Documentation and Coding to Improve Patient Outcomes: 6-Part Series

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    • Non-member - $240
    • Student/Other - $60
    • Member - $120
    • GAC - Free!

This 6-part course with Dr. Kevin Sharp, updated for 2021, will provide the fundamental knowledge necessary to appropriately document patient examinations, what payers need to see in the documentation, how to handle audits, appropriate coding, billing policies, and other relevant compliance-related concepts.  While the focus of the training will be to prepare Doctors of Chiropractic to run a compliant office, it will also show the value of tracking patient outcomes, illustrating improvement, and the positive impact that these tactics can make on both your practice and your patient’s success. Dr. Sharp has also included his 2021 section on E&M coding to bring you and your office up to date.

This course is worth a total of 6 CE credits.  

The following states require the participant to enter the course approval number on their certificate:
California: CA-A-21-09-08101
Missouri: Please view this list for the course approval number and category(s) for this course.


Part 1: Building the Foundation for Clinically Supportive Documentation

After completing module 1, the participant will be able to:
1. Record the patients’ chief complaints.
2. Identify a diagnosis for the patient’s condition based the patient’s history and examination.
3. Determine the appropriate form of treatment for the patient’s condition.
4. Explain how to properly document radiology and Advanced Imaging findings.

Part 2: Documenting and Tracking Treatment Progres

After completing module 2, the participant will be able to:
1. Develop and establish a proper treatment plan that sets realistic goals to assess the patient’s improvement.  
2. Utilize the SOAP note-taking method to document the patient’s condition and progress subsequent to the initial visit.  
3. Select the appropriate modalities to treat the patient’s condition for the patient’s plan of care. 

Part 3: Establishing Medical Necessity and Transitioning to Maintenance Care 

After completing module 3, the participant will be able to:
1. Develop a philosophy of care for each patient’s condition.
2. Establish and illustrate medical necessity throughout the patient’s plan of care.
3. Define Maximal Medical Improvement.
4. Explain the transition from active care to maintenance or supportive care.

Part 4: Critical Components of Quality Documentation and Using it to Make Good Clinical Decisions 

After completing module 4, the participant will be able to:
1. Accurately document key components of the patient's record.
2. Make clinical decisions based on the patient’s documentation.
3. Identify the components of quality clinical documentation.
4. Recognize documentation errors or omissions.  
5. Explain what insurance carriers are looking for in documentation and what they are not.

Part 5: Assigning Appropriate Codes for Patient Conditions and Services Provided 

After completing module 5, the participant will be able to:
1. Assign proper CPT codes for each facet of treatment including evaluation and management (E&M), chiropractic manipulative therapy (CMT), different modalities selected for treatment, and time-based procedures.
2. Utilize modifiers according to standards.   
3. Will be able to properly document time based codes.
4. Will understand which CPT codes to be careful with.

Part 6: Understanding the Payer Perspective on Quality Documentation Practices 

After completing module 6, the participant will be able to:
1. Explain what carriers want and don’t want to see in your notes.
2. Describe the four essential data points that represent a care plan.
3. Relate the date of onset, ICD-10 codes, CPT codes and number of patient visits back to the patient’s chief complaint(s) and treatment plan.
4. Recall the commonly under-coded procedures relevant to the chiropractic profession.
5. Identify the data points within clinical scenarios that express the complexity of a patient’s condition.

Key:

Complete
Failed
Available
Locked
Module 1 - Building the Foundation for Clinically Supportive Documentation
Recorded 08/13/2021
Recorded 08/13/2021 The first module will provide an introduction to the fundamental do's and don’ts of coding and documentation. This webinar will discuss the initial patient visit, how to document and record the patient’s chief complaints and initial diagnosis, how to determine the best form of treatment going forward and documenting potential advanced imagining and radiology findings if necessary. After completing module 1, participants will be able to: • Record the patients’ chief complaints. • Identify a diagnosis for the patient’s condition based the patient’s history and examination. • Determine the appropriate form of treatment for the patient’s condition. And • Properly document radiology and Advanced Imaging findings
Document and Coding Part 1 Quiz
8 Questions  |  Unlimited attempts  |  7/8 points to pass
8 Questions  |  Unlimited attempts  |  7/8 points to pass Document and Coding Part 1 Quiz
Module 2 - Documenting and Tracking Treatment Progress
Recorded 08/14/2021
Recorded 08/14/2021 Part 2 builds upon the basics learned in Part 1 and demonstrates how to apply them to treatment of a patient. The importance and value of outcome assessments will be discussed, as will S.O.A.P. notes and appropriate coding for selected modalities. After completing module 2, participants will be able to: 1. Develop and establish a proper treatment plan that sets realistic goals to assess the patient’s improvement. 2. Utilize the S.O.A.P. note-taking method to document the patient’s condition and progress subsequent to the initial visit. 3. Select the appropriate modalities to treat the patient’s condition for the patient’s plan of care.
Documentation and Coding Part 2 Quiz
6 Questions  |  Unlimited attempts  |  5/6 points to pass
6 Questions  |  Unlimited attempts  |  5/6 points to pass Documentation and Coding Part 2 Quiz
Module 3 - Establishing Medical Necessity and Transitioning to Maintenance Care
Recorded 08/14/2021
Recorded 08/14/2021 Part 3 discusses the philosophy of care and focus on how chiropractors should set treatment goals for each patient that are objective, measurable, reasonable, and intended to improve a functional deficit. The webinar will also define “medical necessity” in the eyes of an insurance provider, and how chiropractic care can fit into that definition, and how to proceed when a patient has reached Maximum Medical Improvement (MMI). After completing module 3, participants will be able to: 1. Develop a philosophy of care for each patient’s condition. 2. Establish and illustrate medical necessity throughout the patient’s plan of care. 3. Define Maximal Medical Improvement. 4. Explain the transition from active care to maintenance or supportive care.
Documentation and Coding Part 3 Quiz
8 Questions  |  Unlimited attempts  |  7/8 points to pass
8 Questions  |  Unlimited attempts  |  7/8 points to pass Documentation and Coding Part 3 Quiz
Module 4: Part 1 - Critical Components of Quality Documentation and Using it to Make Good Clinical Decisions
Recorded 08/14/2021
Recorded 08/14/2021 Part four examines documenting key components of a patient's record, including the initial examination, diagnostics, ICD-10 codes, and more, and how making clinical decisions based on this in-depth documentation will aid in communicating a treatment plan successfully to the patient, common documentation errors and omissions, and how to avoid them through thorough yet concise documentation.
Module 4: Part 2
Recorded 08/14/2021
Recorded 08/14/2021 2021 E/M Code Changes
Coding and Documentation Part 4 Quiz
10 Questions  |  Unlimited attempts  |  10/10 points to pass
10 Questions  |  Unlimited attempts  |  10/10 points to pass Coding and Documentation Part 4 Quiz
Module 5: Assigning Appropriate Codes for Patient Conditions and Services Provided
Recorded 08/14/2021
Recorded 08/14/2021 Part 5 discusses and demonstrates the basics of successful coding for the initial visit/examination, as well as important re-examination codes. Next, proper CMT, modalities/therapies, and DME codes will be explained, including a discussion on why it is necessary to show these codes on the clinical record. Time-based codes will also be identified, as will the important modifiers all chiropractors should know for proper coding, common coding mistakes and pitfalls, and how to avoid them.
Documentation and Coding Part 5 Quiz
8 Questions  |  Unlimited attempts  |  7/8 points to pass
8 Questions  |  Unlimited attempts  |  7/8 points to pass Documentation and Coding Part 5 Quiz
Module 6 - Understanding the Payer Perspective on Quality Documentation Practices
Recorded 08/14/2021
Recorded 08/14/2021 The final installment will look at proper coding and documentation from the payer’s perspective. This course explains what insurance carriers want and do not want to see in your notes, and how the proper procedures discussed in the previous webinars, along with the correct coding strategies, will help prevent some of the more common documentation and coding mistakes. After completing module 6, the participant will to: 1. Explain what carriers want and don’t want to see in your notes. 2. Describe the four essential data points that represent a care plan. 3. Relate the date of onset, ICD-10 codes, CPT codes and number of patient visits back to the patient’s chief complaint(s) and treatment plan. 4. Recall the commonly under-coded procedures relevant to the chiropractic profession. 5. Identify the data points within clinical scenarios that express the complexity of a patient’s condition.
Documentation and Coding Part 6 Quiz
8 Questions  |  Unlimited attempts  |  7/8 points to pass
8 Questions  |  Unlimited attempts  |  7/8 points to pass Documentation and Coding Part 6 Quiz
License Information
2 Questions
2 Questions Please provide your Chiropractic License number and state
Post-Webinar Survey
6 Questions
6 Questions Post-Webinar Survey
Certificate
6.00 CE Credits credits  |  Certificate available
6.00 CE Credits credits  |  Certificate available CE Certificate