Audit Yourself Before Someone Else Does

Transcription

1 Audit Yourself Before Someone Else Does Presented by Evan M. Gwilliam, DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP AAPC Fellow Clinical Director 1 Dr. Evan Gwilliam Education Bachelor s of Science, Accounting - Brigham Young University Master s of Business Administration - Broadview University Doctor of Chiropractic, Valedictorian - Palmer College of Chiropractic Certifications Certified Professional Coder (CPC) - AAPC Certified Chiropractic Professional Coder (CCPC) - AAPC Qualified Chiropractic Coder (QCC) - ChiroCode Certified Professional Coder Instructor (CPC-I) - AAPC Medical Compliance Specialist Physician (MCS-P) - MCS Certified Professional Medical Auditor (CPMA) AAPC, NAMAS Certified ICD-10 Trainer AAPC Certified MIPS Healthcare Professional (CMHP) 4Med Fellow AAPC 2 1

2 Take-away Learn how to use all of the links in the "Chain of Medical Necessity" to prove that your care is payable Understand the "Episode of Care Journey" and how it will help you communicate with third parties Avoid common documentation errors 3 Who is selected for an audit? 2

3 Who is selected for an audit? % 32% 61%

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6 Medical Necessity Services or items reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member -CMS How can you prove medical necessity? Chain of Medical Necessity 1. History of onset 2. Patient complaint 3. Exam findings 4. Diagnosis 5. Treatment plan 6. Progress 6

7 Chain of Medical Necessity 1. History of onset Explain why the patient has a complaint Acute: document mechanism of trauma Chronic: try to establish why the patient decided to come in today, rather than another time Chain of Medical Necessity 2. Patient complaint 3. Exam findings Relate exam findings to complaint Functional loss should be documented in the complaint (ADLs) and consistent with the exam findings. 7

8 Chain of Medical Necessity 4. Diagnosis The diagnosis should provide a plausible explanation for the symptoms. Clinical criteria from the history and exam should match up with the diagnosis. Chain of Medical Necessity 5. Treatment Plan Should be appropriate for the diagnosis. Care given because of provider technique, philosophy, or just routine is not medically necessary. Treatment should transition from passive to active. Avoid cookie cutter care. Plans should vary for different ages and different diagnoses. 8

9 Chain of Medical Necessity 6. Progress Goals should be specific to each patient and measurable Outcomes Assessment Tools are the best way to quantify functional progress Goals must be evaluated and updated over time Chain of Medical Necessity 1. History of onset 2. Patient complaint 3. Exam findings 4. Diagnosis 5. Treatment plan 6. Progress 9

10 OIG report Chiropractic services that are not reasonable or necessary can potentially harm Medicare beneficiaries. They expect the documentation to include either the date of the initial treatment or the date of the exacerbation of the existing condition According to their reviews, many chiropractic claims are incorrect for even those whose billing patterns were not 'aberrant. OIG has called on CMS to conduct more medical reviews 20 10

11 OIG report The low number of views of CMS training video is proof that chiropractors are unwilling to change their policies and procedures CMS should set a threshold for the number of chiropractic services that a beneficiary may receive per year and require medical review for services in excess of that threshold. CMS stated they might consider a new modifier to indicate the beginning of a new episode of care because simply requiring modifier AT has not solved the problem

12 Episode of Care 24 12

13 Episode of Care 13

14 Evaluation Visits Create a clear care plan Include specific, measurable goals Provide rationale for all services provided 27 Evaluation Visits Short term goals restated: 1. Reduce pain 2. Increase pain-free ROM 3. Restore normal vertebral segmental motion 4. Increase ability to move affected area Short term goals improved: 1. Reduce VNRS from 8/10 to 5/10 within 2 weeks 2. Increase pain-free ROM by 50% within 2 weeks 3. If you restore normal vertebral segmental motion, you can t adjust anymore, right? 4. Same as number 2? 28 14

15 Evaluation Visits Two weeks later Assessment should discuss progress towards goals Were goals achieved? If not, why? Patient went on vacation Patient fell down the stairs How will the care plan change to adapt to goals that were not met? Easier or harder exercises? More or fewer visits? Referral or new diagnostic test? 29 Function-based Goals 1. What is the activity (sleep, walk) the patient will be able to perform? 2. Under what conditions (how far or for how long) will they be able to do it? 3. How well will they be able to do it (without assistance, without increased pain)? 4. When will this be accomplished (2 weeks, 2 months)? Keep them patient-centered! 30 15

16 Evaluation Visits Focus on changes Treatment Visits 32 16

17 Documentation Is your documentation a weakness to be exploited by those who do not want to pay? Or, is it a shield that protects you from liability and audits? Chiropractic Services Targeted 2014 CERT Improper Payment Report o 54.1% of chiropractic claims were paid improperly 92.2% of those improper payments were due to insufficient documentation 17

18 Denials Payers often believe that services rendered were unnecessary because: o There were too many visits o There were unnecessary services at each visit o Billing does not match documentation Good documentation can prove that: o The visits were medically necessary o The services were needed to help the patient get better o The billing is an accurate reflection of the record Bad Records Bad records can cause: State board action Claim payment denial Administrative heartburn Miscommunication between payers and the doctors 18

19 Problem Oriented Medical Record 1. Why did the patient begin care? 2. What did the provider find wrong? 3. What did he/she do about it? 4. How did care end? Problem Oriented Medical Record 1. Complete problem list 2. Diagnoses for each problem 3. Treatment goals for each problem 4. Written treatment plan for each problem 5. SOAP notes for ongoing treatment of each problem 6. Date of resolution or referral for each problem 19

20 Common Errors Illegible records Missing dates Missing signature Missing informed consent Missing re-assessment Missing patient identifiers Missing metrics/objective Blanks used to indicate WNL Missing legend for abbreviations Missing care plan Cloned records Billing only or only Using travel cards 39 Signatures Electronic signatures can be o Electronic image using a pen tablet o Digitized and confirmed by valid software Unacceptable signatures include: o illegible signature or initials, not over typed/printed name, not on letterhead, not accompanied by a signature log or attestation statement o unsigned note with provider's printed name o "signature on file" 40 20

21 Signatures Acceptable signatures include: legible first initial and last name illegible signature over typed or printed name, or with clear letterhead illegible signature with a signature log or attestation statement initials over a typed or printed name, or accompanied by a log or attestation statement unsigned handwritten note where other entries on the same page in the same handwriting are signed Cloned records 21

22 Avoiding Clones Watch out for text spinners or random text generators Consider: o Quoting patient statements o Patient age, severity of condition, complicating factors o Specific goals that mention actual ROM or OATs score for that patient o Diagnoses that are specific. (i.e. more than just pain and subluxation) o Highlighting changes to help reviewers 43 Avoiding Clones 44 22

23 Take-away Learn how to use all of the links in the "Chain of Medical Necessity" to prove that your care is payable Understand the "Episode of Care Journey" and how it will help you communicate with third parties Avoid common documentation errors 45 Documentation for Chiropractic Evaluations Presented by Evan M. Gwilliam, DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP Clinical Director 46 23

24 Take-away Understand the requirements to document an initial evaluation Physical Examination o Satisfy E/M requirements o Add in ortho/neuros as desired o Use PART for subluxations Understand the what to include in a reevaluation or discharge evaluation 47 From the new and improved documentation chapter in the 2018 DeskBook 24

25 Evaluations vs. Treatments Evaluation visit (similar to a standard visit to a medical doctor): Record history Note objective test results and observations Establish patient s condition/diagnosis Formulate a plan with quantifiable, patient-centered goals 49 Treatment visit (the plan is carried out) Update patient-centered measurable Subjective and Objective information Assess patient specific functional progress Describe procedures and where the patient is in the plan Evaluations vs. Treatments To get the whole story a reviewer would need the evaluations on either side of the treatments. 50 This describes the entire episode of care rather than an isolated treatment. 25

26 Initial Evaluation 1. History 2. Description of Present Illness 3. Physical Exam 4. Diagnosis 5. Treatment Plan 6. Date of Initial Treatment 51 Initial Evaluation Template 1. History: 2. Description of Present Illness: 3. Physical Exam: 4. Diagnosis: 5. Treatment Plan: 6. Date of Initial Treatment: 26

27 Initial Evaluation: History Symptoms causing patient to seek treatment [Chief Complaint] Family history if relevant [Family History] Past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history) [Past History] Plus 53 Initial Evaluation 1. History 2. Description of Present Illness 3. Physical Exam 4. Diagnosis 5. Treatment Plan 6. Date of Initial Treatment 54 27

28 Initial Eval: Description of Present Illness Mechanism of trauma [History of Present Illness] Quality and character of symptoms/problem [HPI] Onset, duration, intensity, frequency, location, and radiation of symptoms [HPI] Aggravating or relieving factors [HPI] Prior interventions, treatments, medications, secondary complaints [Past History] Symptoms causing patient to seek treatment [Chief Complaint] 55 Initial Evaluation 1. History 2. Description of Present Illness 3. Physical Exam 4. Diagnosis 5. Treatment Plan 6. Date of Initial Treatment 56 28

29 Physical Exam Three distinct things should be documented in the physical exam: 1. E/M code criteria 2. Ortho/neuro testing 3. P.A.R.T. for segmental dysfunction (subluxation) In a way, these each stand alone Physical Exam: E/M code Evaluation and Management (E/M) codes are how we get paid for an evaluation Documentation Guidelines for Evaluation and Management codes provides a standardized outline for a nicely documented evaluation of the musculoskeletal and nervous systems

30 Physical Exam: E/M code Musculoskeletal System Examination of gait and station Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes) Examination of joints, bones and muscles of one or more of the following six areas: 1) head and neck; 2) spine, ribs and pelvis 3) right upper extremity 4) left upper extremity 5) right lower extremity 6) left lower extremity 60 30

31 Physical Exam: E/M code Musculoskeletal System The examination of a given area includes: o Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions o Assessment of range of motion with notation of any pain, crepitation or contracture o Assessment of stability with notation of any dislocation (luxation), subluxation or laxity o Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements 61 Physical Exam Template Musculoskeletal Gait/station: Neck Palpation: ROM: Stability: Muscle: Spine Palpation: ROM: Stability: Muscle: 31

32 Physical Exam: E/M code Neurologic System Test cranial nerves with notation of any deficits Examination of deep tendon reflexes with notation of pathological reflexes (e.g., Babinski) Examination of sensation (e.g., by touch, pin, vibration, proprioception) Where are other ortho/neuro tests? 63 Physical Exam Template Musculoskeletal Gait/station: Neck Palpation: ROM: Stability: Muscle: Spine Palpation: ROM: Stability: Muscle: Neurologic Cranial nerves: DTRs: Sensation: 32

33 Physical Exam: Ortho/neuro Screens for bad things and helps the provider decide if additional diagnostic testing/referral may be warranted Official Disability Guidelines suggest there are two types of neck and back pain patients: o Radicular 5% of all neck pain patients 10% of all lower back pain patients o Non-radicular 95% of all neck pain patients 90% of all lower back pain patients Most ortho/neuro tests are not positive on non-radicular patients. Physical Exam: Ortho/neuro Beware of saying that a test is positive. Just describe the findings. o Foraminal compression test is positive for radiating pain to the posterior left upper arm, indicative of radiculopathy. o Foraminal compression test leads to right sided neck pain of moderate intensity is a better way to document non-radicular problems. Ortho / neuro does not prove the existence of a segmental dysfunction (subluxation). Ortho/neuro does not contribute (much) to E/M code selection. Ortho/neuro does help establish the need for further diagnostic testing. 33

34 Physical Exam: Ortho/neuro Positive Kemp s test: Leg pain: nerve root compression, radiculopathy Ipsilateral lower back pain: sprain/strain, facet syndrome, meniscoid entrapment Pain on contralateral side: strain/sprain Which one is it? As with all orthopedic tests, state what the positive finding reveal in the clinical notes. Example, Kemp s test was positive for radiating right L5 dermatomal pain, indicating L5 nerve root compression Physical Exam Template Musculoskeletal Gait/station: Neck Palpation: ROM: Stability: Muscle: Spine Palpation: ROM: Stability: Muscle: Neurologic Cranial nerves: DTRs: Sensation: Ortho/neuro 34

35 Physical Exam: Segmental dysfunction (Subluxation) Medical record must contain documentation that fully supports the medical necessity for services. Level of subluxation must bear a direct relationship to the patient s symptoms, and the symptoms must be directly related to the level of the subluxation that has been diagnosed. 69 Physical Exam: Segmental dysfunction (Subluxation) Medical necessity requirements apply: Whether subluxation is demonstrated by x-ray or physical exam Applies to both initial and subsequent visits Both participating and non-participating providers Document precise level of subluxation: a) List exact bones involved o C2, L4, etc. b) Area/region, if it implies certain bones o Lumbo-sacral o Sacro-iliac 70 35

36 Physical Exam: Segmental dysfunction (Subluxation) According to CMS, the physical examination for a subluxation is an evaluation of the musculoskeletal/nervous system to identify: P.A.R.T. 71 Physical Exam: Segmental dysfunction (Subluxation) P Pain/tenderness 36

37 Physical Exam: Segmental dysfunction (Subluxation) Pain/tenderness evaluated in terms of location, quality, and intensity Pain and tenderness findings may be identified through observation, percussion, or palpation. Physical Exam: Segmental dysfunction (Subluxation) A Asymmetry/misalignment 37

38 Physical Exam: Segmental dysfunction (Subluxation) Asymmetry/misalignment may be identified on a sectional or segmental level through one or more of the following: Observation (posture and gait analysis), Static palpation for misalignment of vertebral segments, Diagnostic imaging Physical Exam: Segmental dysfunction (Subluxation) R Range of Motion 38

39 Physical Exam: Segmental dysfunction (Subluxation) Range of motion abnormalities may be identified through one or more of the following: Motion palpation Observation Range of motion measurements (i.e. inclinometers) Physical Exam: Segmental dysfunction (Subluxation) T Tissue/tone changes 39

40 Physical Exam: Segmental dysfunction (Subluxation) Tissue, tone changes in the characteristics of contiguous, or associated soft tissues, including skin, fascia, muscle, and ligament may be identified through one or more of the following procedures: Observation Palpation Use of instruments Physical Exam: Segmental dysfunction (Subluxation) To demonstrate a subluxation based on examination two of the four criteria must be: Asymmetry or Range Of Motion P.A.R.T. 40

41 Physical Exam Template Musculoskeletal Gait/station: Neck Palpation: ROM: Stability: Muscle: Spine Palpation: ROM: Stability: Muscle: Neurologic Cranial nerves: DTRs: Sensation: Ortho/neuro Segmental Dysfunction Each Segment: Pain: Asymmetry: ROM: Tissue/tone: Physical Exam Three distinct things should be documented in the physical exam: 1. E/M code 2. Ortho/neuro 3. P.A.R.T. 41

42 Physical Exam Template Musculoskeletal Neurologic Gait/station: Neck Palpation: ROM: Stability: Muscle: Spine Palpation: ROM: Stability: Muscle: Documents E/M criteria Documents subluxation Cranial nerves: DTRs: Sensation: Ortho/neuro Segmental Dysfunction Each Segment: Pain: Asymmetry: ROM: Tissue/tone: Screens for bad stuff Initial Evaluation 1. History 2. Description of Present Illness 3. Physical Exam 4. Diagnosis 5. Treatment Plan 6. Date of Initial Treatment 84 42

43 Initial Evaluation: Diagnosis Primary diagnosis must be M99.00 Segmental and somatic dysfunction of head region M99.01 Segmental and somatic dysfunction of cervical region M99.02 Segmental and somatic dysfunction of thoracic region M99.03 Segmental and somatic dysfunction of lumbar region M99.04 Segmental and somatic dysfunction of sacral region M99.05 Segmental and somatic dysfunction of pelvic region Secondary diagnosis must be a neuromusculoskeletal condition based on the presenting problem. List primary/secondary for each region treated/billed 85 Initial Evaluation: Diagnosis Sample from Anatomic Diagnosis Code List of 2018 ICD-10-CM Coding for Chiropractic 43

44 Initial Evaluation: Diagnosis 1. Nerve related disorders (e.g. radiculopathy) 2. Acute injuries (e.g. sprains and strains) 3. Structural diagnoses (e.g. degenerative disc disease) 4. Functional diagnoses (e.g. difficulty with walking) 5. Symptoms (e.g. neck pain) 6. Complicating factors/comorbidities (e.g. diabetes) 7. External causes (e.g. place and activity) Initial Evaluation: Diagnosis When coding for symptoms, add the phrase due to for better specificity. Complicating factors should also be diagnosed, if relevant. Learn to document a Diagnostic Statement that matches the code requirements

45 Initial Evaluation 1. History 2. Description of Present Illness 3. Physical Exam 4. Diagnosis 5. Treatment Plan 6. Date of Initial Treatment 89 Initial Evaluation: Treatment Plan 1. Recommended level of care (duration and frequency of visits) o o o Acute treatment is shorter duration, higher frequency Chronic treatment is longer duration, but lower frequency Initial exam is not expected to provide all the answers. A treatment trial should be instituted and assessed to determine if the plan should change. 2. Specific treatment goals o With documentation of progress or lack thereof at subsequent visits 3. Objective measures to evaluate treatment effectiveness o Qualitative and/or quantitative 90 45

46 Initial Evaluation: Treatment Plan Outcomes measures should be used at the beginning, during, and after treatment is recommended to quantify progress. Plan of care should include recommendations for ongoing amelioration of musculoskeletal complaints, such as: o Home program, lifestyle modifications, etc Introduce as soon as possible, reinforce, and document in the medical record. 91 Why is a Care Plan Important? Medicare requires providers to have a Care Plan Boards of Examiners require Care Plans Insurance Carriers require a Care Plan Today's patient s demand them It shows you have gone through the decision making process How can I get this patient better? 46

47 Compliant Treatment Care Schedule Plans 47

48 Medicare Care Plans Local Coverage Determination (LCD): Chiropractic Services (L33613), page 6 National Government Services, Inc. Compliant Care Plans 1. Why are you treating the patient? 2. What are you going to do with the patient? 3. How long and how often are you going to see the patient? 4. What are you and the patient trying to accomplish? 5. How do you know when you have accomplished the goals? 48

49 Elements of a Care Plan Diagnoses: Written out as a diagnostic statement Specific procedures/services with rationale Duration: Number of weeks Frequency: Times per week Stages or phases of care (i.e. benchmarks) Goals/outcomes: long and short-term for each phase of care 97 Procedures / Services Tie the treatments to the diagnoses For example, the purpose of Therapeutic exercise is to develop/improve strength, endurance, range of motion, and/or flexibility o Diagnoses like M54.2 cervicalgia may not support this service o But diagnoses like M62.81 muscle weakness might Extraspinal manipulation should not be linked to spinal diagnoses o Such as M50.3- Other cervical disc degeneration 98 49

50 Duration and frequency Set up a trial that is adaptable based on evaluations rather than a long term cook book plan for all patients. Move through phases. CMS recognizes that: o o Acute treatment is shorter duration, higher frequency Chronic treatment is longer duration, but lower frequency Use a combination of 1. clinical expertise 2. patient expectations 3. evidence-based guidelines to determine the recommended level of care Treatment regimens should be based on the individual circumstances and patient condition (s) o Complicating conditions o Exacerbations 99 Duration and frequency Consider LCD L35424 Novitas Solutions, Inc. Twelve (12) chiropractic manipulation treatments for Group A diagnoses. Eighteen (18) chiropractic manipulation treatments for Group B diagnoses. Twenty-four (24) chiropractic manipulation treatments for Group C diagnoses. Thirty (30) chiropractic manipulation treatments for Group D diagnoses 50

51 Set up a template Start by determining your best case scenario Identify the stages or phases of care Decide the number of visits Determine what services you typically perform for each stage Be specific e.g. trigger point therapy vs. manual therapy Times per week and number of weeks Identify the rationales for each service provided Example Intensive Phase 4 weeks CMT 3x week, spine Reduce pain from 7/10 to 4/10 Reduce measurable ROM restriction by 50% EMS (High Volt) 3x week, cervicothoracic region Reduce pain reporting from 7/10 to 4/10 Reduce palpable muscle spasm ICE 3x week, cervicothoracic region Reduce palpable swelling/edema Myofascial Release 2x week, right deltoids Break-up palpable adhesions Increase range of motion by 50% 51

52 Example: Initial Evaluation 1. History 2. Description of Present Illness 3. Physical Exam 4. Diagnosis 5. Treatment Plan 6. Date of Initial Treatment

53 Initial Eval: Date of Initial Treatment 105 Initial Evaluation Template 1. History: 2. Description of Present Illness: 3. Physical Exam: 4. Diagnosis: 5. Treatment Plan: 6. Date of Initial Treatment: 53

54 Re-evaluation Perform every 30 days, at a minimum, to keep progress updated. Consider also evaluating at the midpoint of the initial trial (2 weeks). Only bill for an E/M if the reevaluation is significant and separately identifiable (25 modifier) 107 Re-evaluation Reassess abnormal test results from last evaluation Re-administer OATs Note functional progress or lack thereof and explain (i.e. complicating factors) Update ICD-10 codes based on exam Update goals, procedures, and frequency/duration of care plan If discharged, indicate rationale (MTB)

55 Re-evaluation 1. Were the goals met? 2. Are there new goals? o Improve NDI from 30% to 10% by 7/1/18 3. How will care change now? o More intense home exercises? o Fewer office visits? o Eliminate passive modalities? The key: show progress! The ChiroCode DeskBook is available at ChiroCode.com Most of this presentation is covered in Chapter

56 Take-away Understand the requirements to document an initial evaluation Physical Examination o Satisfy E/M requirements o Add in ortho/neuros as desired o Use PART for subluxations Understand the what to include in a reevaluation or discharge evaluation 111 Documentation for Daily Treatment Visits Presented by Evan M. Gwilliam, DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP Clinical Director

57 Take-away Understand payor requirements to document SOAP notes (aka treatment/subsequent visits) Get a handle on the correlation between SOAP and CMS requirements Disclaimer: this is Dr. Gwilliam s perfect SOAP note, not anyone else s. Somebody out there will think it is flawed, and they might be right. 113 From the 2018 ChiroCode DeskBook 57

58 Daily Visit Requirements According to Optum, daily visit notes require the following: 1. a subjective record of the patient complaint i.e., location, quality, and intensity 2. physical findings to support manipulation in a region or segment e.g., regional/segmental asymmetry or misalignment, range of motion abnormality, soft tissue tone and/or tenderness characteristics 3. assessment of change in patient condition, as appropriate 4. a record of the specific segments manipulated 115 Daily Visit Requirements According to Colorado s Rule 22:

59 Daily Visit Requirements According to a provider network in the Midwest: 1. Patient identification (name and DOB) 2. Date of encounter and visit # in treatment plan (e.g. visit 3 of 8) 3. Chief complaint/rationale for visit (NMS condition) 4. Updated patient-specific measurable subjective and objective attributes 117 Daily Visit Requirements 5. Assessment of functional changes (patient specific) 6. Current diagnosis 7. Procedure specifics (service performed, location, rationale, time) 8. Plan (next treatment date, next re-evaluation) 9. Provider ID and signature, with date/time stamp

60 SOAP Subjective Objective Assessment Plan/Procedures SOAP Subjective- in the patient s words Each complaint (by location) o Region or laterality o Severity (e.g. pain scale) o Character (e.g. stiff, burning, tingling) o Duration/timing (e.g. percentage of time with pain) o Aggravating or relieving factors Emphasize change since last visit o Patient statement of functional change (ADLs) I can walk a few hundred yards further before the pain stops me. OR I can sleep 3 hours before the pain wakes me up. Copy/paste on more than a couple visits will look like cloning 60

61 SOAP Subjective-Patient s point of view S: Mary Jane presents today for continued left sided (C3-C5), dull, achy, neck pain that began last week after "sleeping wrong." She states that "it gets worse during the day, but I slept four hours last night which is the best night since this began." She states that the pain has improved from 6/10 to 4/10 on the VNRS since the last visit. SOAP Objective- Quantifiable information Segmental Dysfunction: PART Other Dx: o Palpation, ROM, stability, muscle strength/tone (97 DGs) o Relevant ortho/neuros, if applicable OATs retest, if applicable Emphasize change since last visit Copy/paste on more than a couple visits will look like cloning 61

62 SOAP Objective- Quantifiable information O: Involuntary muscle contraction (T) is palpated on the right from C3 to C7, with tenderness (P) and restricted left rotation and lateral bending. Right lateral bending is no longer restricted. All other sectional ROM within normal limits. Restricted intersegmental motion (R) is noted at C3, C5, and T4. SOAP Assessment: S+O=A Diagnostic statement / clinical impression Subjective progress (ADLs) Objective progress (exam findings) Patient compliance, or lack thereof Barriers to recovery / complications Progress towards short and long term goals Outline the phase of care (i.e. relief, corrective) 62

63 SOAP Assessment- S+O=A A: Diagnoses include: M99.01 Segmental dysfunction, cervical region M Other muscle spasm (neck) M54.2 Cervicalgia Patient appears to be progressing well as evidenced by decreased pain reporting, and improvement in sleep duration, approaching orginal goal of six hours. Some change to right lateral bending is also favorable. Treatment was tolerated without incident. Short term goals previously outlined are still expected to be achieved by the next evaluation, and as such. Care should continue as per plan dated XX/XX/XXX. SOAP Plan/Procedures- Outline of what is next Procedures CMT (specific segments and technique) Modalities (type/location/time/rationale) DME (type/rationale) Therapy (type/location/time/rationale) Percentage completion towards specific and measurable goals Home instructions Visit # and anticipated date of next evaluation 63

64 SOAP Plan- Outline of what is next The following services were provided at today's encounter: Electrical stimulation - Interferential current was administered to the right neck and upper back for 10 minutes to reduce pain. Settings as outlined in care plan dated XX/XX/XXXX Chiropractic Manipulative Treatment - Diversified technique was used to adjust C3, C5, and T4. Short term goals: Improve pain-free sleep to six hours per night. [50% complete] Reduce pain reporting from 8/10 to 4/10 by first re-evaluation [100% complete] Patient will continue with care plan as outlined, including neck stretches as taught XX/XX/XXXX. This was visit 4 of 10. She is due to return in two days. Next re-evaluation two weeks. Universal LCDs for Chiros Already adopted: Palmetto Sept NGS May 2017 CGS Nov Under review: Noridian No word yet: First Coast Novitas WPS 64

65 Universal LCDs for Chiros SOAP and CMS 1. History (S) 2. Physical Exam (O/A) 3. Treatment Given (P) 4. Fit within Plan (P) 65

66 SOAP and CMS History Review of chief complaint Changes since last visit o Following last treatment o Immediately preceding current visit System review if relevant 131 SOAP and CMS Physical Exam Exam of area of spine involved in diagnosis o Document subsequent changes by updating NMS exam findings for all diagnoses reported o Full repeat of PART is not expected o If a significant and separately identifiable exam is performed, bill an E/M code with 25 modifier

67 SOAP and CMS Physical Exam Assessment of changes in patient condition since last visit o Compare previous findings to current o Evaluation is ongoing, signs and symptoms must be rechecked during the course of treatment. o List and update diagnoses if applicable Evaluation of treatment effectiveness o Acknowledge progress towards goals (or lack thereof) o Patient is responding as anticipated as evidenced by o State Patient tolerated treatment without incident as appropriate o Modify treatment as necessary 133 SOAP and CMS Treatment Given / Fit within Plan Chiropractic Manipulative Therapy (CMT) o List specific vertebra and technique used o Include compensatory segments (not payable) Modalities and therapies (not payable) o as outlined in treatment plan dated 6/12/2016 rather than listing repetitive details State This is treatment 4 of 10 to let everyone know that there is a plan

68 SOAP and CMS 1. History (S) 2. Physical Exam (O/A) 3. Treatment Given (P) 4. Fit within Plan (P) Subsequent visits SOAP and CMS 1. History (S) 2. Physical Exam (O/A) o P o A o R o T 3. Treatment Given (P) 4. Fit within Plan (P) 68

69 98940 M99.0_ PART 137 S: O: Chief complaint: Changes: Each Segment: Pain: Asymmetry: ROM: SOAP Template Tissue/tone: Other NMS findings: A: P: Diagnoses: Progress (S&O): Patient response: Percentage of goals: Complications: Phase of care: Treatment given: Updated goals: Home instructions: Visit #: Next evaluation: 69

70 Take-away Understand payor requirements to document an treatment/subsequent visits Get a handle on SOAP and CMS requirements 139 Audit Yourself Before Someone Else Does Presented by Evan M. Gwilliam, DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP AAPC Fellow Clinical Director evang@paydc.com