ACA - Clinical (Medical) Documentation: The Key To Reimbursement For Chiropractic Claims

Do insurers ask you repeatedly for patient records or for information that you have already provided to them? Is the administrative hassle frustrating you and costing you time and money? By following a simple set of clinical documentation requirements recently endorsed by the American Chiropractic Association (ACA) and a group of major national insurers, you can simplify the reimbursement process and help ensure that your claims are handled fairly and efficiently.

Last year, representatives from 13 of the largest insurance companies in the United States met with ACA representatives during the second meeting of the ACA-sponsored Claim Solutions Work Group. According to insurers at the meeting, they too are frustrated by the documentation process and complained that chiropractic clinical documentation was often unreadable, non-specific and did not effectively convey the improvement being made by the patient.

Based on the suggestions made during this meeting and on recent trends, ACA recommended a set of 11 documentation requirements to be considered as appropriate in patient record keeping. Some of the insurers present at the meeting agreed that using these practices could reduce clinical record requests by 50 percent.

How will ACA's agreement with national insurers on clinical documentation affect you in daily practice?

You can avoid medical record requests from insurers if you know and use these simple steps for patient documentation.
You can tell insurers who ask for unnecessary medical records that you have complied with nationally-accepted standards endorsed by the ACA. In addition, you can point out that further requests for records with disregard to these recommendations represent unfair claim practices.

Use the recommendations on the reverse of this document to help you through the reimbursement process and to get insurers to comply with terms they themselves have proposed as claim handling solutions.

The ACA recommends that these basic requirements be considered as appropriate clinical (medical) documentation in patient record keeping. A concerted effort by the chiropractic profession to standardize clinical (medical) documentation will improve the frustration level and reimbursement experience exponentially.

The nationally accepted HCFA billing 1500 form must be completed in detail. This means all required fields must be completed.
Subjective, objective, and treatment (if rendered) components should be incorporated into patient records on each visit. A customized format is not needed but these elements must exist consistently. Any significant changes in the clinical picture (e.g. significant patient improvement or regression) should be noted.
All ICD-9-CM diagnosis codes and CPT treatment and procedure codes must be validated in the patient chart and coordinated as to the diagnoses and treatment code descriptors.
Uniform chiropractic language should be used within the profession for describing care and treatment. Non-standard abbreviations and indexes should be defined.
Documentation for the initial (new patient) visit, new injury or exacerbation should consist of the history and physical and the anticipated patient treatment plan. The initial treatment plan, except in chronic cases, should not extend beyond a 30-45 day interval. Subsequent patient visits should include significant patient improvement or regression if demonstrated by the patient on each visit. As the patient progresses, the treatment plan needs to be reevaluated and appropriately modified by the treating doctor of chiropractic (chiropractic physician) until the patient can be released from care, if appropriate.
If the patient is disabled, a statement(s) on the extent of disability and activity restriction is needed at initial and subsequent visits as appropriate over the course of care.
Records can be attached to each billing to pre-empt requests; however, it is not mandatory. Local insurers should be contacted for preferences (i.e., No fault PIP insurers may require records every visit while health insurers may not).
All records must be legible and understandable, released within the authority given by the patients, in a secure, confidential manner and in compliance with existing state (or federal) statutes.
The patient name and initials of the person making the chart notation (especially in multi-practitioner offices) should appear on each page of the medical record.
If the above recommendations have been met, then the answers as to why the necessity for continuing treatment are answered.
The insurance industry must improve their claim adjusting procedure by using chiropractic consultants. The ACA can use its resources to assist in this initiative.