Documentation by Dr. Gregg Friedman and The Bulletproof Chiro

More about… Medicare, Medicare, Medicare.   In my last article, I wrote about the TWO THINGS that Medicare wants from us. The first thing is PAIN. So now, let’s discuss the SECOND thing Medicare wants from us. Function Medicare requires that we perform a Functional Outcome Assessment for our patients. They define a Functional Outcome Assessment as “patient completed questionnaires designed to measure a patient’s limitations in performing the usual

Medicare, Medicare, Medicare. I know, we’ve had this hate-hate relationship with them for so many years. So many chiropractors are afraid of it and hate the reimbursement. I get it. But… You need to understand that Medicare drives this whole train. Everyone else follows Medicare. They created the documentation guidelines. They guide the CPT and ICD10 codes. So, instead of fighting them (and losing), how ‘bout we understand their perspective

When we think of documenting a SOAP note, we need to be sure that we connect all the dots. One of the biggest problems I see in the many chiropractic records I review is that the treatment is not justified by the findings. And it’s easily corrected. If you perform an adjustment/CMT at C3, what is the justification for that? The simple answer is restriction/fixation/subluxation at C3. If you perform

This question comes up periodically. “What do we need to document for our maintenance patients?”  Let’s first define what we mean by “maintenance” patients. Some of these patients come in with no symptoms – they just like to get adjusted periodically. Other patients, though, have some level of chronic pain or discomfort that never seems to go anywhere – it just stays the same all the time and they find

Doctors ask me all the time why I chose the worst subject in the history of subjects to teach – documentation. Originally, it was simply because many of us were getting absolutely hammered by insurance companies (commercial and auto) and our reimbursement was getting hit hard, or we were asked to PAY BACK money that had been paid to us (think Medicare and PI post-payment audits). Back then, I spent

Even though Chiropractic has been around since 1895, it’s still a pretty young profession, in the grand scheme of things. While the rest of healthcare has embraced the use of numbers for years, chiropractic is still pondering the idea. While numbers aren’t the “end all,” if used properly, they can be of enormous benefit to chiropractors and our patients. When you go to a medical doctor, the visit often includes

I know, good documentation helps us get reimbursed better by insurance. I get it. But… It’s Not Just About Insurance. I graduated chiropractic college in the late 1980s. Back then, no one cared about our documentation. Ever. We would scribble meaningless stuff on ridiculous travel cards, but it worked for us back then. No one ever looked. Not even for PI. Then, one day, it changed. The health care world

Major League Baseball has been analyzing data, called Sabermetrics, since the middle of the 20th Century. All year long, even in the off-season, baseball people are looking at data in order to determine a variety of scenarios that will help them get the best outcomes (wins). It’s gotten so crazy that there’s now a strategy called a “shift,” in which some of the infielders and outfielders shift more toward one

Documentation is a funny thing. For years, chiropractors have been told that our documentation has to “tell the story.” Unfortunately, many chiropractors take that to think they have to write a novel for each patient encounter. The good news is… You may be talking too much. I agree with the premise that we need to tell the story about what is going on with our patients and with each patient

Documenting treatment goals has been an issue for many chiropractors for years. For the few chiropractors who have made the effort, typical goals tend to be things like “reduce pain, reduce muscle spasm, improve range of motion,” regardless of the conditions being treated. When focusing on the Problem Oriented Medical Record format of documentation, which has been the standard since 1968, if we’re treating a patient for headaches, neck pain

When documenting our Plan, as in what treatment was performed today, it’s important to remember that every form of treatment we provide must be justified by our objective findings. That’s pretty easy when it comes to ice, heat and other passive modalities, like electrical stimulation and ultrasound. Pain and/or muscle spasms are typically enough to justify these modalities. However, the treatments that tend to raise my eyebrows when I review

In my previous article, I wrote about how important a great Assessment is in our SOAP notes and how most chiropractors don’t even come close to documenting a good assessment. Some chiropractors complain that some patients respond more slowly than others and that should be taken into consideration. I couldn’t agree more. In fact, a great idea is to document complicating factors for EACH condition you’re treating for each patient, if they exist. A great resource

There’s ONE part of our SOAP notes that I’ve been preaching about for years, but it seems as though not many doctors are paying close enough attention to it. It’s the Assessment. Here’s what I see in most records that I review in the Assessment part of the SOAP Note: “Patient is responding well to care.” “Patient is the same.” “Patient is responding slower than expected.” To begin with, according

There seems to be some confusion among chiropractors as to what objective findings we need to document on our daily visits.  I, and others, have been teaching for a number of years to follow the PART format of documentation for ALL of our patients.  This PART format is what is REQUIRED by Medicare, and, to be honest, it works quite well for ALL of our patients. So, let’s review what PART is. 

In my last article, I discussed the MUSTs and the SHOULDs of Subjective Documentation, that being Pain Intensity, Pain Frequency and the use of Outcome Questionnaires. Now we’ll tackle the Objective Findings. Even though many chiropractors don’t treat a lot of Medicare patients, please understand that Medicare creates many of the rules. I’ve seen other commercial payors using the Medicare documentation guidelines for their policies, which actually makes it easier

Let’s face it. With regards to our documentation, some doctors don’t say enough, while other doctors say too much. So which is better? Let’s narrow this down to the big three: The Must, the Should and the Could. There are some things we MUST document. They’re required components and if we miss them, we’re toast. Then there are certain things that we SHOULD document. These things aren’t exactly required, but they really enhance our documentation. And then

After being in practice for 32 years, teaching documentation and coding for about 20 years, reviewing records and performing IMEs for a lot of years, I see and hear the same things over and over again with regards to documenting subjective complaints. Let’s make this easy. Initial Visit According to the Mayo Clinic, 80% of the proper diagnosis comes from a good history. Unfortunately, many chiropractors tend to take shortcuts

I remember the “good ‘ole days” of chiropractic. The days when it seemed that everyone in America had health insurance, when the typical deductible was about 100 bucks and the patient only had to pay 20% of the charges. And their policy limited chiropractic treatment to only “UNLIMITED VISITS.” Sigh… When a new patient came in, we did the ortho/neuro exam we all learned in chiropractic school, found a few

In the old movie, Cool Hand Luke, the Captain said to Luke, “What we’ve got here is failure to communicate.” This has been a major problem with the chiropractic profession since our inception. So many people who’ve never been to a chiropractor have simply no idea what it is that we do and why we do it. In fact, the rest of what I like to refer to as the