Make sure that all documentation of patient care is strong and complete to avoid denial of payment for services rendered

Think of a patient case as a chain from the initial confidential history form to the final payment. Every sheet of paper, visit, and insurance claim forms a link in the process of the case. Each examination, diagnosis, and daily note tells a story and structures the strength of the chain. There is no one link that can be stronger and no area of the process that can be weak.

Medicare, workers’ compensation (WC) boards, and insurance carriers are all forming advisory committees to provide adjusters and auditors with the scientific and clinical questions they should be looking for in a patient’s chart. These committees are not necessarily comprised of a brain trust of physicians, but more likely include administrators and actuaries. Their goal is to categorize medical intervention in a cost-effective manner. They expect each patient case to be contained within parameters, guidelines, and care-plan protocols.

Today, too many offices face the fact that payment for services rendered will be denied due to reasons such as “not medically necessary,” “insufficient documentation,” and “failure to substantiate the need for care.”

Evaluation of Evidence
Like it or not, the truth is that patient medical records have become files of evidence. Third-party liability carriers assess adequacy of treatment on the inadequacy of documentation found within a patient’s records. Errors cause barriers: poorly written soap notes, illogical or erroneous treatment plans, failure to upgrade diagnoses, careless mistakes in insurance building, and lost or altered paperwork—all result in nonpayment.

Front desk/paperwork. Every office has a file or two that would not pass this first ethical link, such as patients who do not want to report injuries to their employers, have preexisting dates of onset, or wrote a complaint of low back pain on the intake form but then told the doctor about the daily severe headaches they experience. A patient’s chief complaint must corroborate the diagnosis. When the intake form does not match, the case begins to break down. All paperwork should be checked for errors before it is filed into a patient’s folder and before the patient leaves.

Consultation and exam. Unfortunately, this may be the weakest link in most offices and the most critical to establishing a solid case. The consult/exam section of a patient’s folder is the foundation to the diagnosis and treatment plan. Without proper documentation of facts and significant findings, a sound methodology of case planning cannot be made.

While most doctors establish their findings mentally from this process, sufficient written support is not forthcoming. The methods, forms, and style of each practitioner vary widely. Doctors may choose to use checkoff forms, computerized note-taking, abbreviations, shorthand, dictation, transcription, or narrative-style formats. And yet, patient records must maintain a level of unified standards. Doctors must keep in mind that patient records are not “their” records but those of the patient, and may be viewed by insurance carriers, auditors, peer reviewers, and legal entities.

A critical link can be broken in exam documentation. A positive or negative notation is not enough; there must be documentation of the significance of the findings linked to the patient’s complaint, diagnosis, and treatment plan.

Diagnosis. Simple mistakes make weak links. The diagnosis is more than listing an ICD-9 code or using a checkoff prescripted sheet. A diagnosis should be succinctly written in descriptive format and sequential order, (primary, secondary, etc). A valid, well-established diagnosis is the link to getting a claim paid; likewise, it can also be a reason for denial.

For example, the diagnosis code of a muscle spasm (728.85) must be supported with documented exam findings of loss of ROM to the region. The mechanism of injury is critical in determining the liability and the primary diagnosis in all personal injury and WC cases and must be corroborated by an accident report. If a patient describes a wrist injury as a chief complaint, a low back diagnosis cannot be listed as a primary. Suspected conditions are never written in a medical chart with corresponding ICD-9 codes. Only when a condition is verified by appropriate diagnostic testing can an ICD-9 code be assigned.

Claim forms. On an HCFA 1500, the universal claim form box 24E requires procedures (CPT codes, box 24D) to be related to the diagnosis (ICD-9 codes, box 21, positions 1, 2, 3, and 4). Specifically, the form asks that the diagnosis to be related “by line.” Computer programs that automatically enter “1-4” in this box (24D) are set at default and can easily be changed. Insurance carriers’ computers scan claim forms for inaccuracies and the inability to correlate these two boxes may result in a delayed, reduced, or denied claim.

Treatment plans. Written treatment plans institute a course of action that is recommended to correct a patient’s diagnosis. Errors occur when a treatment plan is not written, not based on the diagnosis, or not followed appropriately.

A treatment plan should be written for a specific time frame with defined short- and long-term goals. The plan must follow accepted standards for the patient’s condition, with clinical rationale for each service rendered and there must be an expectation that the patient’s condition will improve significantly in a reasonable period of time.

Treatment plans need to be revised and updated as a patient’s condition improves. A new treatment plan indicates improvement in the patient’s condition and therefore documents the need for further care.

Daily notes. The daily notes represent a concise record of pertinent changes in the patient’s condition and discusses the patient’s reaction to treatment on that day. Daily SOAP (subjective, objective, assessment, and plan/prognosis) notes are expected to be a per-visit diary of compliance, improvements, set backs, and achievements to the treatment plan. SOAP notes that do not show evidence of change results in denial of payment from third-party carriers. Objective notations such as “improved range of motion,” “reduction in swelling,” “reduced inflammation,” and “patient able to increase isometric and stretching exercises,” will document clinical rationale of treatment.

If a patient does not respond within a generally predictable period of time, a doctor has two choices: change the plan or refer the patient. If the doctor continues to treat the patient with the same protocol, the carrier has one choice: deny payment.

Outcome assessments. To validate the clinical rationale of a case, there are several outcome assessment forms and scoring techniques available. A doctor can choose to use the Oswestry Disability Questionnaire (Fairbank 1980), the Roland Morris Disability Questionnaire (Roland 1983), the Waddell Disability Index (Waddell 1982), or other outcomes measurement tools depending on the specific condition. All provide a standard of respectable, widely accepted instruments for clinical outcomes. The research and scientific literature behind these tools document medical necessity of care or need to refer. Consider these forms, internal, independent, and second opinions.

Release. Whether or not a patient is released from chiropractic care, the case must eventually end. A misconception of insurance is that the carrier is always responsible for medical care. The carrier (liability) will release patients who never show improvement or appear to continue care after an anticipated period if there are no indications of reoccurrence, new trauma, or a relapse.

Statements in progress reports such as “prognosis/status is undetermined at this time,” “patient will continue to have lifetime residual symptoms,” “patient will need unlimited care,” or “patient can expect to continue to experience pain,” are red flags for a review.

A case needs a beginning, middle, and an end. While it may be true that the patient will continue to experience pain, it may not be true that the carrier or liable party will pay for unlimited care. Even in a legal case, there must be closure in order for settlement. A prognosis of “undetermined” will get the patient sent to an independent medical exam (IME) for a decision, most likely one that the chiropractor will not agree with.

Documentation. All clinical documentation must be legible. It may be handwritten, dictated and transcribed, or computerized. The most important feature of clinical documentation is not style or quantity, it is quality. The documentation must be logical in nature and follow a standard of acceptable protocol.

Commensurate evidence within a patient’s medical chart forms critical links to receiving full payment and benefits from the patient’s insurance carrier. While assessing blame for nonpayment comes easily, the transformation required to build a stronger patient file will take commitment, consistency, and accountability. CP

Ces Soyring, CA, is cofounder of the National Academy of Chiropractic Assistants (www.naca-online.com) and a chiropractic consultant. She can be reached via email: naca_csoyring@yahoo.com.

For more information on Secret to Linking seminars, visit www.naca-online.com  or email csoyring@naca-online.com.