Telling a good story through chiropractic documentation of each patient visit is essential. Whether recording important, clinically appropriate data to meet minimum chiropractic documentation requirements or clarifying the medical necessity of the treatment for a payer or auditor, your notes have the power to make or break you.
In order for you to be reimbursed, your documentation needs to support medically necessary, episodic care.
Could your documentation stand up to an audit? Find out by taking our Documentation Self-Assessment Survey!
KMC University’s Proven Documentation System addresses six aspects of documentation.
Medical Necessity is only a concern with a third-party payer, like Medicare. A large differentiator between medically necessary and clinically appropriate care is if a functional deficit exists and can be resolved through proper treatment.
Taking a history on a chiropractic patient is a required component of the Evaluation and Management service (E/M) that will establish the episode of care, whether it is a new patient, new condition, or new episodes of care.
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The Significance of Documenting Your Chiropractic Patient's Initial Assessment
This crucial assessment step must never be missed.
Understanding Requirements of the Chiropractic Treatment Plan
Your treatment plan is required for every episode of active care with your patient.
The majority of patient charting in a chiropractic setting include routine daily visits during active, medically necessary care visits.