A decade ago, the OIG reported that 94% of chiropractic documentation had serious errors or missing information. Sadly, there’s nothing to indicate in the intervening ten years that this statistic has improved by much. With the OIG and third-party payers ramping up records requests and audits—it’s turned out to be quite profitable for them! Your practice is likely more at risk than ever.
You’ve already protected yourself in a profound way by becoming a ChiroHealthUSA provider so you know that you’re not offering illegal dual fee schedules or inducements. But being a ChiroHealthUSA provider doesn’t guarantee that your documentation is bulletproof, and there are still any number of ways in which you could get flagged. Here are just a few of the most common:
- Missing Components – you were probably trained to document using SOAP (Subjective, Objective, Assessment, Plan) notes. Are you really hitting every one of those benchmarks in every chart in your office? All it takes is one missing item and your documentation no longer justifies medically necessary care.
- Missing Signature – DCs who use Electronic Medical Records (EMR) can produce their signature with one click. But if you aren’t using EMR, understand that you’re required to sign all of your daily notes. ALL of them. One missing signature is enough to bounce your claim back to you, or trigger a records request.
- Missing Keys – Like every profession, chiropractic is rife with jargon and acronyms. But keep in mind; a non-chiropractor won’t necessarily know what you’re talking about when you use non-specific or unusual abbreviations. Even an auditor who is a DC won’t necessarily follow your shorthand without a key. Don’t make records reviewers work to understand what you’re talking about. Quite simply, they don’t have time. And they’re more likely to flag you than take the time to figure your notes out.
- Missing the Mark – If you’re still making notes by hand, are you sure than anyone besides you can read your handwriting? As above, records reviewers and auditors don’t have time to try and decipher illegible notes. It is easier for them to declare your notes illegible, “fail” you, and move on.
- Missing Variety –Does all of your documentation look the same? Have you fallen into the habit of billing the same code sets over and over? EMR can actually put you at risk here, especially if you’re just copying one daily note to the next. Homogenous documentation is a red flag.
All of this seems sort of obvious, laid out like this. But as a busy doctor myself, I know firsthand that when it’s 7 p.m. and you want to get home to your family, it’s easy to unknowingly cut corners or forget important details. You figure one chart isn’t a biggie. You figure you’ll do better the next day. You get frustrated by how much paperwork you have to get done, and you let a few details slip.
I understand and fortunately, I can offer a solution. As a ChiroHealthUSA provider, you have access to our on-going webinar series featuring many of our experts that can offer help on a wide-range of topics. Among the best and brightest minds in the business, they can advise you on how to make sure your documentation is clean, compliant, and risk-free. Be sure and join us for our on-going weekly Webinar Series to stay up to date on the latest issues facing our profession, as well ideas for a more profitable practice in 2015!