To get paid under managed care, you must know what information is considered important by claims reviewers. You also need to record and report it very quickly.
At a recent seminar, Dr. Thomas Allenburg, president of the American Chiropractic Network (ACN) stated that he routinely dictates a two page initial ACN report in two minutes. When challenged, he stood in front of the microphone and did it. So can you.
The "trick" is to know what information really matters, and what doesn't. The following is intended to help field doctors reduce their paperwork time and get paid while providing excellent health care to more people.
Here's what reviewers need to approve your care for payment:
History of Current Complaint
How did present signs and symptoms begin? What provoked the immediate situation? Intake forms that ask the patient simple questions in logical order are worth their weight in gold. They vastly reduce your time, and can obviate many narratives altogether.
Tip: If there has been trauma, draw a word picture that makes the reviewer say "ouch." Find out relative speeds and sizes of vehicles, road conditions, weights and sizes of materials lifted, distances of falls, body position at moment of injury, loss of hats, glasses, property damage, etc. Let your reader feel the hurt. Don't overdo the adjectives; avoid "tremendous," explosive," etc., but be graphic.
Relevant Health History
If the area of complaint was compromised prior to this episode, how does that impact the current lesion? If the patient has IDDM, say so. Point out that a history of multiple auto accidents may complicate a minor low back sprain. Answer this question: Why should this be considered any more serious than a Mercy back strain?
Relevant Examination Findings
In your narratives, don't report all the negative tests. Wasting a reviewer's time can make him mad. Show both positives and negatives in your chart notes, but give the reviewer a summary of findings that demand professional intervention.
The phrase, "foraminal compression: positive," is obscure and archaic, a relic form the dark ages. The most primitive work processor can create a permanent template or macro that automatically pops us with: "foraminal compression of the cervical spine produced (cervicodorsal) pain graded (5)/10 (bilaterally) with(out) radiation into the upper extremities." Fill in just four blanks and there is a precise picture of your findings.
Following reexamination you'll easily document significant improvement: "...pain 2/10, left side only." Do you think "medicos" accomplish that in one month? No. You got it, doctor. Flaunt it.
Diagnosis
The Dx must be consistent with history and exam findings. If your diagnosis is off the wall, what does that say about your proposed treatment?
By the way, do you expect noninfectious colitis (558.9), nocturnal enuresis (788.3), and/or gastritis (535.5) to improve as a result of your chiropractic adjustments? Put them in the diagnosis.
Is the case complicated by gestational ligamentous laxity (728.5), musculoskeletal effects of stress (306.0), adhesive myofibrositis (729.1), or the iatrogenic destruction caused by prescribed cortisone (255.0)? Put these things in the diagnosis.
Doctors who bill insurance, but diagnose nothing but vertebral subluxations (839s or 739s) and strain/sprains, are painting this profession into a cold corner of the managed care basement. If all you do is analyze the spine for subluxations, that's OK. But getting paid by third parties is going to get harder. You may be happier if you get out of managed care now and enjoy an education intensive cash practice. Many are doing just that.
Treatment Plan
What specifically do you plan to do? You might want to explain what specific effects spinal adjustments produce (e.g., "restore normal intersegmental mobility, reduce inflammation and interference with normal neurological function, and revitalize natural homeostatic repair mechanisms in the gastric mucosa"). What about intersegmental traction? Hot fomentations? Nutrient prescriptions? Keep it brief, but pithy.
If your chart notes clearly show good, ongoing patient improvement, the reviewers I've spoken with don't seem to care which technique you use to adjust subluxations. Abbreviations, codes, and shorthand are generally acceptable for that. But if you provide other therapies, instructions, etc., and expect to be paid for them you need to legibly document and justify each one.
Daily chart notes do not have to be in narrative form. No points for grammar. Brief, pith, KISS.
Therapeutic Goals
What quantifiable improvements do you expect to see in this case? Symptoms reduced from average 6/10 down to 2/10? Patient RTW full-time without restrictions? Recovery of full ROM? Normal posture and leg lengths? Equal weight distribution on bilateral scales? Patient able to walk one mile without stopping? X-ray changes? Resolution of ortho/neuros? Normal muscle tone? What else?
This is possibly the most glaring omission in health care today. It's probably missing from your records. Beware: physical therapists are far ahead of the pack in this particular. It's time to update your paperwork and set aside a special place for targets. Just setting them is half of getting them.
Prognosis
When do you anticipate these therapeutic goals will be reached? "I have no idea, because everybody is different," won't cut it under managed care. If you have graduated from chiropractic college you should have some idea, based on diagnosis, mechanism of onset, medical history, and concurrent complicating factors, of how this particular patient will respond to your care. If you don't, call your college and bawl them out. Then get on top of this, or you'll be out of managed care.
Patient Progress
Very important: Your daily chart notes should document solid improvement. Your regular reexaminations must. If you expect to be reimbursed for treatment beyond two to four weeks, you must routinely show measurable, rapid resolution of subjective symptoms and clinical signs. A simple progress questionnaire, completed by the patient at reexamination, is invaluable.
I suggest that if you are not generally seeing marked improvement in two to four weeks, you're being sloppy. Chiropractic works, and as a rule innate manifests itself very quickly -- subjectively and objectively.
Complications and Exacerbations
If your treatment suddenly escalates or is prolonged, you must document why. One good doctor I know simply starts his daily chart note with "exacerbation" if one has occurred. I suggest a couple words of explanation. "Slipped on step --> LBP. Plan: PTR 3/w X 1-2 wk. PT next 3 OCs." Brevity is brilliant, but silence in these situations, is suicide.
To summarize: Reviewers want to see that your diagnosis reflects the history and examination findings. Testing and treatment are expected to be the minimum necessary to provide covered benefits. You must document ongoing improvement, both subjective and objective, or stop treating. Technique is immaterial as long as you are getting rapid results.
Your report should build a solid case for your treatment: past, present, and future. Keep it short. Make it compelling. Cite current authoritative references (Kellet, Roy, Jackson, Cyriax, Bogduk, etc.) that support your decisions ... and make me look like a fool if I don't.
Truth makes sense to people. Present your findings and conclusions in a way that makes sense, doctor. Give us the facts we need to justify payment in full for your services.
Jonathan Sevy, DC
Vancouver, Washington
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