT treatment and procedure codes must be validated in the patient chart and coordinated as to the diagnoses and treatment code descriptors. 4. Uniform chiropractic language should be used within the profession for describing care and treatment. Non-standard abbreviations and indexes should be defined. 5. Documentation for the initial (new patient) visit, new injury or exacerbation should consist of the history and physical and the anticipated patient treatment plan. The initial treatment plan, except in chronic cases, should not extend beyond a 30-45 day interval. Subsequent patient visits should include significant patient improvement or regression if demonstrated by the patient on each visit. As the patient progresses, the treatment plan needs to be reevaluated and appropriately modified by the treating doctor of chiropractic (chiropractic physician) until the patient can be released from care, if appropriate. 6. If the patient is disabled, a statement(s) on the extent of disability and activity restriction is needed at initial and subsequent visits as appropriate over the course of care. 7. Records can be attached to each billing to pre-empt requests; however, it is not mandatory. Local insurers should be contacted for preferences (i.e., No fault PIP insurers may require records every visit while health insurers may not). 8. All records must be legible and understandable, released within the authority given by the patients, in a secure, confidential manner and in compliance with existing state (or federal) statutes. 9. The patient name and initials of the person making the chart notation (especially in multi-practitioner offices) should appear on each page of the medical record. 10. If the above recommendations have been met, then the answers as to why the necessity for continuing treatment are answered. 11. The insurance industry must improve their claim adjusting procedure by using chiropractic consultants. The ACA can use its resources to assist in this initiative. Contact the American Chiropractic Association Office of Professional Development by phone at (800) 986-4636, ext. 222, or by e-mail at [email protected] for more information. ### 4 Wisconsin Chiropractic Association Recommendations for Chiropractic Documentation (1996) Wisconsin Chiropractic Association Recommendations for Chiropractic Documentation 5 General Disclaimer This document contains recommendations for the clinical documentation of chiropractic care. These recommendations are intended for educational and instructional purposes only and do not constitute a standard of care for any specific clinical situation. These recommendations, which may need to be updated, are intended to be flexible. In is not the purpose of this document, which is advisory in nature, to take precedence over any federal, state or local statute, rule, regulation or ordinance which may affect chiropractic practice. This document may provide some assistance to third parties in the evaluation of chiropractic care, but it is not by itself a proper basis for evaluation. Many factors must be considered in determining clinical or medical necessity. Methods of chiropractic documentation must be sufficiently flexible to allow for variations in practice methods, as well as differing complexities of individual cases. Further, these recommendations will require constant re-evaluation as additional scientific and clinical information becomes available. 6 Wisconsin Chiropractic Association Recommendations for Chiropractic Documentation Table of Contents: Acknowledgments Introduction Chapter 1: Documentation recommendations ……………………………… 8-17 Format Legibility Patient consent Initial entry: Subjective Initial entry: Objective Initial entry: Assessment Initial entry: Treatment plan Daily notes Progress notes X-ray reports Chapter 2: Commonly used mechanisms of record keeping ……………… 18-20 Chapter 3: Commonly used outcome assessment measurements …………. 21-23 Chapter 4: A primer on chiropractic listings ………………………….…… 24-25 Chapter 5: Glossary ……………………………………………………….. 26-27 Chapter 6: Commonly used abbreviations ………………………………… 28-31 Appendix A: HCFA Guidelines for Patient History Level Selection ……… 32 Appendix B: Bibliography ………………………………………………… 33-34 Acknowledgments: The Wisconsin Chiropractic Association is indebted to chiropractic colleges and insurers who provided valuable background information for the work of the Committee, and also to the Committee members for their diligent effort on this project. 7 Introduction: Over the past decade, chiropractic has occupied a constantly growing position in today’s complex health care delivery system. Chiropractors in Wisconsin now work routinely with a myriad of parties who are interested in assessing the quality of clinical work performed by the chiropractor. The principal method through which other parties attempt to assess the quality and necessity of a chiropractor’s work is through submitted clinical documentation. The clinical records of Wisconsin chiropractors are now examined with an increased amount of scrutiny. Many different payors and agencies have the right to access a chiropractor’s clinical records, including: insurers who wish to determine whether a claim is a covered benefit under the terms of their contract with the patient managed care organizations who conduct reviews of clinical record keeping as part of their quality assurance and utilization review programs attorneys who utilize clinical documentation as evidence in personal injury litigation attorneys who represent patients in malpractice suits against chiropractors other health care providers who may request records in order to coordinate interprofessional patient care other chiropractors who assist with treatment for a patient state regulatory agencies, who investigate consumer complaints, review payment for government programs, etc. Methods of chiropractic documentation must be sufficiently flexible to allow for variations in practice methods, as well as differing complexities of individual cases.
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