Documentation, CPT Coding & Record Keeping for Personal Injury, Sports Injury & Rehab

Proper documentation and proper CPT coding and are co dependent in today’s chiropractic practice. A thorough discussion of documentation of the doctor’s encounter with the new patient and subsequent follow up visits including establishing medical necessity for all treatments recommended and performed along with the proper use of CPT coding as it pertains to the most common examination and treatment procedure codes in the modern chiropractic practice.

This discussion begins with the end in mind by starting from the insurance reimbursement check and works backward through a thorough dissection of the health insurance claim form, daily SOAP notes, and the initial report. The entire discussion is centered on medical necessity and the doctors are shown how medical necessity is developed and where it comes into play from the initial visit to the printing of a claim form.

We continue with a discussion of various CPT codes used in chiropractic practice. Compare and contrast therapeutic modalities with physical therapies. Examples are given throughout showing (1) how to choose the appropriate code and (2) how to document the use of that code in the patient’s records.

Learning Objectives

  • Understand how to establish medical necessity to support their treatment plans and to document appropriately to (a) avoid payment delays or denials
  • Reduce the likelihood of compliance audits and fraud, and (3) to get reimbursed for their time and expertise