When treating personal injury or automobile accident cases, good documentation is extremely important for potential legal and liability issues. In a recent review of several hundred acupuncture insurance claims, I found that only a handful of claims had adequate records.Most did not. The problems included illegible records, incomplete or unclear treatment notes and billing for services not supported by the documentation.
Why keep good records?
The primary value of records is to record patient progress and evaluate treatment. This remains important regardless of insurance involvement. Good records illustrate the type of care given and provide insight into its quality. They also promote communication between diverse practitioners as well as attorneys and insurance carriers.
Good records become even more important when a third party is involved in payment. If records are reviewed, written notes will substantiate prior billings and help address issues with continuing treatment and reimbursement. A final benefit is that aggregate records may be useful in research with regards to cost-effectiveness and revealing treatment trends.
What and how to document
Make sure to document three areas: what the patient tells you, what you discover through your examination and observations, and the treatment or advice you provide. Having too much documentation will rarely be an issue, but having too little can create problems. It is important to understand that if it isn't written down, then for most purposes, it wasn't said, found or done. And if what wasn't documented gets billed, it is considered fraud.
It is imperative that documentation be legible and readable by third parties. Short statements with standard abbreviations are fine and if you use personal abbreviations, keep them uniform and provide a guide. Make additional notes if there are exacerbations or complications, or if your treatment results are unexpected. Consistent styles like SOAP (Subjective, Objective, Assessment, Plan) or DARP (Data, Action, Response, Plan) provides a basic framework for your treatment notes. Which format you use is not critical.
On the first visit, present your working diagnosis. Discuss the severity of the diagnosis and provide a brief prognosis. In subsequent visits, evaluate how the patient is faring as treatment continues.
The First Visit
The first visit record and intake documents hold pertinent data about the injury including relevant past illnesses and accidents. Red flags to treatment are discovered and noted during this process. Automobile accident intake forms should request details regarding the accident, conceptually divided into the mechanics of the accident and the impact of it on the patient. While this is not intended to make us accident reconstruction experts, it provides a framework for better understanding the injuries.
- Date, time and location of the accident;
- Vehicle type (car, truck, bus, mini-van, etc.);
- What was the vehicle doing: turning left/right; stopped in traffic or at a red light; accelerating; slowing down; parking, etc.);
- Describe the road conditions;
- What was the visibility when the accident occurred (foggy, clear, light, dark, or dusk);
- What was the point of impact(s) on the vehicle?
- Who hit what;
- Did any airbags deploy (front or side)
- Vehicle speed (if 2 vehicles both speeds);
Patient Injury Details:
- Patient's position in vehicle (front, rear, passenger side)
- Was the patient wearing a seat belt (lap or shoulder or both)
- Did the patient see the impact coming?
- Did the patient brace for impact?
- Did the patient's body strike anything inside the car?
- What was the patient's head position at the time of impact?
- Did the patient lose consciousness?
- If the patient was a pedestrian, describe the impact and immediately subsequent events
- The patient's description of the accident in their own words.
Initial Examination and Billing
Initial paperwork that lists the patient's complaints along with orthopedic and neurological tests you perform (a checklist is fine) is at the core of your intake. This includes observations of restricted motions, antalgic postures, abnormal gait, guarding motions while standing or sitting. Pain on a VAS scale is noted for each complaint area, often using a body diagram. Mark areas of bruising, hematomas or abrasions that are from the accident. Pictures are also useful. When you find notable functional impairments, evaluate the impact of the injury on the patient's activities of daily living using Oswestry and/or Roland Morris Back and Neck indices. The result of the intake will be a prioritized complaint list.
You must also examine the condition of the zhang-fu as well as the state of qi and blood in affected channels. Shen issues like depression, anxiety or insomnia should also be documented.
It is appropriate to bill the initial examination with CPT 99202 or 99203.
Assessment of the Injuries
Assessment of the injuries must adequately describe their unique nature. A statement of causality relates the specific complaints to the accident. Diagnose and code all problems you find, even those you are not going to treat. Because the diagnosis (ICD codes) identifies the various injuries, but not their severity, your written assessment should include an evaluation of the severity of the different injuries.
When writing your prognosis, do not describe the patient's condition as "guarded" unless the injuries are serious and the prognosis for recovery is uncertain. Spinal fractures, organ ruptures and severe concussions may be guarded, strain/sprains are not. Avoid boilerplate assessments that remain identical from patient to patient.
Initial Plan and Follow-up Visits
Your treatment plan reflects your evaluation and assessment and varies from patient to patient because each case is unique. It is a flexible roadmap to reaching specific and well defined
Dr. Steven Schram has been a licensed acupuncturist since 1996. He is the past president of the Acupuncture Society of New York, and is the current president of the Manhattan District of the NY State Chiropractic Association. In addition, he serves on the Insurance Committee of the AAAOM, remains a member in the States President's Council of the AAAOM, and has maintained a private practice in Manhattan since 1984.