Sometimes, “Adjustments” are Necessary 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 may be considered fraudulent. CMS has direct guidance…
Implementing NCQA Standards
The National Committee for Quality Assurance (NCQA) has an important mission. It guides the standards for documentation for all of healthcare, and especially as it relates to 3rd Party payers. Every practice needs a standard to follow, and this is one that is easily duplicated and simple to understand. As you review this Quick Byte…
Quality and Purposeful Documentation and Coding
Healthcare Documentation Has Many Facets and Requirements To meet the standards expected by the many different audiences that review your patient records, you need to be familiar with the standards set by the healthcare community at large. That standard is defined by The National Committee for Quality Assurance (NCQA). NCQA is an organization dedicated to…
Medicare’s Documentation Reference Documents
Download Reference Documents Medicare publishes helpful documents and alerts to keep providers in the know about important topics. Included here are several documents that relate specifically to documentation of Chiropractic care and medical necessity. These tools relate to the elements of Chiropractic documentation and the overall rulebook for Medicare policy, The Benefit Policy Manual. Download,…
Incident, Burst, or Episode
Download Support Tool The terms incident, burst and full episode were coined by us here at KMC University as a way for providers to consider the length of an episode of care. When sitting down to document the initial visit of a new episode, consideration of the potential length of the episode can be put…
Medicare’s Medical Necessity Reference Documents
Download Reference Documents Medicare publishes helpful documents and alerts to keep providers in the know about important topics. Included here are several documents that relate specifically to Chiropractic care and medical necessity. These tools relate to the proper use of the AT Modifier, Chiropractic documentation and the overall rulebook for Medicare policy, The Benefit Policy…