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