What No One Tells You About Documentation- by The Evidence Based Chiropractor

Fact: Chiropractors leave millions of dollars on the table due to incorrect third party payor denials each and every year. Unfortunately, chiropractors also return millions of dollars each and every year due to incorrect coding and billing. It goes without saying that patient care, billing, and coding should always be executed with the highest amount of integrity. However, it is foolish to not be paid for your hard work due to inadequate documentation.

For instance, did you know that time is NOT a primary determining factor in your examination coding?

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The 3 Criteria for Properly Coding Chiropractic Examinations

1. History

2. Examination
3. Medical/Chiropractic Decision Making

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Compliance experts like John Davila have helped hundreds of chiropractors sort out their documentation standards and create a playbook for success. Some chiropractors are not in need of a full internal compliance audit, but simply need improve day to day documentation to substantially increase their bottom line and decrease medical denials.

So, you spend X thousands of dollars on a new EMR system. Then you implement your intake, examination, and daily soap notes based on your previous forms or you grab a template from a friend.

Let me ask a 3 simple questions-

1. What determines the inclusion or exclusion of information on your forms (clinical, educational, required by law,required by documentation standards)?
2. Did the form creator just "make it up" or develop it off of coding guidelines?
3. Are you confident in your documentation to bill the appropriate examination, or do you just try to fly under the radar?

If you just attempt to fly under the radar you are more than likely leaving money on the table. If you are unsure of the requirements to code (and bill) for a examination at 99203 then you may be putting yourself at risk for denials due to incomplete records. Either way is potentially detrimental to your practice. The good news is that you don't need to spend 100 hours learning the ever changing documentation standards relating to examination coding. We have created a simple, easy to follow guide to the documentation standards necessary for billing and coding examinations. It comes free with our Chiropractic Office Forms set. For docs that may need a little more help, we even offer a Professional Package with one-on-one implementation. For docs that need just the basics we offer a Basic Package. 

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-The Evidence Based Chiropractor has assisted hundreds of chiropractors around the globe build interdisciplinary referral relationships.

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