AS A DOCTOR OF CHIROPRACTIC (DC), you should aim for high-quality patient care, and place practice risk management at the forefront in order to maintain ethically and legally sound operations. Putting appropriate policies and procedures into place will help prevent you, your staff and patients from becoming involved in legal matters.
According to Centers for Medicare and Medicaid Services’ (CMS) Medicare Fee-for-Service 2013 Improper Payment Rate Report, the chiropractic profession had a 51.7 percent improper payment rate, of which 92.5 percent was attributed to insufficient documentation.1 Inadequate documentation is one of the most problematic practice issues for the chiropractic profession
Common documentation mistakes include altered records, omission of the patient’s identification or the date on entries, unsigned entries, illegible records, uncommon abbreviations and failure to document patient noncompliance.2 Subpar recordkeeping can put a DC’s practice at risk.
Chiropractic assistants (CAs) can be a helpful resource in ensuring that patient records reflect all services and interactions between DCs and patients. Have your CAs check that records incorporate patients’ responses to your questions, clinical findings and differential diagnoses. They can also stickynote questionable entries that may seem invalid, inadequate or altered.3
Poor paperwork can put chiropractic physicians at risk when submitting documentation to CMS after receiving a request for records as part of the Comprehensive Error Rate Testing (CERT) review. CMS’ random audit will determine if medical documentation follows all requirements, especially in indicating medical necessity. If not, unnecessary time is expended on denials and appeals. Documenting properly the first time should become second nature for all DCs. (Read more about CERT in the November ACA News on Page 22.)
To emphasize the importance of proper documentation, Dr. Ray Tuck, the owner of 11 clinics throughout Virginia, holds continuing education seminars that focus on coding and documentation for the 15 DCs who work at his clinics. He has also hired non-chiropractic doctors to come in to the clinics and conduct independent audits.
As the only DC on the Virginia Board of Medicine, Dr. Tuck has seen firsthand erroneous documentation by not only chiropractic physicians but by the medical field as a whole. “The biggest thing we’re finding is that there is more of a necessity to share educational resources.”
Dr. Tuck believes keeping up-to-date on constant changes in the practice management side of health care can sometimes pose a challenge for medical professionals. “Most DCs are putting the majority of their time into patient care and are unable to focus on many of these changes in health care that can actually help medical professionals minimize risks,” Dr. Tuck says. One change includes CMS’ incentivized switch to electronic health records (EHR.)
"As of June 2014, only 8,480 DCs were actual active participants in the incentive program," says Meghann Dugan-Haas, ACA’s director of federal and regulatory affairs. This is approximately ten percent of total active DCs in the United States.4 If DCs show EHR meaningful use, such as data capture and sharing, advanced clinical processes and improved outcomes, they may be eligible for monetary incentives. (For more on EHR and meaningful use, see the April 2013 ACA News, Page 20).
While learning to use an EHR system takes time, it eventually rids the use of error-prone paper charts and saves time. The use of EHR also eliminates many of the aforementioned documentation risks.
Leo Bronston, DC, MAppSc, ACA’s Wisconsin state delegate and chair of ACA’s coding and documentation committee, prefers using EHR, as all of the information he needs is consolidated and easily accessible. “Documentation is an extension of your ability to perform a service and if you have done well at [performing] it,” he says.
EHR use can benefit the DC and patient simultaneously. “What’s been great about EHR is that I can show my patients their outcomes in my system,” Dr. Bronston says. “The outcomes metrics show both my patients and I whether or not their pain levels have decreased and/or functional ability increased at each visit. Depending on these results, I can customize the treatment plan to improve his or her complex.”
Informed Consent and HIPAA
EHRs allow DCs and clinical staff to easily record all forms of patient communications, including when a patient gives informed consent. The ACA Code of Ethics states, “Doctors of chiropractic should employ their best good faith efforts to provide information and facilitate understanding to enable the patient to make an informed choice in regard to proposed chiropractic treatment.5" DCs should use lay terminology to explain to patients the methods they will use to treat them, the expected outcomes and all associated risks before recording their informed consent. [Note: Informed consent laws vary by state.]
Such discussions should be strictly confined to patient care areas to avoid a breach of the Health Insurance Portability and Accountability Act (HIPAA). All DCs and their clinic staff must adhere to HIPAA laws in and out of the office. State and federal laws may differ; the most stringent takes precedence.
Familiarize yourself with HIPAA, and provide information about it in your office’s procedure manual for new and old employees to reference. A notice of privacy practices should be distributed to patients on their first visit to inform them of their rights and to comfort them in knowing their health information is private and secure.
“While EHRs streamline clinic documentation and recordkeeping, doctors and staff need to remember that implementation of an EHR does not change any of the privacy protections and security safeguards mandated under HIPAA,” says Julie Lenhardt, ACA’s senior director of insurance advocacy. “In fact, clinics need to be vigilant to make sure that the proper protections are in place including, but not limited to, implementing such safeguards as access control, for example PIN numbers and passwords on devices and computers, encryption of stored electronic information and documents and logs documenting access to electronic records.”
Being knowledgeable about malpractice risks and implementing protocols make a DC more cautious, but human error can still occur, and accidents can happen. In these cases, malpractice insurance acts as protection. In fact, malpractice insurance is required by some states to maintain an active license, according to the Federation of Chiropractic Licensing Boards.6
1. U.S Department of Health and Human Services. The Supplementary Appendices for the Medicare Fee-for- Service 2013 Improper Payment Rate Report. www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/November2013ReportPeriodAppendixFinal12-13-2013_508Compliance_Approved12-27-13.pdf
2. NCMIC. Common Documentation Mistakes. Spring 2005 Examiner. www.ncmic.com/prc/risk-management/documentation/common-documentation-mistakes.aspx.
3. NCMIC. Five Ways Your StaffCan Help You Reduce Practice Risk. Summer 2007 Examiner. www.ncmic.com/prc/risk-management/employee-and-practice-considerations/five-ways-your-staff-can-help-you-reduce-practice-risk.aspx.
4. Federation of Chiropractic Licensing Boards. Licensure Statistics US. 2013. http://directory.fclb.org/Statistics/LicensureStatisticsUS. Aspx
5. American Chiropractic Association. Code of Ethics. Sep 2007. www.acatoday.org/content_css.cfm?CID=719.
6. Federation of Chiropractic Licensing Boards. Malpractice Insurance Requirements for DCs. www.fclb.org/AboutCINBAD/Malpractice.aspx
HHS OIG Auditing Chiropractic Records: ACA Offers Member Help
The ACA was notified that the Office of the Inspector General (OIG) is conducting a nationwide review of the chiropractic profession. Doctors of chiropractic have received letters requesting records for services provided during calendar year 2013. It is critical that all DCs who receive a letter from the OIG respond with the requested documentation and by the specified deadline. [The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) is the entity dedicated to identifying and combating fraud, waste and abuse and improving efficiency in Medicare, Medicaid and other HHS programs.]
ACA strongly recommends that doctors of chiropractic who receive an OIG record request consult with their personal attorney and also contact ACA via e-mail at OIGrequest@acatoday.org so ACA can provide essential information to help you navigate the OIG request process.
What to Do if You Receive a CERT Request
ACA provides resources for doctors of chiropractic receiving a request for CERT records. Simply go to our website and follow the step-by-step instructions: http://bit.ly/1qZk0RP