Documentation for Daily Treatment Visits (DeskBook Chapter 4.3)

Transcription

1 Documentation for Daily Treatment Visits (DeskBook Chapter 4.3) Presented by Evan M. Gwilliam, DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP Vice President 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 2 1

2 Take-away Understand payor requirements to document notes (aka treatment/subsequent visits) Get a handle on the correlation between and CMS requirements Disclaimer: this is Dr. Gwilliam s perfect note, not anyone else s. Somebody out there will think it is flawed, and they might be right. 3 From the new and improved documentation chapter in the 2018 DeskBook 2

3 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 5 Daily Visit Requirements According to a state scope regulation: 6 3

4 Daily Visit Requirements According to a provider network: 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 7 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 8 4

5 Subjective Objective Assessment Plan/Procedures 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 5

6 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. 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 6

7 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. 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) 7

8 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. 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 8

9 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. and CMS 1. History (S) 2. Physical Exam (O/A) 3. Treatment Given (P) 4. Fit within Plan (P) 9

10 and CMS History Review of chief complaint Changes since last visit o Following last treatment o Immediately preceding current visit System review if relevant 19 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 20 10

11 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 21 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 22 11

12 and CMS 1. History (S) 2. Physical Exam (O/A) 3. Treatment Given (P) 4. Fit within Plan (P) S: O: Chief complaint: Changes: Each Segment: Pain: Asymmetry: ROM: 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: 12

13 The ChiroCode DeskBook is available at ChiroCode.com This presentation is covered in Chapter 4.3 Take-away Understand payor requirements to document an treatment/subsequent visits Get a handle on and CMS requirements 26 13