Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 528
Compliance & Insurance-Licensure Audits 41 CA

From the Desk of Dr. Mark Studin
Academy of Chiropractic
Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time.

“Documentation Alert”

1.  How did the patient respond to care? This is an often overlooked item and critical. The lack of this documentation signifies no ongoing improvement and a reason for both denials and audits. 

You can either respond with pain scale comparisons pre and post treatment or more of a descriptive note. This does not need to be a robust note, only one that signifies what you are doing is working. 

2.  Clock time vs. running time: Any “time-based” code must have actual clock time and not the amount of minutes spent. If a code required a typical 15 minutes, then you have to document 9:00am – 9:15am… NOT 15 minutes. This is a huge flag for audit and reason to lose. 

3.  Signatures: All notes must be signed. Electronic signatures are acceptable. Without a signature, the note does not exist… PERIOD.

4.  Treatment Plans: I have talked about this often before and you must have orders for everything BEFORE you do it. This includes EVERYTHING you do. If you are adjusting 2-3-4-5 areas, then you need an order for each region, a diagnosis attached and a clinical finding. It is also necessary to have a symptom because the carriers function in the medical model. This is where eliciting symptoms of affected regions are applicable and acceptable. 

NOTE: Kathy Mills Chang wrote a very good (brief) article in the May 2015 American Chiropractor (page 20) on compliance and I urge you all to read it.




Adjunct Associate Professor of Chiropractic, University of Bridgeport, College of Chiropractic
Educational Presenter, Accreditation Council for Continuing Medical Education Joint Partnership with the State University of New York at Buffalo, School of Medicine and Biomedical Sciences

Academy of Chiropractic
US Chiropractic Directory
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