Do I need to have documentation if I am a Cash only practice?

Cash practice- No need for documentation! WRONG!!!!!!!

patient files and documentationAs I speak with Doctors all over the country I hear the same thing. Doctors that do not accept insurance assignment will tell me “I don’t have to document because I am a CASH practice.” I also hear I am still using paper charts or travel cards so I don’t have to document as if I was using Electronic Health Records. There are so many confusing variations of what MUST be document and what IS documented.

Did you know that documentation across the board is the same? It does not matter if you are a CASH, Insurance, PI Workers Comp or whatever kind of clinic. The bottom line is you MUST document and you MUST document correctly.

Do you know what is required in computing your Evaluation and Management codes? Did you know there are 3 parts to determining this code? Here is a quick 3 part process to documenting a New Patient visit.

3 parts to Evaluation and Management:

  1. Case History. A good case history will encompass the following:
    1. Patient Condition- Main complaint
    2. Past Health History (Relative and Absolute Contraindications)
    3. Family History
    4. Social History
    5. HPI (History of Present Illness)
    6. Review of all 14 body systems
  2. Examination
    1. There are 35 bullet points to doing an examination.
  3. Medical Decision Making
    1. What are the Problems, Data and Risk of the patient you are going to treat?

Starting off on the right foot with a New Patient documentation can mean the difference between success and failure in your office. If you start from the first encounter and document correctly you will save yourself a lot of time, money and headaches.

All payers—Medicare and private health insurance companies, PI and Workers Comp all maintain requirements that you must meet to receive reimbursement for your services. Each state has its own requirements (based on license type) as documented within its state practice act. Over the years reimbursements have been declining and more Chiropractors are moving to Cash type practices. There is by no means anything wrong with moving to a Cash practice. You must keep in mind the following documentation guidelines though:

Proper documentation is your first line of defense if anything should go wrong. The last thing you want it to have a problem with malpractice and or your state board and not have documentation.

One more thing to consider: As health savings account become more popular and deductibles go up more and more patients will be utilizing these types of accounts. Health savings accounts still require documentation of services in order to utilize the funds. Patients have to show services received in order to properly use the funds. Do you really want to risk making a patient mad because you did not document correctly.

Documentation takes time- Yes, but not as much as you think. And, just think of the peace of mind you will have from doing it right – compliant. Besides, with the development of SMART programs like SilkOne EHR, your fully compliant documentation can be completed in seconds. Best of all, SilkOne is the only self-coding program on the market; you document and the system will suggest the most appropriate CPY billing code. Now, you have real peace of mind because you don’t have to worry about over coding which means you’ll have to return money if you are audited. On the other hand, this self-coding feature also makes sure you get paid for all your hard work. Watch this short video.

The Collection Coach is here to help you start keep more of your money and providing you peace of mind at the end of the day with proper documentation.

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