Little Documentation Mistakes That Add Up to Big Problems

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With auditors examining our every move, many chiropractors are growing increasingly concerned about the state of their documentation.  Here’s the really bad news: as a Certified Professional Auditor and Professional Coder myself, I have reviewed countless chiropractic records and many DCs have good reason to worry.  Here’s the good news: this article will teach you how to avoid surprisingly common and easily overlooked mistakes in your documentation that generally spell big trouble during an audit.

First, why the focus on the little items?  Here’s why. Most audit tools used by insurance companies have about 18 items that a chiropractor would need to pass, typically with an 80% score or better.  If you do the math, that means you have to get 15 items “correct” to pass your audit.  Unfortunately, that doesn’t leave much room for error. So you simply can’t afford to make mistakes, especially those that are small and easily preventable.  With that in mind, here are the most common ones that I see chiropractors routinely make:

  • Signatures - There are a variety of “acceptable” signatures that Medicare and other payers will permit as standard documentation, but the one signature that is definitely not acceptable is the one that is absent.  Put simply, you are required to sign all daily notes in some way, shape or form (See Medicare Program Integrity Manual, Pub. 100-08, Chapter 3, Section B).  If you are utilizing EMR, you are likely ahead of the game, as this is generated with the push of a button.  If you have delayed using EMR, perhaps the cramp in your hand you get from signing every note will persuade you!
  • Abbreviations - If you are audited, don’t count on a chiropractor reviewing your records who will know what “PR-L” or “ASRA” or even “Sublux” means.  For that matter, even a non-chiropractor may have difficulty with non-specific abbreviations like “PT.”  Did you send the patient for Physical Therapy or part-time work?  The auditor is not going to try and translate your abbreviations, especially if a key isn’t present that explains them.  A wonderful SOAP note with one unidentifiable abbreviation can cause you to fail your audit. So, make sure that you are spelling it out clearly (another advantage to EMR, push the button and the word comes out!) or that you provide a key that clearly translates all your abbreviations.
  • Referrals - As the saying goes, if it isn’t documented, it didn’t happen.  Sure you may have referred your patient to receive massage therapy, but where is it in the SOAP note?  If you are trying to get that massage visit paid, you better be able to track a referral somewhere.  Insurance company denying the necessity of your care? Where is your documentation regarding your patient’s visit to the Orthopedic Surgeon whose recommendation was to continue with chiropractic care?  You should be documenting all referrals to and from your clinic.  An auditor who looks through your notes and finds none does not conclude that you never refer. He thinks that he has found a chiropractor who fails to document thoroughly and looks to see what other mistakes he can find.
  • Legibility - This should be no issue for those using an EMR system, but for the docs who are still considering the switch, let me say this: Cranky auditors have no reason to try and decipher your chicken scratch! They can just declare your notes illegible and move on.  Remember, these people are paid on volume, so they want to give you the pass or fail and move on quickly to the next victim.
  • Identical Notes - If every one of your visits looks the same, watch out!  Certainly EMR can make note-taking simple and easy, but this is one area where there can be too much of a good thing.  Do not simply copy one daily note to the next visit after visit without ever making a change.  After a handful of visits or so, it is apparent that you have a nice system that you are not using correctly!
  • Phone Documentation - Does your staff ever speak to a patient who cancels for some other medical reason?  Do you speak to patients over the phone about care issues? If either of these situations are happening, they better be documented!  As above with referrals, the lack of this information actually speaks louder to an auditor than the presence of this standard documentation.

If the above items and cautions seem simple, they should be!  The problem is that if an auditor finds that any of these “basics” are missing, they know that you are more than likely to be deficient on bigger items as well.  In other words, your little issues have now created a big problem. So, don’t give auditors or claim examiners more reason to go through your notes with a fine-toothed comb.  Instead, be sure your documentation covers the basics, is legible and well organized enough to make a good impression, and essentially communicates to your auditor that they are wasting their time (and their money) trying to audit a good doctor like you!
Tom Necela, DC, CPC, CPMA of The Strategic Chiropractor helps chiropractors to maximize reimbursements and minimize audit risks by teaching sound billing, coding, documentation and collections strategies. A former Insurance Claims Analyst, he is also a Certified Professional Coder and the first and only chiropractor to achieve Certified Professional Medical Auditor status as offered by the National Alliance for Medical Auditing Specialists. For more information on his products and services, go to