Compliant Documentation "SNAPSHOT" Survey

Question Title

* 1. We have a CLEAR office procedure for communication between our staff and insurance patients about what is/is not covered under our participating carrier plans, they understand about ACTIVE and MAINTENANCE care, and we ALL understand what determines "Medical Necessity."

Yes

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* 2. DC NOTES are ALWAYS dated and signed (not just SAVED) within 48 hours of the patient visit:

Yes

Always dated and signed, but not always within 48 hours

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* 3. IF you have licensed therapists on-staff, how do they do their notes (EVERY DOS):

PAPER notes (dated & signed)

ELECTRONICALLY (dated & signed, and therapist is signed in to EHR as a provider)

N/A: Do not perform those services

Question Title

* 4. How is LENGTH of time indicated for every therapeutic procedure performed?

Electronically or paper indicate START/STOP time

Electronically or paper indicate LENGTH of time performed

Electronically or paper indicate UNITS performed

Have not been documenting TIME/LENGTH/UNITS

N/A: Do not perform therapeutic procedures

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* 5. ALL insurance patients are documented as "ACTIVE" or "MAINTENANCE" in every daily note?

Yes

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* 6. I use S8990 as a CPT code (EXCEPT for Medicare!) for "maintenance"/wellness adjustments after I release them from an 'Active' episode of care?

Yes

No (I only use 989__ codes to indicate adjustments)

What is S8990?

Question Title

* 7. Looking at a current DAILY NOTE for an ACTIVE-CARE patient:
Which of the following items IS CONSISTENTLY in your daily documentation for EVERY DOS? (check ALL that apply):

Most recent FUNCTIONAL score, date, and name of assessment tool used.

FUNCTIONAL short- and long-term goals for this entire plan of treatment.

FUNCTIONAL deficiencies and changes in response to care.

Today's SUBJECTIVE status contains at least 1 NARRATIVE and UNIQUE sentence/patient comment.

ASSESSMENT includes unique DC statement that corresponds to findings in Subjective and Objective sections.

Complete PLAN OF CARE outlined, areas to be treated, number of visits expected, techniques and therapies that MAY be used, AND anticipated release date.

"TODAY'S" PLAN: (Adjustment) vertebral levels noted, techniques used. States "TODAY" and is separate from the complete CARE PLAN.

"TODAY'S" PLAN: (adjustment) does # of levels documented support the CPT code used (98940, 98941, or 98942)? (subluxation levels listed only in "Objective" portion of notes do NOT COUNT!)

"TODAY'S" PLAN: (Therapy) each therapy performed/billed is listed, time rendered, area noted, specific purpose, AND states "TODAY."

"TODAY'S" PLAN: response to today's visit noted, and follow-up action (return as planned, release, adjust plan, etc).

FUNCTIONAL RE-ASSESSMENTS are performed and documented every 30 days and compared to previous tests/scores.

Actually, I'm a ROCKSTAR. I have all of these things. :-D

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* 8. How many provider documentation seminars/workshops/webinars have you attended in the past 3 years?

None

4 or more

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* 9. IF you have attended at least 1 provider documentation workshop in the past 3 years, how CERTAIN are you that your documentation is compliant on every date of service? (select all that apply)

I am positive that I am compliant at least 95% of the time (i.e. maybe something small slips through from time to time by accident)

I could not say for sure whether or not I am compliant most of the time (I haven't 'built my notes' to carrier guidelines)

I am pretty sure I have missing elements, I just haven't had the time/not sure how to fix it.

I'm not sure because I haven't been to a documentation workshop in over 3 years.

Check here is you do paper notes.

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* 10. Describe your level of enthusiasm in working towards improving your documentation compliance (check all that apply):

This SUCKS. I think insurance companies/Medicare are setting unreasonable standards, but I'll try.

I am determined to do whatever it takes to get my documentation SOLID. It's one of the necessary components to running an office that provides therapeutic procedures.

Forget it. I'm really wondering about going cash...

Compliant Documentation "SNAPSHOT" Survey

Question Title

* 1. We have a CLEAR office procedure for communication between our staff and insurance patients about what is/is not covered under our participating carrier plans, they understand about ACTIVE and MAINTENANCE care, and we ALL understand what determines "Medical Necessity."

Question Title

* 2. DC NOTES are ALWAYS dated and signed (not just SAVED) within 48 hours of the patient visit:

Question Title

* 3. IF you have licensed therapists on-staff, how do they do their notes (EVERY DOS):

Question Title

* 4. How is LENGTH of time indicated for every therapeutic procedure performed?

Question Title

* 5. ALL insurance patients are documented as "ACTIVE" or "MAINTENANCE" in every daily note?

Question Title

* 6. I use S8990 as a CPT code (EXCEPT for Medicare!) for "maintenance"/wellness adjustments after I release them from an 'Active' episode of care?

Question Title

* 7. Looking at a current DAILY NOTE for an ACTIVE-CARE patient: Which of the following items IS CONSISTENTLY in your daily documentation for EVERY DOS? (check ALL that apply):

Question Title

* 8. How many provider documentation seminars/workshops/webinars have you attended in the past 3 years?

Question Title

* 9. IF you have attended at least 1 provider documentation workshop in the past 3 years, how CERTAIN are you that your documentation is compliant on every date of service? (select all that apply)

Question Title

* 10. Describe your level of enthusiasm in working towards improving your documentation compliance (check all that apply):

* 7. Looking at a current DAILY NOTE for an ACTIVE-CARE patient:
Which of the following items IS CONSISTENTLY in your daily documentation for EVERY DOS? (check ALL that apply):