Documentation - Chiropractic Doctor

Documentation 175
Documentation Standards for Evaluation and Management

1.0

  • Use an E/M auditing tool to identify which level of E/M code is appropriate for the documentation provided
  • Recognize the required elements of history, examination, and clinical decision making in documentation
  • Provide the required minimum documentation for both new and established patients
  • Audit E/M visits in the context of a compliance audit

Mills Chang, MCS-P, CCPC

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$20.00 USD

Documentation 174
Compliant Documentation for Adjusting Multiple Spinal Regions

1.0

  • Interpret in documentation, the difference between active, medically necessary care vs. clinically appropriate but possibly maintenance adjustments
  • Able to distinguish compensatory vs. primary subluxations and document them properly
  • Specify proper documentation techniques as a full spine adjuster
  • Demonstrate the ability to classify documentation for each chiropractic technique employed

Mills Chang, MCS-P, CCPC

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$20.00 USD

Documentation 173
Why render a prognosis? Defining the problem

5.0

  • Describe the need for prognosis
  • Summarize what a prognosis is
  • Demonstrate the use of prognostic tools
  • Appraise your individual patient’s outlook for recovery.
  • Measure the progress
  • Make evidence based clinical decisions
  • Substantiate your opinion for expert testimony.
  • Illustrate the evidence for care.
  • Prescribe evidence based care plans.
  • Increase your reimbursement for complicated cases.
  • Improve the patient report of findings and discharge

Taylor, DC, DABCN, FIACN

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$100.00 USD

Documentation 172
In-Processing Federal Patients: Active or Maintenance

1.0

  • Recognize and document the difference between active and maintenance care
  • Use a decision-making matrix to determine the reportability of active treatment, and to be able to help the patient understand the distinction
  • Apply the Medicare standard of recordkeeping to intake requirements to establish a baseline for episodes of care
  • Determine whether routine visits qualify as active treatment when presented with new and updated complaints

Mills Chang, MCS-P, CCPC

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Android Compatible
AudioVisual Course
Iphone/Ipad Compatible

$20.00 USD

Documentation 171
Ancillary Services: Yes, You Have to Document Those Too

1.0

  • Know how to document exactly what’s required for initial visit treatment plans including physical medicine procedures
  • Apply sample language to include in each daily visit note that will meet documentation guidelines for these modalities and procedures, including properly recording time for timed services
  • Command the mechanics of how to authenticate documentation for services provided by auxiliary team members
  • Tie the patient’s diagnosis to the treatment plan for tissue-specific, physical medicine solutions
  • Tell a complete and coherent account of the patient’s daily visit journey, outlining the crucial language necessary to justify medical necessity for all services rendered

Mills Chang, MCS-P, CCPC

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Android Compatible
AudioVisual Course
Iphone/Ipad Compatible

$20.00 USD

Documentation 170
Medicare and the Quality Payment Program

1.0

  • Discuss Medicare’s new guidelines for documenting quality measures 
  • Discuss Medicare’s new Merit-Based Incentive Program (MIPS)
  • Identify and determine the eligibility requirements for MIPS
  • Identify and discuss the 4 categories under MIPS (Quality, Cost, Clinical Practice Improvement Activities (CPIA) and Advancing Care Information (ACI)
  • Recognize how Medicare calculates MIPS to determine payment adjustments

Sherman, DC

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$20.00 USD

Documentation 169
Triage Your Patients with Compliant Treatment

1.0

  • Compose Complete and Accurate Treatment Plans
  • Formulate multiple Standard Treatment Protocols for better compliance and efficiency
  • Differentiate patient care plans per Patient condition severity
  • Propose recommendations based on exam findings, not third party coverage

Mills Chang, MCS-P, CCPC

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Android Compatible
AudioVisual Course
Iphone/Ipad Compatible

$20.00 USD

Documentation 168
The Secrets of Chiro-Compliant Coding

1.0

  • Utilize documentation requirements for the most commonly used CPT codes in the profession
  • Apply coding techniques and algorithms to ensure the proper code is selected to meet E/M documentation guidelines
  • Recognize the codes that carry the highest degree of risk and confirm that documentation meets the code requirements
  • Identify the mandatory elements of medical review policy for selected chiropractic codes

Mills Chang, MCS-P, CCPC

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Android Compatible
AudioVisual Course
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$20.00 USD

Documentation 167
The Life Cycle of a Patients Chart

1.0

  • Apply best practices for using abbreviations, addressing legibility, authentication of signatures, and managing the day-to-day flow of your patient records 
  • Delineate the beginning and end of episodes of patient care, how to record these episodes, and how to best address these boundaries with patients 
  • Define medically necessary care, and differentiate it from clinically appropriate care
  • Assess examples we’ll use of documentation across the life cycle of the patient’s chart from history to discharge and on through maintenance and wellness care

Mills Chang, MCS-P, CCPC

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$20.00 USD

Documentation 166
Documentation and Coding of Therapeutic Activities

1.0

  • Cite the difference between Therapeutic Exercise and Therapeutic Activities
  • Properly document all aspects required when utilizing timed therapy services
  • Assimilate payer policy details to ensure proper code utilization
  • Discuss common errors when documenting and billing therapy services

Mills Chang, MCS-P, CCPC

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Android Compatible
AudioVisual Course
Iphone/Ipad Compatible

$20.00 USD

Documentation 165
Compliant Coding and Documentation for all Chiropractic Techniques

1.0

  • Recognize the varying specific requirements for documenting unique adjusting techniques in regards to compliant records and risk management
  • Properly document patient encounters for medical necessity
  • Discuss the Medical Review Policy insurers use in reviewing medical documentation
  • Review case studies and examples to identify documentation errors during self-auditing

Mills Chang, MCS-P, CCPC

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Android Compatible
AudioVisual Course
Iphone/Ipad Compatible

$20.00 USD

Documentation 164
Compliance with Federal Guidelines for Timed Physical Medicine Procedures

1.0

  • Differentiate between supervised modalities, constant attendance modalities, and therapeutic procedures
  • Properly document the time and service for any physical medicine modality and procedure
  • Clearly define the rationale for these services within the patient's medical record

Mills Chang, MCS-P, CCPC

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Android Compatible
AudioVisual Course
Iphone/Ipad Compatible

$20.00 USD

Documentation 163
Documenting for Medical Necessity of Manual Therapies

1.0

  • Properly document findings and recommendations around muscle therapies
  • Master the documentation necessary in daily visits to verify medical necessity
  • Identify and implement strategies the most important findings and rationale necessary to add muscle therapies to the treatment plan
  • Recognize how to differentiate between various manual therapies to meet the requirements of third-party payers' medical review policy

Mills Chang, MCS-P, CCPC

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Android Compatible
AudioVisual Course
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$20.00 USD

Documentation 162
Regs and Risk Management with Maintenance Care

1.0

  • Differentiate between active and maintenance care in clinical documentation
  • Execute the use of advance notice in third party patients correctly and accurately
  • Identify and implement strategies to clarify the difference between active and maintenance care in documentation
  • Recognize and adopt best practices in proper notification about maintenance care vs. active treatment

Mills Chang, MCS-P, CCPC

Adobe PDF Download
Android Compatible
AudioVisual Course
Iphone/Ipad Compatible

$20.00 USD

Documentation 161
Keys to Clinical Documentation

2.0

  • MEETS OREGON 2016 2 HOUR DOCUMENTATION REQUIREMENT
  • Recognize the key components regarding good documentation and record keeping
  • Identify the legal requirements of informed consent and the key elements of the informed consent process
  • Discuss why doctors are held to higher standards
  • Describe the 21 NCQA guidelines for record keeping
  • Document progress notes (SOAP) to meet insurance guidelines and medical necessity
  • Apply the PARTS system and its transformation utilizing a new method AIR S & M
  • Utilize CMT coding appropriately
  • Utilize E/M (Evaluation/Management) coding appropriately to meet insurance guidelines and medical necessity
  • Identify the 3 categories and 2 subcategories of E/M codes
  • Identify the 5 levels of E/M services for new and established patients
  • Identify the 7 components (descriptors) used to determine the level of E/M service
  • Select the appropriate level of E/M services utilizing 7 simple steps

Sherman, DC

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$40.00 USD

Documentation 160
ICD-10:  Navigating the Coding Maze

1.0

  • Discuss the history of ICD-10-CM codes
  • Discuss the Official ICD-10-CM Guidelines for Coding and Reporting
  • Identify and discuss the tools needed to navigate the ICD-10 codes
  • Discuss the General Equivalence Mappings (GEM’s) and their significance and how they relate to ICD-10-CM Tabular List of Diseases and Injuries
  • Identify and discuss how to select the appropriate ICD-10 code to its highest specificity
  • Examples to be discussed

Sherman, DC

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$20.00 USD

Documentation 158
ICD-10

1.0

  • Comprehend the reasons for transitioning from ICD9 to ICD10
  • Determine the critical differences with the new ICD10 codes
  • Utilize the proper alpha and numeric aspects of commonly used ICD10 codes for  Chiropractic
  • Observe the practicality of combining clinical documentation and the proper use of ICD10 codes.

Friedman, DC

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$20.00 USD

Documentation 157
Clinical Documentation

2.0

  • Define the Problem Oriented Medical Record (POMR).
  • Demonstrate taking a complete patient history.
  • Define the Evaluation and Management examination for the musculoskeletal system.
  • Define Outcome Assessment.
  • Illustrate the P.A.R.T. format of documentation.
  • Define proper assessment for SOAP notes.
  • Discuss proper documentation of treatment performed on each visit.
  • Discuss proper documentation of treatment plans.

Friedman, DC

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$40.00 USD

Documentation 154
Risk Management Considerations for Documentation

1.0

  • Develop the skills for medical documentation record-keeping for proper patient care
  • Recognize the importance and benefits of documentation methodology from the standpoint of risk management
  • Identify selected documentation problems and errors
  • Summarize recommendations for improving patient care documentation

Cupon/Jahn, DC, DABFP

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Text

$21.00 USD

Documentation 153
Documenting Bodily/Personal Injury Cases

4.0

  • Develop the skills for medical documentation record-keeping for proper patient care and adherence to insurance value based parameters
  • Recognize the importance, and benefits of thorough chart documentation from the standpoint of the patient, the provider, the profession and third-party payors
  • Show how outcome assessment documentation benefits the patient, the provider, the profession, and third-party payors
  • Demonstrate physical examination procedures that are the basis for diagnosis formulation and value based data
  • Examine skills necessary to incorporate an outcomes-based, evidenced-influenced approach to patient-centered health care in bodily injuries

Cupon/Jahn, DC, DABFP

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Downloadable Course
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Slide Show;
Text

$85.00 USD

Documentation 101
Documentation and Insurance protocols related to medical record keeping, billing and coding

2.0

  • Develop the skills for medical documentation record keeping for proper patient care and adherence to insurance protocols
  • Summarize informed consent, Evidenced-based care, Medicare guidelines and NCQA guidelines
  • Identify common treatment procedures and modalities used in a chiropractic practice And recognize contraindications to them
  • designate specific items to consider when interpreting and/or taking plain film X-rays
  • Summarize the value of laboratory and diagnostic testing.
  • Recognize the importance of patient communication skills in order to assist in the diagnosis and treatment of patients
  • Modify procedures and forms to prevent the possibility of a legal malpractice action against the doctor

Sherman, DC

Android Compatible
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Text

$44.00 USD