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Documentation - Chiropractic Doctor


Documentation 200
ICD 10 Documentation

4.0

$80.00 USD

Select for Purchase    Click here to Show Approved States/Countries
Hour 1
  • Label the main driver is for “Medical Necessity”, how and why you must communicate this to 3rd party payers
  • List the foundation of coding and be able to apply pertinent ICD10 coding guidelines
  • Discover how correct coding may dictate our strength to 3rd parties and have national implications for our profession.
  • Discuss critical questions of the benefits and risks of our Chiropractic diagnosis codes in the insurance industry.
  • Identify red flags, complicating factors, and have awareness of Risk management when documenting and coding.
  • Identify how insurance companies rank the importance of various diagnoses and its effect on claims’ coverage and processing
Hour 2
  • Apply critical ICD10 coding Guidelines, like sequencing, Excludes notes, and combination codes.
  • Recall how ICD10 categorizes common NMS diagnoses seen by the DC
  • Appraise the differences between Medicare’s coding guidelines for DC’s and the ICD10 guidelines.
  • Explain Medicare’s definition of medical necessity and produce correct documentation to support it by reviewing the NCD.
  • Solve the documentation issue that leads to incorrect diagnoses.
  • Analyze and print tables (slides) of coding to help you for clinic ASAP
  • Apply the knowledge gained within a visit to correctly document the encounter’s Assessment and diagnosis.
  •  Apply critical thinking to diagnosing and coming up with an appropriate ICD10 code.
Hour 3
  • Review numerous printable tables that will expand your ICD10 knowledge base of NMS diagnoses.
  • Identify the differences in diagnosing, documenting, then coding numerous spinal disc disorders, spondylopathies and radiculopathies according to medical necessity and ICD10-CM’s categorization.
  • Using clinical examples, discover and demonstrate the appropriate manner of documenting the evolution of changing diagnoses within a Plan.
  • Recognize, document, diagnose and appropriately pair examples of specific etiologies of NMS inflammation with an ICD10 code.
Hour 4
  • Record, diagnose and code various possibilities of types of the elusive ICD10-CM’s Facet Syndrome, according to Dr. Shapiro.
  • Document and appropriately code for instabilities VS ligament laxity of spine and extremities.
  • Identify Kyphosis as a complicating factor to healing. Then evaluate and code its types, areas and corresponding ICD10 codes.
  • Design a comprehensive list of diagnoses from an MVA, that may help a PI attorney with their demand letter.

Grant Shapiro, DC

AudioVisual Course

Documentation 199
Documentation and Risk Management - From Medical Necessity to Clinical Appropriateness

4.0

$80.00 USD

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Hour One: Documentation and Compliance Overview, Rules and Regulations

  • Recognize and avoid or correct behavior that is contrary to the rule of “no opt-out for chiropractors”
  • Apply compliance rules set forth by governmental agencies that apply to providers of service to Federally insured patients
  • Demonstrate day-to-day application of guidance on Federal Program and state requirements for coding, billing, and finances
  • Differentiate between active and maintenance care, according to the official Medicare definitions and other third-party guidelines
  • Interpret the four types of risk the Office of Inspector General (HHS) expects providers to focus on with Policy and Procedure, per the OIG Guidance for Small Practices
  • Recognize the limitations of experimental, investigational, and unproven technologies

 Hour Two: Documentation of Initial Visits-New Patients, New Episodes, and New Conditions

  • Identify and apply concepts that differentiate types of initial visits, from new patients to updated episodes
  • Produce documentation of initial visits that comply with board requirements for chiropractors
  • Summarize documentation requirements as they apply to the new initial Evaluation and Management guidelines set forth January 1, 2021
  • Establish medical necessity for your care and know with surety that initial visit documentation is complete
  • Rank complicating factors and contraindications according to priority and include with initial assessment
  • Populate a required treatment plan for care, whether for short- or longer-term care

 Hour Three: Documentation and Case Management for Routine Visits, Preventive Maintenance, and Wellness Care

  • Differentiate between requirements for medically necessary services vs. maintenance which is self-pay
  • Apply primary subluxation vs secondary compensation logic to mitigate risk for the full-spine adjustment
  • Reproduce the key elements of routine chiropractic visits in documentation as set forth by third-party, State and Federal guidelines
  • Interpret functional data to determine stages and levels of care
  • Demonstrate the ability to implement therapeutic withdrawal and to document its results
  • Recognize maximum therapeutic benefit (MTB) and properly document discharge from active treatment

 Hour Four: The Risks Associated Billing and Financial Compliance Regulations

  • Give examples of billing and financial compliance that cross the line of False Claims Act and Anti-Kickback Statute violations
  • Apply billing and financial compliance regulations to the day-to-day operations of the practice, including payment and prepayment plans
  • Execute random auditing of charges and collections to meet OIG compliance guidelines
  • Recognize and apply the rules of offering financial hardship discounts
  • Produce advertising that falls within the guidelines of board and federal rules

Kathy Mills Chang, MCS-P, CCPC

AudioVisual Course

Documentation 198
Routine Visits are Often Far from Routine

1.0

$20.00 USD

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  • Properly document “doctor thinking” daily in routine patient visit documentation
  • Recognize the role of the PART documentation process in Routine Office Visit notes
  • Identify and execute the key components of written assessment in daily documentation
  • Recognize aspects of documentation and coding of Route Office Visits (ROV) whether active treatment, preventative maintenance, or wellness care.
  • Distinguish the unique components of Subjective, Objective, Assessment and Plan

Kathy Mills Chang, MCS-P, CCPC

AudioVisual Course

Documentation 197
The Clinical and Written Diagnosis Process

1.0

$20.00 USD

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  • Apply the changes in the 2022 ICD-10 code set to the clinical diagnosis process
  • Compare examination findings, couple with history, to select the most appropriate written diagnosis
  • Document within the clinical record your thought process of selecting diagnostic codes
  • Classify diagnoses in order of severity and hierarchy to match projected treatment plan

Kathy Mills Chang, MCS-P, CCPC

AudioVisual Course

Documentation 196
2021 Changes for Evaluation and Management (E/M) Services

1.0

$20.00 USD

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  • Apply the new algorithm to choose your E/M code appropriately using either time or decision making
  • Disucss existing E/M codes were deleted and details on the new Prolonged Service codes
  • Uses the the new process for typical chiropractic evaluations
  • Identify elements that count as Time-Activities and how to calculate appropriately
  • Discuss what it means to do a clinically appropriate history and exam

Kathy Mills Chang, MCS-P, CCPC

AudioVisual Course

Documentation 195
Documenting Compliantly for Your Audience

1.0

$20.00 USD

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• Identify missing components before they become critical issues for your practice
• Determine the basic requirements of documentation for all payer classes
• Learn to identify payer requirements as part of your documentation standards
• Understand the key documentation components that boards, auditors and reviewers expect

Kathy Mills Chang, MCS-P, CCPC

AudioVisual Course

Documentation 194
1.0

$20.00 USD

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  • Recognize the key documentation requirements and components required to be eligible to treat Veterans Administration referrals
  • Compose documentation that meets these required VA elements, while avoiding missteps most commonly found in denials and audits
  • Appraise and self-audit the VA process from referral through discharge,
  • Determine key factors known to be often missing, and understand what to do to correct the deficiency
  • Demonstrate the proactive steps to take in treating VA patients from clinical and financial submisisons

Kathy Mills Chang, MCS-P, CCPC

AudioVisual Course

Documentation 193
Medicare Mastery Part 2 Complicated Compliance in Medicare

1.0

$20.00 USD

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  • Identify Dually Eligible Individuals (QMB) and Understand How Medicare Works with Medicaid
  • Ascertain the practice’s obligations for QMB patients, regardless of Medicaid participation or coverage
  • Provide accurate and legal advance notice to dually eligible individuals within the new guidelines
  • Recognize the differences between acute, chronic, and maintenance care and how that affects billing and charges
  • Duplicate Medicare financial rules and collections guidance into a process within the practice

  • Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 192
    Medicare Mastery Part 1 Medicare Fundamental Regulations

    1.0

    $20.00 USD

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    • Demonstrate the components of recognizing Medical Necessary Care vs. Clinically Appropriate
    • Identify CMT coding trends and indicators as they relate to medical necessity
    • Properly manage treatment effectiveness for exacerbations and reoccurrences
    • Determine Proper Diagnosis and Assessment for Federal Patients
    • Acknowledge and audit CMT coding ratios to evaluate the potential risk

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 191
    How to Perform a Baseline Documentation Audit

    1.0

    $19.00 USD

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    • Understand the necessary components of initial and routine visit documentation
    • Recognize and evaluate the relationship between documentation and billed codes
    • Demonstrate how to conduct a complete baseline audit of medical record documentation
    • Establish the parameters for subsequent audit requirements

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 190
    Changes for Evaluation and Management (E/M) Services

    1.0

    $20.00 USD

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    • Demonstrate understanding of the key elements of the “Patients Over Paperwork” initiative
    • Apply the new algorithm to appropriately code for E/M services under the new model
    • Determine the elements that count as Time-Activities and how to calculate appropriately
    • Establish protocol to determine Medical Decision-Making element of E/M encounter
    • Discover how to still demonstrate Medical Necessity with the new initiative

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 189
    The Art and Science of Diagnosis Coding

    1.0

    $20.00 USD

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    • Demonstrate why each and every digit of the DX tells the payer something important Distinguish the nuances of specialized DX coding rules for carriers such as Medicare.
    • Discover the importance of DX pointing, and which CPT codes are an absolute MUST to point to DX
    • Illustrate how to diagnose with a higher level of specificity and through proper hierarchy Identify the role of the diagnosis in the documentation process'

    multiple

    AudioVisual Course

    Documentation 188
    Documentation and Coding of Exercise Services

    1.0

    $20.00 USD

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    • 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 exercise therapy services

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 187
    Creating the End to Every Story with Proper Patient Discharge

    1.0

    $20.00 USD

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    • Understand the difference between clinically appropriate and medically necessary care
    • Identify the clinical indications of when to initiate therapeutic withdrawal
    • Execute the components of a final discharge evaluation with proper documentation and recommendations
    • Learn how to transition a client from an active phase of care to maintenance as a part of your treatment plan

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 186 - 188
    4.0

    $80.00 USD

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    Hour 1
    • Discern Part B from Part C and know the rules for each
    • Discuss mandatory enrollment necessary for Chiropractic specialty
    • Master the definition of medical necessity vs. clinical appropriateness and who pays in either case
    • Recognize the differences between acute, chronic, and maintenance car
    • Locate and understand the Medicare Local Coverage Determination (LCD) for your state including all the rules and guidelines
    • Identify CMT coding and how it is differentiated from maintenance in Medicare
    Hour 2
    • Review of statistical data that shows how risk is identified through data analysis
    • Engage in billing compliance and random auditing to meet OIG compliance guidelines
    • Avoid risk issues with proper use of the Medicare Advance Notice-Both Voluntary and Mandatory
    • Discuss the role of SOP and Policy in practice risk mitigation, especially with Federal patients
    Hour 3
    • Understand the difference between clinically appropriate and medically necessary care
    • Identify the clinical indications of when to initiate therapeutic withdrawal
    • Execute the components of a final discharge evaluation with proper documentation and recommendations
    • Learn how to transition a client from an active phase of care to maintenance as a part of your treatment plan
    Hour 4
    • 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 exercise therapy services

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 186
    Medicare Billing Compliance Made Simple

    2.0

    $40.00 USD

    Select for Purchase    Click here to Show Approved States/Countries
    Hour 1
    • Discern Part B from Part C and know the rules for each
    • Discuss mandatory enrollment necessary for Chiropractic specialty
    • Master the definition of medical necessity vs. clinical appropriateness and who pays in either case
    • Recognize the differences between acute, chronic, and maintenance car
    • Locate and understand the Medicare Local Coverage Determination (LCD) for your state including all the rules and guidelines
    • Identify CMT coding and how it is differentiated from maintenance in Medicare
    Hour 2
    • Review of statistical data that shows how risk is identified through data analysis
    • Engage in billing compliance and random auditing to meet OIG compliance guidelines
    • Avoid risk issues with proper use of the Medicare Advance Notice-Both Voluntary and Mandatory
    • Discuss the role of SOP and Policy in practice risk mitigation, especially with Federal patients

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 185
    Managing Risk through Compliant Documentation and Coding

    1.0

    $20.00 USD

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    • Discover how proper documentation impacts the revenue cycle and profitability of your office
    • Distinguish between Medically Necessary and Clinically Appropriate Care
    • Demonstrate how your office compliance program either leaves you vulnerable or reduces your risk
    • Develop understanding of compliant fee systems
    • Evaluate federal guidelines regarding discounting and/or hardship

    Colleen Auchenbach, DC

    AudioVisual Course

    Documentation 184
    Minimize Medicare Risk for Peace of Mind

    1.0

    $20.00 USD

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    • Recognize the mandatory enrollment guidelines for chiropractors and apply the rules to daily practice
    • Distinguish between active and maintenance care and employ proper procedure to administrate both types of care
    • Complete and document required elements of documentation of active treatment
    • Prepare patients to best differentiate care that Medicare considers medically necessary from care that the patient is expected to pay for
    • Apply the Medicare standard of financial transactions with patients in order to stay within the Federal collection guidelines

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 183
    The Established Patient Evaluation - Who, What, When and How

    1.0

    $20.00 USD

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    • Evaluate the necessary elements to properly document established patient re-evaluations of all types
    • Deliver appropriate evaluation and management services to justify continued care, assess progress, and discharge from this active care when the time is right
    • Report the necessary components of documenting the transitional diagnosis and treatment plan after a periodic re-evaluation
    • Complete the fundamentals of documenting the assessment of change since the last evaluation as it applies to federal regulations in Medicare

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 182
    The 5 Documentation Mistakes You're Probably Making

    1.0

    $20.00 USD

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    • Differentiate and document for the difference between medical necessity and clinical appropriateness
    • Execute a complete and compliant treatment plan that includes all required elements
    • Properly record the elements necessary to justify the full-spine adjustment
    • Command the mechanics of properly documenting clinical rationale for ordered diagnostics and treatment
    • Ensure the inclusion of diagnostic assessment and doctor’s rationale in routine daily visit notes

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 179

    Documentation Nuances for All Interested Parties


    1.0

    $20.00 USD

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    • Awareness of the value of orderly documentation to you and others
    • Ability to duplicate key documentation components that auditors and reviewers expect
    • Steps necessary to address how poor documentation can turn a simple record review into a full audit
    • Ability to identify commonly missed links connecting documentation to treatment

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 178

    Documenting and Coding for Unproven, Investigational or Experimental Procedures


    1.0

    $20.00 USD

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    • Define and recognize common procedures that may be deemed unproven, investigational or experimental
    • Determine how individual state boards and payers view these various treatments
    • Recognize guidance or rulings from state boards that dictate the need for informed consent
    • Properly document the procedures in the medical record
    • Apply correct coding to describe the procedure provided
    • Personalize a sample Consent to Treat for the procedure provided

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 177

    The Ideal Documentation for an Episode of Care


    1.0

    $20.00 USD

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    • Discover all the elements necessary for appropriate documentation of an episode of care, from the initial visit through the discharge from active treatment
    • Have clearer delineation of the beginning and end of episodes of patient care
    • Decide when an active episode of care should turn into maintenance care, and document the decision making appropriately
    • Identify the required components of documentation as they are outlined in state board documentation requirements, Medicare documentation requirements and other entities’ regulations

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 176

    Document Clinical Rationale for Active Care Rehab


    1.0

    $20.00 USD

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    • Perform functional testing to identify patients who will benefit from active care rehab
    • Correlate functional testing findings with a protocol-driven care plan customized to the patient’s diagnosis
    • Recognize and document preferred outcomes that result from properly executed active care techniques
    • Follow clinical algorithms to best understand the beginning, middle and end points of active care rehab
    • Properly document the clinical rationale for active care rehab by linking it to the diagnosis and treatment plan of initial visit documentation

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 174

    Compliant Documentation for Adjusting Multiple Spinal Regions


    1.0

    $20.00 USD

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    • 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

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 173 - 174
    6.0

    $120.00 USD

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    Hour 1 - 5

    • 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

    Hour 6

    • 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

    Course Group includes all Documentation Courses numbered 173 thru 174

    multiple

    AudioVisual Course

    Documentation 173

    Why Render A Prognosis? Defining the Problem


    5.0

    $100.00 USD

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    • 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.
    • Properly document and code complicated cases
    • Improve the patient report of findings and discharge procedures

    David Taylor, DC, DABCN, FIACN

    AudioVisual Course

    Documentation 172

    In-Processing Federal Patients: Active or Maintenance


    1.0

    $20.00 USD

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    • 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

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 171

    Ancillary Services: Yes, You Have to Document Those Too


    1.0

    $20.00 USD

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    • 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

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 170

    Medicare and the Quality Payment Program


    1.0

    $20.00 USD

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

    Paul Sherman, DC

    AudioVisual Course

    Documentation 169

    Triage Your Patients with Compliant Treatment


    1.0

    $20.00 USD

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    • 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

    April Lee, DC, CPCO

    AudioVisual Course

    Documentation 167

    The Life Cycle of a Patients Chart


    1.0

    $20.00 USD

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    • Apply best practices for using abbreviations, addressing legibility, authentication of signatures, and managing the day-to-day flow of your patient records 
    • Clearly delineate the beginning and end of episodes of patient care, proper recording of these episodes, and boundary discussions with patients 
    • Locate and utilize the definitions of medically necessary care, and apply it as a differentiator from clinically appropriate care
    • Assess documentation across the life cycle of the patient’s chart from history to discharge and on through maintenance and wellness care based on live examples demonstrated
    • Identify the deficiencies that may be present in your documentation through the eyes of an auditor

    Colleen Auchenbach, DC

    AudioVisual Course

    Documentation 165

    Compliant Coding and Documentation for all Chiropractic Techniques


    1.0

    $20.00 USD

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    • 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

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 164

    Compliance with Federal Guidelines for Timed Physical Medicine Procedures


    1.0

    $20.00 USD

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    • 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

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 163

    Documenting for Medical Necessity of Manual Therapies


    1.0

    $20.00 USD

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    • 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

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 162

    Regs and Risk Management with Maintenance Care


    1.0

    $20.00 USD

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    • 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

    Kathy Mills Chang, MCS-P, CCPC

    AudioVisual Course

    Documentation 161

    Keys to Clinical Documentation


    2.0

    $40.00 USD

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    • 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

    Paul Sherman, DC

    AudioVisual Course

    Documentation 160

    ICD-10: Navigating the Coding Maze


    1.0

    $20.00 USD

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    • 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

    Paul Sherman, DC

    AudioVisual Course

    Documentation 158

    ICD-10


    1.0

    $20.00 USD

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    • 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.

    Gregg Friedman, DC

    AudioVisual Course

    Documentation 157

    Clinical Documentation


    2.0

    $40.00 USD

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    • 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.

    Gregg Friedman, DC

    AudioVisual Course

    Documentation 154

    Risk Management Considerations for Documentation


    1.0

    $20.00 USD

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    • 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 for those Doctors not using an EHR

    Leanne Cupon, DC, DACRB and Warren Jahn, DC, DIANM (US)

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    Documentation 153
    Documenting Bodily/Personal Injury Cases

    4.0

    $80.00 USD

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    • 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

    Leanne Cupon, DC, DACRB and Warren Jahn, DC, DIANM (US)

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    Documentation 149
    Avoiding Pitfalls with Evaluation & Management Services

    1.0

    $20.00 USD

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    • Demonstrate understanding of the key elements of revised E/M services
    • Determine the elements that count as Time-Activities and how to calculate appropriately
    • Establish protocol to determine Medical Decision Making element of E/M encounter
    • Apply the new algorithm to appropriately code for E/M services under the 2021 model
    • Discover how to still demonstrate Medical Necessity with the revised E/M codes
    • Determine why history and examination are still needed

    Kathy Mills Chang, MCS-P, CCPC

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    Documentation 105
    Avoiding Medicare ABN Pitfalls Establish a Compliant Process

    1.0

    $20.00 USD

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    • Recognize the common pitfalls that can put your clinic at risk
    • Review the difference between a mandatory ABN and a voluntary ABN
    • Identify the appropriate time to initiate a mandatory ABN
    • Implement customized and compliant ABNs for your clinic by following the rules

    Kathy Mills Chang, MCS-P, CCPC

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    Documentation 104
    Documenting Medical Necessity

    3.0

    $60.00 USD

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    Hour 1

    • Define standard of care.
    • Examine the requirements of Chiropractic documentation.
    • Evaluate Chiropractic care and the functional relationship.
    • Review state specific examples of documentation requirements.
    • Discuss what is mean by episode of care.

     Hour 2

    • Establish the baseline of care.
    • Identify the inadequacies of intake forms.
    • Comply with the requirements of the initial encounter report.
    • Review the consultation documentation in various case scenarios.
    • Apply appropriate medical decision-making processes and documentation.

     Hour 3

    • Examine the Documentation Requirements of a SOAP Note.
    • Utilize PART in documentation.
    • Utilize outcome assessment tests in documenting medical necessity of care.
    • Identify Assessment and its relationship to medical necessity.
    • Solidify elements of the treatment plan to support medical necessity.
    • Apprise utilization management and review analysis of documentation.

    Mario Fucinari, DC, CPCO, CPPM, CIC

    AudioVisual Course

    Documentation 103

    Medicare Documentation - Part 2


    4.0

    $80.00 USD

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    Hour 1

    • Demonstrate the key elements pertaining to Medicare’s documentation requirements for initial and subsequent patient encounters  
    • Describe the three categories of chiropractic care covered through Medicare and the one category exempt from Medicare coverage
    • Apply Medicare’s x-ray requirements for documenting a subluxation
    • Utilize Medicare Advance Beneficiary Notification (ABN) form and its guidelines 
    • Use Medicare’s PARTS system to document a subluxation
    • Summarize the transformation of Medicare’s PARTS system utilizing the AIR S & M method               
    • Include proper Medicare documentation for daily progress notes (SOAP), in order to meet insurance guidelines and meet medical necessity 

    Hour 2

    • Integrate a 4 step approach to meet E/M (Evaluation/Management) coding requirements to meet Medicare’s guidelines

    Hour 3

    • Review Medicare Access and CHIP Reauthorization Act of 2015 (MARCA) aka Medicare Quality Payment Program (QPP) and the Merit Based Incentive Payment Program (MIPS)                                                                    

    Hour 4

    • Apply the critical components of Chiropractic Manipulative Treatment (CMT) coding and Medicare’s requirements for documentation
    • Use diagnostic codes ICD-10 (primary subluxation M-codes biomechanical lesions and secondary medical codes) to meet Medicare’s diagnosis requirements
    • Recognize Current Procedure Terminology (CPT) codes and how it relates to the Medicare system
    • Utilize Medicare modifiers   
    • Identify some of the key items with regards to completing the Center for Medicare and Medicaid Services (CMS) 1500 claim form   
    • Summarize Medicare’s mandatory claims submission policy                                   
    • Explain the five levels of Medicare appeals process
    • Distinguish between Medicare participating vs. non-participating provider requirements

    Paul Sherman, DC

    AudioVisual Course

    Documentation 102

    Medicare Documentation - Part 1


    4.0

    $80.00 USD

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    Hour 1

    • Utilize improved patient communication skills with Medicare Patients 
    • Apply appropriate risk management procedures to enhance patient communication
    • Identify the four elements of legal malpractice and recognize the key components to avoid a malpractice action  
    • Utilize key components of good documentation and record keeping
    • Integrate the legal requirements of informed consent in your informed consent process 

    Hour 2

    • Summarize why doctors are held to higher standards
    • Discuss the Do’s and Don’ts of record keeping
    • Use the 21 NCQA guidelines for appropriate medical record keeping and integrate the 3 key components of Evidence Based Practice (EBP)

    Hour 3

    • Assess Medicare’s mandatory Electronic Health Records (EHR) requirement        
    • Discuss key items related to the Office of Inspector General (OIG) reports regarding Medicare and chiropractic services
    • Summarize Executive Order issued by the White House titled reducing improper payments and eliminating waste in the Federal Programs

    Hour 4

    • Determine what triggers an audit and key items to consider if audited
    • Utilize a step by step approach to meet all Federal Medicare Documentation guidelines 
    • Summarize Medicare’s guidelines for necessity of chiropractic care and its covered services
    • Prepare treatment plans per Medicare’s regulation requirements
    • Recognize Medicare’s policy requirements pertaining to x-ray/diagnostic reimbursement
    • Determine if ordering vs. referred services meet Medicare’s policy when performed by a chiropractic physician

    Paul Sherman, DC

    AudioVisual Course

    Documentation 101

    Documentation and Insurance Protocols Related to Medical Record Keeping, Billing and Coding


    2.0

    $40.00 USD

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    • 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

    Paul Sherman, DC

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