EHR vs Paper The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient’s medical history and care across time within one health care provider’s jurisdiction. The role of the health record is to keep a sequential record of all the conditions and treatment…

There are many definitions that must be clear when you’re running the business of healthcare, and of Chiropractic. The most important reference documents to be familiar with are the Medical Review Policies published by the payers with whom you do business. These documents outline the responsibilities of the provider when billing the services, such as…

Proving Medical Necessity Can Be… Painful. Medical necessity for chiropractic treatment is defined by third-party payers. The specific requirements are usually outlined in their medical review policies and the criteria must be met in order for services to be reimbursed. The doctor must not only perform the appropriate history and exam, but must also document…

The core concept of compliant documentation, billing, and coding is that of whether the service would be deemed medically necessary. A keen understanding of the difference between the two is an essential element of running the business of chiropractic. While the service provided may not be different, and the documentation may be similar when a…

Documenting Medical Necessity Proper documentation of the medical necessity for treatment begins with the patient’s initial intake and must be reported from visit to visit concluding with discharge from active treatment. Continuity is key – the documentation must match the diagnosis, the treatment provided, and the goals the patient is expected to meet. This process…

Medically Necessary vs. Clinically Appropriate Care A properly trained and licensed healthcare professional, such as a Doctor of Chiropractic, can diagnose and develop a treatment plan for their patients.  Their decision-making skills allow them to determine the frequency of the patient’s visits and what services the patients will receive.  As long as the doctor exercises…