The Missing Link in Documentation

Written by Billing Dynamix

Gregg Friedman, DC

Let’s keep talking about who makes the rules for documentation, that being…

Centers for Medicare and Medicaid Services (CMS)

In my last article, I talked about the first thing they want from us, which is to assess pain for each condition and on every visit.  So now, let’s talk about…

The Second Thing

CMS requires that our documentation includes a “functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies.”  To make this a bit easier to digest, all they’re really wanting is for us to use functional outcome questionnaires.  “Functional questionnaires seek to directly quantify symptoms, function and behavior, rather than draw inferences from relevant physiological tests.”

CMS also states that clinicians should use validated self-report questionnaires/tools that are useful for identifying a patient’s baseline status relative to pain, function, and disability and for monitoring a change in a patient’s status throughout the course of treatment.

How Often?

CMS wants us to have the patient complete a functional outcome questionnaire for each complaint we’re treating, on the initial visit, and then every thirty days or sooner.  Our care plan should include measurable treatment goals for each condition, based on the scores on the functional outcome questionnaires.One problem I’ve seen, though, is that some questionnaires, well, suck.  They’re too complicated and/or time-consuming and patients hate filling them out.  The most despised ones include the Revised Oswestry Low Back Disability Questionnaire and the Neck Disability Index.  While there are only 10 questions on each, each question has 6 different options, so patients have to read 60 different options and select an answer for each.  There are a number of functional outcome questionnaires we can use that are much easier and faster for patients to complete.