Coding Questions: How to prevent insurance audits and refunds

Published: 2010-06-20 16:04:32
Author: Marty Kotlar | | March 2010

Q: How can I  prevent an insurance company from asking me for my SOAP notes? And if they do, what can I show them that will allow me to sleep better at night?

A: Your desire to be proactive and learn how to prevent potential problems is commendable. It’s difficult to provide specific recommendations because the type of practice you manage is not known.

There are, however, basic documentation and billing items that are important for every chiropractor to know, even if you’re a cash practice.

1. Compliant documentation. When you decided to become a DC, it was probably because you wanted to help people get well through high-quality chiropractic care, not because you wanted to become an expert in documentation and coding. In today’s healthcare environment, proper documentation is extremely important and required.

In order to receive the reimbursement you rightfully deserve, you must document properly and bill compliantly. Good quality patient care involves documenting everything that occurs during every patient encounter. After all, your documentation is the only way to substantiate the care you provided was actually performed.

This is extremely important if you are ever involved in a malpractice case or insurance audit. Good documentation is also important if your files are ever asked to be reviewed by a chiropractic state board or if the patient simply asks to see their files.

2. The first visit. All new patients should complete a good, quality health history intake questionnaire. It’s important to document the following items:

• History: Make sure to comply with the guidelines. Example, CPT code 99203 requires four items documented in the history of present illness (HPI).

• Examination: Here again compliance is vital. Example, CPT code 99203 requires 12 examination findings be identified and documented in the patient chart.

• Diagnosis: List all the diagnoses, even if there are 10.

• Short-term goals: Example, improve lumbar flexion range of motion from 40 degrees to 75 degrees within four weeks.

Services: List the services going to be rendered and the reasons why you are going to do them.

• Visit schedule: List the duration and frequency.

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