Reporting to the MD

I am in the process of writing a Consultation on being effective when creating you documentation.  The idea is to DO IT ONCE and once only.  The quality of your report should meet the needs of the insurance carrier, regulatory agency, covering doctors and co-treating providers.  I talk to chiropractors on a daily basis that work too hard on reporting.  Everything is a different document and the redundancy is spectacular!

It is simple, an initial report that meets all of the criteria of the E/M level you are billing as well as any treatment modalities.  There is the daily SOAP progress notes that cover your evaluation and treatment between evaluations and then there is the re-evaluation.  Following medicare guidelines, that is required every 30 days. 30 days is the marker not the number of patient visits. Most doctors don't get that.  The re-evaluation is the same as the initial but shorter time and subsequently a lower E/M code. That is it. 

To be successful in an integrated practice style (that can mean that you practice separately from the other providers or in a group practice) you MUST be able to teach though your reports.  It is easy but you must understand the proper descriptive terms and proper vocabulary for a cooperative care practice.