Many chiropractors dangerously dance right into the grey area with respect to treatment goals between medically necessary care, maintenance care and PRN care. Unfortunately, every payer requires a treatment plan and without one, your claims could be deemed maintenance. Worse, depending on your office procedures, your fee policies on “cash” or “time of service” patients who may be receiving maintenance or PRN care may get you into even more hot water.
The scenarios are many and easy to imagine: the “I will come when I feel like it patient,” the “one hit wonder,” the “it’s the second Tuesday, so I’m here” patient, the “un-scheduler” and many more that can jeopardize our income.
Fortunately, Medicare has suggested a simple documentation strategy to handle these scenarios (imagine that!). Certainly, I want to let you in on it, so that you can get paid for what you do AND protect yourself from audits demanding repayment from Medicare or other commercial payers. Here’s the all-too-common question that can be applied to many of our patients?
How do I address chiropractic treatment goals if I see the patient once and no further treatment is necessary?
After all, no treatment goals, no medical necessity, no payment (or a payback request). On the other hand, what’s the goal like when you know darn well that this patient isn’t going to stick around for more than a visit (at least based on the fact that they never have for the last 42 visits).
Or due to the fact that they are here for their monthly checkup and that’s all she wrote.
Documentation Suggestions to protect your chiropractic practice:
1) If a patient is seen once and no further treatment is necessary at that time, this would be considered an ‘As Needed’ or PRN (Pro Re Nata) treatment. A PRN visit should be documented the same as an initial visit, with the exception being that the goal of treatment is realized in one visit.
2) Since the treatment goal must be specific and measurable, you can easily state some very simple goal (that you know will be achieved in this one visit). For example, the patient comes in with a kink in their neck and can’t rotate right at all without pain. After the adjustment, their normal pain free ROM is restored. You deem that this was a minor occurrence that is not likely to reoccur and was not due to some underlying problem or injury that is going to require additional treatment. Therefore, in your notes, you state that your goals were to reduce pain by at least 50% and increase ROM by at least 50%. When the patient responds immediately and is able to move their neck normally and without pain, you have achieved both goals!
3) A treatment plan also requires the duration and frequency of care. Since you fixed them in one visit, you should document that no further treatment is necessary at the time and they may return as needed –PRN. End of story.
The Un-Scheduler / Walk-In / Non-compliant patient
- Patient who needs more care but is likely to not come in. YOU must still create a treatment plan, even though they won’t stick to it.
The Clockwork Patient / Maintenance Care
- Patient is going to come in once per month, like clockwork. This is maintenance and should be separated in your head from the above scenario.
- Maintenance care may also be PRN based (as opposed to scheduled monthly), but it is not medically necessary because there are no chief complaints, objective findings or ongoing injuries to warrant regularly scheduled care.
- As such, Maintenance Care should not be expected to be reimbursed.
- In Medicare, this means ABN will be required to be fully compliant.
- With other payers, you may also need additional strategies to remain compliant and/or get paid for these non-reimbursable services without violating your payer contract, breaking fee rules and/or being accused of a dual fee schedule if you are extending a “cash” rate or “time of service” discount for those services.
Protect Yourself From Audits or Suffer the Consequences!
Hopefully, this brief article will help you protect yourself from unnecessary audits due to poor documentation practices. Implement these suggestions immediately for best results. For additional strategies, even more protection and interactive compliance training to help you get paid and keep your money, you may want to consider my Chiropractic Audit Armor service and/or attending one of my chiropractic billing, coding, documentation seminars in the near future. The rules are constantly changing, it’s tough to keep up, but it’s also necessary to do so for the sake of your business!