Documentation styles may vary from provider to provider, but the foundational pieces should be the same. As a Chiropractic Assistant, understanding key components of the treatment notes can lead to future opportunities to assist the doctor as a scribe or in follow-up on claim submissions. Locate the Support Tool titled The Anatomy of an Initial New…
Download Reference Documents The first two resources listed here are neck and low back diagnosis tables pulled, with permission, from the Sousa textbook. Refer to these tables to ensure your doctoring is leading to the most accurate diagnosis codes and that you have the findings to verify the codes you are using. In the third…
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Standardized Documentation and Coding Guidelines It would be wonderful if there were a magic button to press to know exactly what documentation guidelines to follow when performing self-audits and evaluating your compliance. Unfortunately, this isn’t so. Documentation standards are often open to interpretation, whether from a licensing board, a payer, or a malpractice attorney. For…
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