I get asked this question all the time: How should we document for a personal injury patient?
That question drives me crazy. Let me be clear:
There is no such thing as documentation for PI patients, documentation for cash patients, documentation for insurance patients or documentation for Medicare.
Wanna know how to document for ALL PATIENTS? It’s easy.
I know, I know – now you’re rolling your eyes at me and muttering to yourself, “But I hardly see any Medicare patients!”
It doesn’t matter. CMS (Centers for Medicare and Medicaid Services) creates the rules – for everyone in healthcare. And before you get mad about it, take a breath and relax. Because Medicare tells us…
Exactly What They Want.
And everyone else follows Medicare. When I step in to help doctors with insurance audits, like with BCBS or anyone else, I tell the doctors that the insurers are all following the same guidelines – and that’s Medicare. It amazes me to see how many chiropractors still don’t get this. I’ve also seen more and more state boards following the Medicare guidelines. So, instead of arguing about it, how ‘bout we just learn it and do it?
Medicare requires THREE things from chiropractors. First, they require that we assess PAIN on every visit (and for each condition that we’re treating). Second, they require that we assess FUNCTION with the use of standardized functional outcome questionnaires, every 30 days or sooner (and for each condition that we’re treating). Third, they require that we use the P.A.R.T. format to document our daily findings. If you do these three things, you will be amazed how much easier things get. When I review PI records, it amazes me that all of the various software programs I see have no idea what I’m talking about.
Learn Medicare. You’re Life Will Get Easier.