Ancillary Services: Yes, You Have to Document Those Too!
Simply documenting your chiropractic adjustment isn’t enough. If you also deliver ancillary services, like modalities and procedures or other adjunctive therapies, there are particular rules to follow in both initial and subsequent visit documentation requirements. This session will dive deep into the requirements necessary in your plan of treatment to justify medical necessity for these adjunctive services. Likewise, we’ll review the exact language crucial to the requirements of daily visit documentation. You’ll be ready to apply these winning suggestions to your documentation on Monday Morning. At the end of this program, the attendee will be able to:
- Know how to document exactly what’s required for initial visit treatment plans including physical medicine procedures
- Apply sample language to include in each daily visit note that will meet documentation guidelines for these modalities and procedures, including properly recording time for timed services
- Command the mechanics of how to authenticate documentation for services provided by auxiliary team members
- Tie the patient’s diagnosis to the treatment plan for tissue-specific, physical medicine solutions
- Tell a complete and coherent account of the patient’s daily visit journey, outlining the crucial language necessary to justify medical necessity for all services rendered
Use Recent Audit Findings to Improve Documentation
The Centers for Medicare and Medicaid Services (CMS) hired Strategic Health Solutions (SHS) to audit the documentation for swaths of chiropractors throughout the country. The first round of audit findings has been published and the majority of DCs audited failed miserably. Six core documentation principles were consistently found to be lacking as a common denominator throughout the audit findings. This timely session will explore each of the six core issues found, identify the weakness that caused the failure, and educate providers on the best way ensure their documentation meets the standards.
Because of this session, attendees can expect the following outcomes and learning objectives:
- Recognize the key documentation components required by the state boards, Medicare, and third-party payers
- Compose documentation that meets the required elements, while avoiding missteps most commonly found in audits
- Appraise and self-audit existing documentation, looking for key factors known to be oft missing, and understand what to do to correct the deficiency