Transcript document

DOCUMENTATION
STEP BY STEP PROCEDURE
TO GOOD RECORDS
INITIAL PATIENT FORMS
 Name,
age, sex, address, SS#, Married
 Consent forms
 Family history
 Medical history: surgery, medications
 Past traumas
 Visual Analog scale
 Oswestry forms
CONSULTATION
 Go
over forms and ask questions
 Confirm reason for visit
 Past DC care - what kind, did it help?
EXAMINATION
 Chiropractic
A) palpation
B) inspection
ORTHOPEDIC EXAM
 Range
of motion
 Regional orthopedic tests
NEUROLOGIC EXAM
 Sensory
 Motor
 DTR
 Cerebellar
 Cortical
RADIOGRAPHIC
 When
and why?
 Who?
 What
views?
 Repeat studies
DIAGNOSIS
 How
to choose?
 How many to use?
 When to change?
HOW TO CHOOSE
 The
diagnosis should be based primarily on the
examination information.
 Secondary information should be the nature of the
incident.
 Generally, the diagnosis should not be based on the
radiographic findings.
HOW MANY
 HCFA forms
only have space for 4 codes.
 Optimize that space
 List the primary diagnosis first
 List neurologic diagnosis next
 List complicating diagnosis last
EXAMPLE 1
 Primary
- 847.0
 Secondary - 723.4
 Complicating - Arthritis
EXAMPLE 2
 Primary
- 847.2
 Secondary - 724.3
 Complicating - Scoliosis
EXAMPLE 3
 Primary
- 722.10
 Secondary - 728.85
 Complicating - previous surgery
WHEN TO CHANGE
 When
the soft tissue injury has reached MMI.
 When your care is subluxation based.
 When the patient is in active rehab.
 When the condition has worsened.
 When there is a new injury.
CERVICAL SPRAIN/STRAIN
 Subjective
neck pain
 Affected joint movement painful
 Spasm or hypertonicity
 Tenderness by palpation
 History of trauma/insult to region
THORACIC SPRAIN/STRAIN
 Subjective
mid-back pain
 Affected joint movement painful
 Spasm or hypertonicity
 Tenderness by palpation
 History of trauma/insult to region
LUMBAR SPRAIN/STRAIN
847.2
 Subjective
low back pain
 Affected joint movement painful
 Spasm or hypertonicity
 Tenderness by palpation
 History of trauma or insult to region
LUMBOSACRAL
SPRAIN/STRAIN=846.0
 Subjective
low back/sacral pain
 Affected joint movement painful
 Spasm or hypertonicity
 Tenderness by palpation
 History of trauma or insult to region
CERVICAL DISC
722.0
 Subjective
neck pain
 Affected joint movement painful
 Reduced neck motion
 Spasm or hypertonicity in cervical spine
 History of trauma
 Positive cervical compression tests
 Radicular symptoms
LUMBAR DISC
722.10
 Low
back, buttock, and/or posterior leg symptoms
with at least one of the following positive tests:
A) SLR (+) at 30-70 degrees
B) Bechterew’s test
C) Lasegue’s test
D) Kemp’s test
E) Antalgic posture
BRACHIAL PLEXUS LESION
353.0
 Cervical
rib
 Costoclavicular
 Scalenus anticus syndrome
 Thoracic outlet syndrome
BRACHIAL PLEXUS LESION
353.0
 Tenderness
at the supra-clavicular and/or lateral
aspect of the lower cervical spine
 At least one of the following test (+)
A) Adson’s test
B) Wright’s test
C) Costoclavicular test
D) Hyperabduction test
ACUTE ACQUIRED TORTICOLLIS
= 333.83
 Acute
neck pain - no trauma
 Spasms usually involving the trapezius or
stenocleidomastoideus
 Head tilt present
MYOFASCITIS
729.1
 A condition
of chronicity
 Circumscribed palpable nodule (trigger point)
 Causes referred pain
HEADACHES
784.0
 Tension
 Muscular
 Vertebrogenic
 Tenderness
by palpation in the suboccipital and
upper cervical region
MIGRAINE, CLASSICAL
346.0
 Aura
consisting of at least one of the following:
A) Visual disturbances
B) Numbness or weakness on one side of the body
C) Transient aphasia
D) Vertigo
MIGRAINE, CLASSICAL
346.0
 Unilateral
head pain
 Nausea and/or vomiting
COMMON MIGRAINE
346.1
 Unilateral
or bilateral head pain
 Pain in the eye (stabbing)
 Often aggravated by light or noise
WHAT TO BILL?
 Examination
 X-rays
 Manipulation
 Modalities
codes
Examination
 E/M
codes
 99204 – 99214 – Moderate to high
 99203 – 99213 - Moderate
 99202 – 99212 – Low to moderate
 Consider adding – modifier 25 when using 9894?
 Use 99212-25 when reviewing outside films
X-rays
 X-ray
area of chief complaint with initial clinically
significant findings
 Full spine radiographs not diagnostic for trauma
 Repeat films inappropriate in absence of
documented instability
 Incomplete studies without explanation and
appropriate billing
Manipulation codes
– 1 to 2 areas
 98941 – 3 to 4 areas
 98942 – 5 to 6 areas
 98943 – Extremity
 Modifier –51 When billing 9894? + 98943-51
 Modifier – 59 When using 9894? + 97140-59
 98940
Modalities
add modifier –59 to your manual therapies
This indicates independent service
 This will aid in preventing bundling by the
insurance company
 Billing 1 or 2 units of therapy. Minimum of 8
minutes for one and at least 23 minutes for 2
 Make sure and link each therapy with a different
region(diagnosis)
 Always
DAILY DOCUMENTATION
 SOAP NOTES
a) Inappropriate examples
b) Good examples
c) Computerized notes
PROPER DAILY NOTES
 SOAP FORMAT
PROPER DAILY NOTES
 SOAP NOTES
S
= Subjective data - What the patient has
experienced since last visit. The VAS can be used
here. No objective data. The response to last visit
is recorded here
PROPER DAILY NOTES
 SOAP
O
= Any objective data. Use short phrases and/or
medical abbreviations. Inspection, palpation,
laboratory, or diagnostic exams listed here.
PROPER DAILY NOTES
 SOAP
 A = Assessment,
the patient’s progress since last
visit, new diagnosis, doctor’s conclusions, working
impressions, discharge diagnosis when
appropriate.
PROPER DAILY NOTES
 SOAP
P=
Plan/Procedure. The first recorded SOAP
should include a treatment plan or future
diagnostic plans, short and long term. All
subsequent plan/procedure sections should include
treatment rendered and when the patient is to
return.
PROPER DAILY NOTES
 EXAMPLE
 S:
Pt states he is sleeping better, less pain,
adjustment seemed to help
 O: muscle tone improved, Fixations noted; C1, T8,
PI (R) ilium.
 A: #1 improved, #2 no change
 P: TX per TP, RTC 11-22
RE-EXAM DOCUMENTATION
 What
to do?
 How often?
 What to bill?
RE-EXAM SHOULD INCLUDE
 Brief
consultation about current condition
 Repeat (+) tests & significant (-) tests
 Visual analog scale
 Oswestry repeated
 Have patient sign exam form
RE-EXAMINE HOW OFTEN?
 Every
10-12 visits
 Every 4 weeks
 Whenever there is a worsening of the condition
 Whenever there is a new area of complaint
 Upon release from care or MMI
WHAT TO BILL?
 Simple
re-exam - 99211/99212
 New injury possibly - 99213
 Significant new injury - 99214
A) Major auto accident with multiple injuries
requiring detailed history and detailed examination
NOW WHAT?
 Treatment
plan needs to change
 If patient is improving the following needs to
happen:
A) fewer weekly visits
B) fewer modalities
C) move towards active vs passive care
NOW WHAT?
 If
the patient has not made significant
improvement the following needs to happen:
A) A change in the treatment
B) Referral for second opinion to DC, MD, or DO
C) Additional advanced testing - CT, MRI, EMG