Dr. Robert A. Bailey
DC, DADFP, CICE, CIRE
812-882-4108 or drbailey@drrobertbailey.com

You want what every doctor wants – an office that runs smoothly, high satisfaction for all employees, systems and procedures in place, no compliancy issues, and financial rewards for all your hard work.

But let’s face it; coding is the language of reimbursement. You have certain numbers to describe your work and your patients’ conditions. If you don’t know every nuance of using these numbers, it can cost you thousands of dollars.

The following are three of the biggest coding and documentation mistakes that, when avoided, allow for smooth sailing.

Under and Over Coding E/M Services

Evaluation and management (E/M) Codes are one of the most important sets in your coding arsenal. You must strive to get it right and document thoroughly since codes set the tone for the care you will render to your patients.

Periodic re-evaluations carry significant weight to justify medical necessity for ongoing care. However, E/M codes are also one of the sets that are under and over coded most often. Lack of understanding among practitioners of the requirements for new and established patient E/M codes is of them the problem.

The Centers for Medicare and Medicaid Services (CMS) has set fourth clear guidelines for what’s required for documentation of these services. Because many doctors have never seen these guidelines, they tend to use whatever code feels right, or rely on the amount of time spent.

Because of this, some doctors are actually either too high or too low for the amount of work performed. It’s likely that when you review your information, and make a checklist of the items required, you will be surprised at how much work you’re doing that you’re not charging for. Or, it may indicate that you’re not documenting completely.

Coding and Documenting Incorrectly

Far too often, doctors code services incorrectly. One challenge comes from taking coding advice from inappropriate sources, such as from manufacturers of products without written references.

Doctors often rely on the fact that they may know what they did to the patient and feel justified in coding the service, but the documentation in the record doesn’t correlate. Remember that "what isn’t written down, never happened,” so you must ensure all the services rendered are properly documented according to reasonable and standard guidelines.

When you bill a chiropractic manipulative treatment coding for a certain level of service, but the documentation only justifies a lower number of regions treated, it could create problems.

For example: If a treatment plan was originally designed for two spinal regions, but a third region was added on a given visit – and the higher level spinal treatment code was billed – the documentation may not be there to prove why the extra area was treated and how it correlates to the treatment plan and diagnosis codes.

These errors are most often found on a post-payment audit review, and can cost a practice thousands of dollars in repayment. This should be a reminder to ensure your daily documentation record and billing record match exactly. This includes your modalities and therapeutic procedures.

Similarly Justifying Necessity

When each chiropractic visit looks the same as the last and statements like “same as last visit” pepper the daily notes, it’s difficult for a third-party reader to ascertain the necessity of each visit.

Standard guidelines dictate what must be included, and it can be very easy to get into the trap of rushing through your daily documentation. Some documentation software programs even allow you to start with the notes from the last visit, so you can modify from there. If you get rushed or lax you may be tempted to modify and move on.

Consider each visit "encounter specific" when writing your daily notes. As Medicare documentation requirements dictate, be sure you consider each of the following in your everyday documentation.

1. 1. History:
   • Review of chief complaint;
   • Changes since last visit; and
   • System review, if relevant.
2. 2. Physical Examination:
   • Area of spine involved in diagnosis;
   • Assessment of change in condition since last visit; and
   • Evaluation of treatment effectiveness.
3. 3. Treatment given:
   • It’s easy to get into a routine of average documentation and basic coding. However, lack of attention to detail in this area can lead to a decrease in reimbursements, or worse, problems on a post-payment audit.

You owe it to yourself and your practice to be diligent in correct coding and documentation procedures.

Source : www.chiroeco.com, Author: Kathy Mills Chang