The term, Medical Necessity, doesn’t always land well in the ears of Doctors of Chiropractic. This terminology is driven by third-party payers as a definition of a level of service that must be met to receive their reimbursement. However, medical necessity is also a requirement of most Chiropractic licensing boards and can be in the…

Download Reference Document Medicare understands, Chiropractors can be wonderfully effective providers, yet they often make unforced errors in the documentation.  Also, it’s clear that providers may become aware of pertinent patient information needed to add to a completed note.  This Reference Document is Medicare’s own Change Request document that outlines exactly what they are looking…

Amending the Medical Record Despite best efforts and good intentions for perfect documentation at the time of service, errors and omissions occur. When that happens, the situation has its own documentation requirements. Failure to properly amend the medical record may give the appearance of falsifying documentation, which is considered fraudulent. CMS has direct guidance for…

Sometimes in our busy day-to-day life, patients don’t remember the details of their health record. This is one reason for the portability of health records…to be able to glean information from provider to provider in an effort to have the most complete health record. What if the patient failed to mention something? What now? Don’t…

Pros and Cons of Using a Scribe The practice of using a scribe is as ancient as the practice of medicine itself. Priests, politicians, physicians, and scholars have long taken advantage of using another person to write down their thoughts and actions. This guide outlines ideology, guidelines, and other considerations for using a clinical scribe….

Guidelines For Scribes Medical practices using Electronic health records (EHRs) have increased their use of scribes. Medical and nursing students make good scribes because of their knowledge of anatomy and medical terminology, but there are no training or certification requirements to become a scribe. The Joint Commission, which accredits and certifies healthcare organizations and programs,…