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The Single Most Important Strategy For SOAP Notes That Earn Reimbursements

Did you know that Medicare’s denial rate for chiropractic reimbursements ranges from 60 to 100%, based on each practice? On top of that, according to a 2013 review of documentation, only 40% of doctors responded to Medicare requests for information related to claims, which of course results in no reimbursement. These reimbursement denials add up to a serious loss of revenue—yet they are avoidable.

The biggest reason for reimbursement denials is faulty documentation of SOAP notes.

If you’re documenting your SOAP notes wrong, or if your documentation process is inconsistent, you’re not only wasting time, you’re also losing revenue. Here’s the most important strategy to clean up your SOAP notes so that your hard work earns the reimbursements you deserve:

Shift To Function Based Notes

Are you still taking PART based notes focusing on a patient’s level of pain at any given visit? If so, your documentation process is 10 years old. In 2009, the Medicare manual changed the definition of medical necessity to: “The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must have a direct therapeutic relationship to the patient’s condition.”

What this means is that your documentation must show the improvement or change of function and a reasonable expectation of recovery. Before 2009, Medicare looked at one treatment on one day individually. Now they want to see how one treatment on one day relates to the treatments before that, and your plan and expectation for the treatments to come. It’s not enough to just show the patient had an adjustment, you must show changes in how they are functioning.

It’s the patient’s response to care that matters in documentation now, not just their level of pain.

With each new patient, start by asking what they can’t do today that they could do before they began experiencing the pain or symptoms that brought them to your office. Then build a plan based on returning them to that level of function and show the progress of change at each visit, with they are in active care or have progressed to maintaining function with wellness care.

Your EHR software should make it easy for you to document a patient’s progress based on function, resulting in SOAP notes that earn you reimbursements. Plus, your EHR software should make SOAP notes faster so that you can spend more time interacting with your patients. You could be gaining hours each month, as well as substantial revenue, if your EHR software is designed to document faster, better, and stronger notes.

Platinum System EHR software is designed to work the way you do, and to make SOAP note documentation faster, more accurate, and compliant so that you earn the reimbursements you deserve. Plus, the newly released Platinum X update is designed to be even more responsive to work the way that you do, with built-in features that allow you to customize your screens, searches, and SOAP notes.

If you’d like to learn more about how Platinum System is set up for compliant note taking, see Platinum System’s webinar, Quick & Compliant Daily Notes with Dr. John Davila.

See for yourself why 99% of doctors stay with Platinum System for the life of their practice. To discuss how Platinum System might serve the unique EHR and billing needs of your practice, contact us online, or call us at 888-808-4898.


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