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Documentation for Daily Treatment Visits

(DeskBook Chapter 4.3)

Presented by Evan M. Gwilliam, DC MBA BS

CPC CCPC QCC CPC-I MCS-P CPMA CMHP

Vice President

Dr. Evan Gwilliam• Education

• Bachelor’s of Science, Accounting - Brigham Young University

• Master’s of Business Administration - Broadview University

• Doctor of Chiropractic, Valedictorian - Palmer College of Chiropractic

• Certifications• Certified Professional Coder (CPC) - AAPC

• Certified Chiropractic Professional Coder (CCPC) - AAPC

• Qualified Chiropractic Coder (QCC) - ChiroCode

• Certified Professional Coder – Instructor (CPC-I) - AAPC

• Medical Compliance Specialist – Physician (MCS-P) - MCS

• Certified Professional Medical Auditor (CPMA) – AAPC, NAMAS

• Certified ICD-10 Trainer – AAPC

• Certified MIPS Healthcare Professional (CMHP)– 4Med2

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Take-away

• Understand payor requirements to document SOAP notes (aka treatment/subsequent visits)

• Get a handle on the correlation between SOAP and CMS requirements

Disclaimer: this is Dr. Gwilliam’s perfect SOAP note, not anyone else’s. Somebody out there will think it is flawed, and they might be right.

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From the new and improved documentation chapter in the 2018 DeskBook

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According to Optum, daily visit notes require the following:

1. a subjective record of the patient complaint i.e., location, quality, and intensity

2. physical findings to support manipulation in a region or segment e.g., regional/segmental asymmetry or misalignment, range of motion abnormality, soft tissue tone and/or tenderness characteristics

3. assessment of change in patient condition, as appropriate

4. a record of the specific segments manipulated5

Daily Visit Requirements

According to a state scope regulation:

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Daily Visit Requirements

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According to a provider network:

1. Patient identification (name and DOB)

2. Date of encounter and visit # in treatment plan (e.g. visit 3 of 8)

3. Chief complaint/rationale for visit (NMS condition)

4. Updated patient-specific measurable subjective and objective attributes

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Daily Visit Requirements

5. Assessment of functional changes (patient specific)

6. Current diagnosis

7. Procedure specifics (service performed, location, rationale, time)

8. Plan (next treatment date, next re-evaluation)

9. Provider ID and signature, with date/time stamp

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Daily Visit Requirements

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Subjective

Objective

Assessment

Plan/Procedures

SOAP

SOAPSubjective- in the patient’s words

• Each complaint (by location)o Region or laterality

o Severity (e.g. pain scale)

o Character (e.g. stiff, burning, tingling)

o Duration/timing (e.g. percentage of time with pain)

o Aggravating or relieving factors

• Emphasize change since last visito Patient statement of functional change (ADLs)

• “I can walk a few hundred yards further before the pain stops me.” OR “ I can sleep 3 hours before the pain wakes me up.”

• Copy/paste on more than a couple visits will look like cloning

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Subjective-Patient’s point of view

S: Mary Jane presents today for continued left

sided (C3-C5), dull, achy, neck pain that began

last week after "sleeping wrong." She states that "it

gets worse during the day, but I slept four hours last

night which is the best night since this began." She

states that the pain has improved from 6/10 to 4/10

on the VNRS since the last visit.

SOAP

SOAP

Objective- Quantifiable information• Segmental Dysfunction: PART

• Other Dx: o Palpation, ROM, stability, muscle strength/tone (97 DGs)

o Relevant ortho/neuros, if applicable

• OATs retest, if applicable

• Emphasize change since last visit

• Copy/paste on more than a couple visits will look like cloning

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Objective- Quantifiable information

O: Involuntary muscle contraction (T) is palpated

on the right from C3 to C7, with tenderness (P) and

restricted left rotation and lateral bending. Right

lateral bending is no longer restricted. All other

sectional ROM within normal limits. Restricted

intersegmental motion (R) is noted at C3, C5, and T4.

SOAP

Assessment: S+O=A

• Diagnostic statement / clinical impression

• Subjective progress (ADLs)

• Objective progress (exam findings)

• Patient compliance, or lack thereof

• Barriers to recovery / complications

• Progress towards short and long term goals

• Outline the phase of care (i.e. relief, corrective)

SOAP

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Assessment- S+O=AA: Diagnoses include:

• M99.01 Segmental dysfunction, cervical region

• M62.838 Other muscle spasm (neck)

• M54.2 Cervicalgia

• Patient appears to be progressing well as evidenced by

decreased pain reporting, and improvement in sleep

duration, approaching orginal goal of six hours. Some

change to right lateral bending is also favorable.

Treatment was tolerated without incident. Short term

goals previously outlined are still expected to be

achieved by the next evaluation, and as such. Care

should continue as per plan dated XX/XX/XXX.

SOAP

Plan/Procedures- Outline of what is next

• Procedures

• CMT (specific segments and technique)

• Modalities (type/location/time/rationale)

• DME (type/rationale)

• Therapy (type/location/time/rationale)

• Percentage completion towards specific and measurable goals

• Home instructions

• Visit # and anticipated date of next evaluation

SOAP

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Plan- Outline of what is next

The following services were provided at today's encounter:

• 97014 Electrical stimulation - Interferential current was

administered to the right neck and upper back for 10 minutes

to reduce pain. Settings as outlined in care plan dated

XX/XX/XXXX.

• 98940 Chiropractic Manipulative Treatment - Diversified

technique was used to adjust C3, C5, and T4.

Short term goals:

• Improve pain-free sleep to six hours per night. [50% complete]

• Reduce pain reporting from 8/10 to 4/10 by first re-evaluation

[100% complete]

Patient will continue with care plan as outlined, including neck

stretches as taught XX/XX/XXXX. This was visit 4 of 10. She is due to return in two days. Next re-evaluation two weeks.

SOAP

SOAP and CMS

1. History (S)

2. Physical Exam (O/A)

3. Treatment Given (P)

4. Fit within Plan (P)

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• Review of chief complaint

• Changes since last visito Following last treatment

o Immediately preceding current visit

• System review if relevant

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SOAP and CMSHistory

• Exam of area of spine involved in diagnosiso Document subsequent changes by updating NMS

exam findings for all diagnoses reported

o Full repeat of PART is not expected

o If a significant and separately identifiable exam is performed, bill an E/M code with 25 modifier

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SOAP and CMSPhysical Exam

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• Assessment of changes in patient condition since last visito Compare previous findings to current

o Evaluation is ongoing, signs and symptoms must be rechecked during the course of treatment.

o List and update diagnoses if applicable

• Evaluation of treatment effectivenesso Acknowledge progress towards goals (or lack thereof)

o “Patient is responding as anticipated as evidenced by…”

o State “Patient tolerated treatment without incident” as appropriate

o Modify treatment as necessary 21

SOAP and CMSPhysical Exam

• Chiropractic Manipulative Therapy (CMT)o List specific vertebra and technique used

o Include compensatory segments (not payable)

• Modalities and therapies (not payable)o “…as outlined in treatment plan dated 6/12/2016”

rather than listing repetitive details

• State “This is treatment 4 of 10” to let everyone know that there is a plan

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SOAP and CMSTreatment Given / Fit within Plan

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SOAP and CMS

1. History (S)

2. Physical Exam (O/A)

3. Treatment Given (P)

4. Fit within Plan (P)

S:Chief complaint:

Changes:

O:Each Segment:

Pain:

Asymmetry:

ROM:

Tissue/tone:

Other NMS findings:

A:Diagnoses:

Progress (S&O):

Patient response:

Percentage of goals:

Complications:

Phase of care:

P:Treatment given:

Updated goals:

Home instructions:

Visit #:

Next evaluation:

SOAP Template

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The ChiroCode DeskBook is available at ChiroCode.com

This presentation is covered in Chapter 4.3

Take-away

• Understand payor requirements to document an treatment/subsequent visits

• Get a handle on SOAP and CMS requirements

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