Chiropractic Documentation

The SOAP Notes Page
A Chiro.Org article collection
The SOAP Notes Page contains articles about using daily notes more effectively.

What is Medical Necessity?
A Chiro.Org Editorial
Medicare defines “medical necessity” as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. From an Insurers standpoint, this is why documentation of the patient encounter is so important. The standard note taking format for every patient encounter is the SOAP note. Medical (chiropractic) necessity is defined by your own notes. Let's review what actually defines reasonable and necessary in the SOAP note.

Maximizing the Effectiveness and Efficiency of Clinical Documentation
Best Practices in Clinical Chiropractic ~ FULL TEXT
This Full-Text from the TICC collection Best Practices in Clinical Chiropractic outlines efficient charting methods and supplies valuable forms to improve your charting efficiency.   Our thanks to Aspen Publishers and Robert Mootz, D.C. for releasing this article exclusively at Chiro.Org!

Informed Consent: What Does It Mean?
Health Insights Today ~ Sept 2013 ~ FULL TEXT
In 2013, The Back Letter gave extensive coverage to an article by Dagenais et al in The Journal of Manipulative and Physiological Therapeutics on informed consent in the chiropractic profession, calling it, “perhaps the best article ever written on informed consent for low back pain.”

    Part 1:   The 3 Key Components of the E/M Guidelines

   Part 2:   A Closer Look at E/M Guidelines

   Part 3:   Mastering the E/M Guidelines

   Sample Worksheet (PDF format)

Consensus Terminology for Stages of Care:
Acute, Chronic, Recurrent, and Wellness
J Manipulative Physiol Ther. 2010 (Jul); 33 (6): 458–463 ~ FULL TEXT
As the chiropractic profession delineates its role in the emerging health care marketplace, it will become increasingly important that the scope of appropriate chiropractic care is clearly defined relative to overall patient case management. Therefore, the Council on Chiropractic Guidelines and Practice Parameters engaged in a multidisciplinary consensus process addressing the terminology related to "levels of care."
You may also enjoy this review of this process by the ACA, titled:
Chiropractic Reaches Consensus On Terminology For Stages Of Care.

Medicare Documentation Requirements:
The Hurdle That Continues to Block Our Progress
Dynamic Chiropractic ~ January 26, 2010 ~ FULL TEXT
The rules for Medicare are spelled out in section 240 of chapter 15 of the Medicare Benefit Policy Manual [3] and in your local carrier's or administrator's Local Coverage Determination (LCD). The terminology is generally consistent; however, it can be confusing based on how the language is misinterpreted by chiropractors and those who teach documentation and coding seminars. Contrary to what many believe, Medicare documentation is not subluxation-based, even though parts of section 240 can mislead one in this direction. Why do we say this? Because “subluxation-based” to chiropractors is a different concept compared to subluxation-based to Medicare, and this fact is clearly spelled out in the rules.

The Differences Between ICD-9 and ICD-10 Coding  PDF
American Medical Association Fact Sheet #2 ~ FULL TEXT
This is the second fact sheet in a series and is focused on the differences between the ICD-9 and ICD-10 code sets. Collectively, the fact sheets will provide information, guidance, and checklists to assist you with understanding what you need to do to implement the ICD-10 code set. The ICD-10 code sets are not a simple update of the ICD-9 code set. The ICD-10 code sets have fundamental changes in structure and concepts that make them very different from ICD-9. Because of these differences, it is important to develop a preliminary understanding of the changes from ICD-9 to ICD-10.

Documentation for the Pediatric Practice
By Claudia Anrig, D.C. ~ FULL TEXT
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.

Documentation for the Pediatric Practice: Part II
By Claudia Anrig, D.C. ~ FULL TEXT
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   PDF
The Association of Chiropractic Colleges
This 8-page Adobe PDF 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
Today's Chiropractic
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 Protocols for Chiropractic Office Visits
Institute for Chiropractic Ethics
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.

How Insurance Companies Define Medical Necessity
NJ Division of Insurance
This FULL TEXT article 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
Dynamic Chiropractic ~ May 17, 1999 ~ FULL TEXT
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.

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Part II: The Roland-Morris Questionnaire
Dynamic Chiropractic ~ June 14, 1999 ~ FULL TEXT
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
Dynamic Chiropractic ~ November 17, 1997
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
Dynamic Chiropractic ~ March 8, 1999
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   PDF
Medicare Part B Bulletin ~ November 2000
This Adobe PDF 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
Dynamic Chiropractic ~ November 7, 1990
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.

Documentation of Physical Capacity: It's Purpose in Rehabilitation
Dynamic Chiropractic ~ April 3, 2000
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.