Academy of Chiropractic Personal Injury & Primary Spine Care Program

Quickie Consult 930
Narratives 66N

From the Desk of Dr. Mark Studin
Academy of Chiropractic
Preamble: many of these issues are small, yet each issue is just that… an issue. If you take care of the small issues, then the larger issues often take care of themselves and you can focus on the larger issues… a larger, more profitable practice and more family time.

“Is Your Documentation Protecting You”

ONE OF THE MOST IMPORTANT CONSULTATIONS OF THE DECADE 

 “In a sea of confrontation and controversy, I am the light because I am the truth” Mark Studin 2018

 

Today, just like EVERY day, I help doctors defend themselves, and in every instance, short of a sexual allegation it all centers on your documentation. Here is a partial list:

 
1.      I am going to arbitration today because I didn’t get paid and I had to sue the carrier, but my notes don’t reflect pain scales or           improvement, what do I say?
2.      I am going to arbitration today and I have to defend myself because the carrier is claiming I over-treated
3.      I have a deposition today and my notes are deficient, what do I say?
4.      I am going to court today and how do I answer the question “why did I treat the cervical spine with no diagnosis?”
5.      I was “served” today because of billing fraud, claiming my notes do not reflect necessary care
6.      I got an IME stating that I treated for too long and which recommends that I refund 80% of the money paid to me
7.      I just got an audit request for 30 charts from Blue Cross Blue Shield and upon reviewing my notes I realized they are horrible.             Can I make changes before I send them out?
8.      I treated this patient for an unusually long amount of time, because without my care he couldn’t work. However, my notes do       not reflect any exacerbations or work loss that occurred. Now I am being accused of overtreating and billing fraud; what do I do?
9.      The lawyer just offered me 15% of my lien amount and said it was because of my poor documentation that the settlement                 was so low. He claims I did not do timely re-evaluations or have appropriate pain scales. How can I get paid?
10.  I billed a 99203 and now I am being sued for RICO violations and the carrier is requesting treble damages for the $600,000                they paid me over the last 10 years claiming I have a pattern of omitting review of systems.

 
These are only a few of the scenarios that I heard recently. It is significantly more extensive in its totality and in every case the doctor would have been paid, not have been audited or not have been sued if their documentation was complete. Over the years I have done compliance reviews for hundreds of doctors nationally and recently I have found that over 90% of the of the reviews I have done reveal the doctor’s documentation is severely deficient, fraudulent and in most cases the doctors have exposed themselves to federal RICO violations (the racketeering statute). Perhaps this is chiropractic’s “dirty little secret” and I only have one intention; to fix it!

 
Many feel the insurance carriers and licensure boards are getting more aggressive coming after you… They are not. The carriers have been consistent through the years in investigating what they feel are either improper or fraudulent claims and they have a fiduciary responsibility to their shareholders and insureds to verify that what they are paying for is valid. I’m not saying the insurance companies don’t often cross the line (they consistently do and that is a topic for different consultation) however, they aren’t crossing the line any more than they did a few years ago and often do play fair. With that being said:

 
YOUR DOCUMENTATION MUST SPEAK FOR ITSELF.

 
Your documentation is what defends you, should give a complete story of what is occurring during that encounter and should require no clarification. If you are still using the old “travel cards,” you are not only “antiquated” in this industry, you are leaving yourself exposed to significant legal issues and potentially paying back a significant amount of money. On the other side of the coin, the challenge arises as to how to keep up with the documentation and a busy practice, let alone growing a practice.

 
The above scenario is the #1 question asked of me by doctors nationally. They asked “how do I to keep up with the documentation requirements with my current practice and what will I do if I get busier because there is just not enough time in the day?” This is a universal problem across all healthcare providers nationally as I currently consultant for many healthcare disciplines and the issues are the same. The solution is either a very efficient paper system, dictation system or electronic medical record system. My solution of choice has always been utilizing the latest technology. However, in the chiropractic industry after a decade of searching there is no EMR system that currently meets the needs of the profession for both efficiency (short amount of time), completeness and compliance.

 
When I say that your documentation must speak for itself, it also must reflect the code that you billed. If you billed 99203 – 99204-99205, did you include past medical history, family history, social history, review of systems, the chief complaint and all of the other required elements in that code? For every area touched did you include a symptom (elicited symptoms are acceptable), clinical findings and diagnoses for those regions? Do you have a stated treatment plan prior to rendering the treatment? Are you quoted disparate guidelines that have nothing to do with your patient’s care?

 
All of the above dictate compliance and either your paper documentation or electronic record must reflect these issues on a consistent basis. The areas above in blue represents just some of the compliance issues I confront on a daily basis with doctors nationally. These are some of the prime areas you should be focused on in your E & M and SOAP Note documentation to ensure compliance. The next issue is one of efficiency.
 
We currently have a prototype for an electronic medical record system that will allow you to completely document a new patient evaluation, regardless of the level in approximately 12 minutes, a re-evaluation in 8 minutes and a SOAP note in 15 seconds. Our challenge has been trying to make this prototype fit into a current EMR system that is on the market and after five years of trying we realize it doesn’t exist. Therefore, we are currently in negotiations to either partner with, acquire or build an EMR system from the ground up that will be able to accomplish everything needed to ensure compliance, accuracy and efficiency. This will be based on not only my “close to four decades” of experience, it will also encompass what I have learned in both compliance reviews and defending doctors and their documentation at the reimbursement, licensure and fraud levels. This process will take approximately 6 to 12 months to accomplish, but it will get done.

 
To help understand the full process ramifications of your documentation at both compliance and personal injury level, I urge each of you to take the testifying course (CLICK HERE). Most of the course discusses documentation and rendering complete reports inclusive of an accurate and descriptive history, past history, past records and the myriad of other topics regarding your documentation. In the near future, I am creating a course that will cover the entire E & M process to ensure you understand every facet and miss nothing in your documentation.
 
Please understand that I “feel your pain” and when I actually practiced, documentation was the “least favorite thing” that I did in my entire day. Also understand, that is the most important thing you get to do after caring for your patients.

 
Your documentation must speak for itself.

 
Your documentation must protect you.



Respectfully,




Mark Studin DC, FASBE(C), DAAPM, DAAMLP

Adjunct Associate Professor of Chiropractic, University of Bridgeport, College of Chiropractic
Adjunct Post Graduate Faculty, Cleveland University-Kansas City, College of Chiropractic
Adjunct Professor, Division of Clinical Sciences, Texas Chiropractic College
Graduate Medical 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 

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