Download Reference Documents These documentation samples are provided not only as examples of the necessary components of the treatment plan in a note, but also to indicate in the sidebar the reasoning for the individual pieces needed to create the best possible note—one that will document and relay the information essential for an initial and…
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Non-Third-Party Patients Best practice for an office is to have all health record documentation at the same level of comprehensiveness. Documentation must meet the standard of care guidelines from the licensing board, and protect the provider in a risk management situation. Additional requirements for coding and medical necessity are required when dealing with a third-party…
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One of the key elements in Medicare’s documentation requirements is the need to state the short- and long-term goals within the initial visit treatment plan. An easy way to determine goals and a great way to show treatment effectiveness is to use and evaluate the Outcomes Assessment Tools (OATs) at regular intervals throughout each episode…
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Functional Treatment Goals One of the most important aspects of a properly written treatment plan is the inclusion of functional goals. Guidelines for compliant treatment plans call for both functional short-term (STG) and functional long-term (LTG) goals for treatment. These should be outlined with the specific dates of expected achievement. A patient-centered and functional approach…
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Ancillary Service Recommendations The treatment plan is an outline of the care you believe may be necessary to treat your patient. This includes your recommendations for the primary service, Chiropractic Manipulative Treatment (CMT), and all ancillary services (e.g., therapies, active treatment, and home care recommendations.) Every service you plan to order during treatment should be…
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Download Support Tool This Support Tool provides a snapshot of the thought process that occurs when the doctor is establishing the CPT codes to be billed via the documentation; the treatment plan is a vital step in that process. Documentation Drives Coding
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