Chiropractic Forms That Satisfy Your Medicare Documentation Obligations

Unlike trying to unlock the Google search algorithm, it is well known what Medicare and insurance carriers want (and expect) in the documentation that justifies your reimbursement claims. The fact that many chiropractors neglect to meet these requirements is evidenced by 1) increasingly failing post review audits and having to return thousands of dollars, and 2) an alarming number of claims being cut or denied for a lack of “medical necessity.” Reversing this trend begins by better documentation.

Sadly, many Chiropractic Clinic Singapore use a rag-tag collection of hand-me-down chiropractic forms that they got at a seminar years ago. Worse, they assume that their travel card notes are sufficient to justify being paid for their care since the checks from insurance carriers keep showing up. The painful truth eventually emerges after they are asked to surrender a dozen files for closer inspection to commissioned auditors who quickly find some omission or other breach.

And while you can’t do anything about the past, starting today you can begin collecting the information that satisfies your chiropractic Medicare requirements and insurance company expectations. It starts with the new patient intake forms used to collect their health history and details surrounding their current complaint.

Chiropractic Intake Forms

Obviously you’ll want to collect the demographic information, policy numbers of any insurance carriers and the patient’s contact details. Besides the history of the current illness, make sure to collect information about their ability to conduct “activities of daily living” so you have a baseline for proving functional improvement-the foundation for proving medical necessity. Oh, and keep it short. Patient should be able to complete your admitting paperwork in 10-minutes or less.

Chiropractic Exam Forms

After reviewing the chiropractic intake form with the patient during the consultation and the patient seems to be a good chiropractic candidate, you’ll want to conduct a thorough physical, orthopedic, neurological and chiropractic exam. You’ll record your findings on the appropriate examination form that conforms to the 1997 CMS Evaluation and Management Documentation Guidelines for musculoskeletal specialists.

Chiropractic Diagnosis Codes Form

You must give your findings a specific diagnosis code for each region you wish to treat, based on the current ICD-9 codes. Use a chiropractic diagnosis form that arranges the most commonly-used chiropractic codes by tissue type. This will simplify your ability to link the patient’s treatment plan to your diagnosis. Assign the correct codes! Mistakes here can get you in hot water with your board and will reduce your reimbursement.

Chiropractic Treatment Plan Form

How do you propose to help the patient? Just start adjusting and hope for a chiropractic miracle? If your idea of a care plan is three times a week for four weeks, followed by two times a week for four weeks, etc., and you recommend the same thing for virtually every patient, the jig is up! This one-size-fits-all approach will no longer work. Use a chiropractic Treatment Plan Form that includes specific functional goals and treatment effectiveness measurements.

Chiropractic SOAP Note Form

Simply put, most chiropractors don’t collect the right information on each visit, or it’s so repetitive as to suggest a lack of attention or accountability. When Medicare and insurance carriers look for a way to justify cutting your claims, they often start here. And rightfully so. Many chiropractors resent the reporting requirements and their SOAP notes are glaringly incomplete and fail to suggest that the patient is making progress. Is your current SOAP note complete?

Chiropractic Evaluation Form

At reasonable periodic times you must reevaluate the patient and their progress. This procedure is an automatic obligation and makes you accountable to your treatment plan. You’ll want to use a chiropractic form that reports the progress of patient’s chief complaint as well as accommodates a returning patient suffering a relapse or an entirely new health issue. Does yours?

Discharge Form

If you open a case, you must close the case. The notion that you can morph a patient’s care into some type of supportive or maintenance care and expect carriers to pick up the tab is one of the biggest mistakes chiropractors make. Especially with Medicare patients. Expecting reimbursement for once-a-month maintenance visits won’t cut it either. Do you have a discharge form that officially closes the episode of acute care? If not, get one!

Maintenance Care Form

Let’s assume that you’ve resolved the patient’s most obvious symptoms and you’ve ended the third party’s obligation to pay for their care. Well done. Even better, the patient has opted to pay for continued supportive care out of his or her own pocket. Your documentation responsibilities aren’t over. Record their subjective observations, nonsymptomatic subluxation patterns and the areas you’ve adjusted.

These requirements aren’t unreasonable or capricious. If the tables were turned and you were asked to reimburse for the services someone else was delivering, you’d want the same justification and proof of efficacy too.

While some believe the Insurance Era is behind us, the truth is there are ample insurance monies available for episodic treatment if your chiropractic paperwork collects the vital information that insurance carriers justifiably expect. If you want a piece of it, it’s your responsibility to use the right Chiropractic Clinic Singapore forms to collect the data and prove that what you do is making a difference.


News Reporter