Close This Window


Documentation

Documentation 189
The Art and Science of Diagnosis Coding

1.0

  • 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'

Kathy Mills Chang, MCS-P, CCPC

Adobe PDF Download
AudioVisual Course

$20.00 USD

Documentation 188
Documentation and Coding of Exercise Services

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 exercise therapy services

Kathy Mills Chang, MCS-P, CCPC

Adobe PDF Download
AudioVisual Course

$20.00 USD

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

1.0

  • 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

Adobe PDF Download
AudioVisual Course

$20.00 USD

Documentation 185
Managing Risk through Compliant Documentation and Coding

1.0

  • 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

Kathy Mills Chang, MCS-P, CCPC

Adobe PDF Download
AudioVisual Course

$20.00 USD

Documentation 184
Minimize Medicare Risk for Peace of Mind

1.0

  • 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

Adobe PDF Download
AudioVisual Course

$20.00 USD

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

1.0

  • 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

Adobe PDF Download
AudioVisual Course

$20.00 USD

Documentation 182
The 5 Documentation Mistakes You're Probably Making

1.0

  • 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

Adobe PDF Download
AudioVisual Course

$20.00 USD

Documentation 181

Evaluation and Management Documentation Guidelines Made Simple Part 2


1.0

  • Recognize and apply E/M documentation requirements for medical decision making, to include levels of risk, problem points, and data points.
  • Calculate the appropriate levels of medical decision making based on complexity tables
  • Properly execute the appropriate documentation medical decision-making components necessary to meet E/M documentation requirements
  • Reproduce quality documentation elements necessary in new and established patient documentation
  • Compute, using appropriate algorithms, the levels of E/M coding based on documentation

Kathy Mills Chang, MCS-P, CCPC

Adobe PDF Download
AudioVisual Course

$20.00 USD

Documentation 180 - 181
2.0

  • This contains all courses with the educational objectives listed from Documentation 180 through Documentation 181

Kathy Mills Chang, MCS-P, CCPC

Adobe PDF Download
AudioVisual Course

$40.00 USD

Documentation 180

Evaluation and Management Documentation Guidelines Made Simple Part 1


1.0

  • Recognize and apply E/M documentation requirements for history and consultation
  • Properly execute the four sub-components of history to be documented for new and established patient documentation
  • Properly execute the appropriate documentation for chiropractic examination components necessary to meet E/M documentation requirements
  • Reproduce quality documentation components within history and examination for new and established patients
  • Distinguish necessary elements of E/M documentation guidelines necessary for various levels of coding

Kathy Mills Chang, MCS-P, CCPC

Adobe PDF Download
AudioVisual Course

$20.00 USD

Documentation 179

Documentation Nuances for All Interested Parties


1.0

  • 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

Adobe PDF Download
AudioVisual Course

$20.00 USD

Documentation 178

Documenting and Coding for Unproven, Investigational or Experimental Procedures


1.0

  • 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

Adobe PDF Download
AudioVisual Course

$20.00 USD

Documentation 177

The Ideal Documentation for an Episode of Care


1.0

  • 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

Adobe PDF Download
AudioVisual Course

$20.00 USD

Documentation 176

Document Clinical Rationale for Active Care Rehab


1.0

  • 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

Adobe PDF Download
AudioVisual Course

$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

Kathy Mills Chang, MCS-P, CCPC

Adobe PDF Download
AudioVisual Course

$20.00 USD

Documentation 173 - 174
6.0

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

multiple

Adobe PDF Download
AudioVisual Course

$120.00 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.
  • Properly document and code complicated cases
  • Improve the patient report of findings and discharge procedures

David Taylor, DC, DABCN, FIACN

Adobe PDF Download
AudioVisual Course

$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

Kathy Mills Chang, MCS-P, CCPC

Adobe PDF Download
AudioVisual Course

$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

Kathy Mills Chang, MCS-P, CCPC

Adobe PDF Download
AudioVisual Course

$20.00 USD

Documentation 170

Medicare and the Quality Payment Program


1.0

  • 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

Adobe PDF Download
AudioVisual Course

$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

Kathy Mills Chang, MCS-P, CCPC

Adobe PDF Download
AudioVisual Course

$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

Kathy Mills Chang, MCS-P, CCPC

Adobe PDF Download
AudioVisual Course

$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 
  • 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

Kathy Mills Chang, MCS-P, CCPC

Adobe PDF Download
AudioVisual Course

$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

Kathy Mills Chang, MCS-P, CCPC

Adobe PDF Download
AudioVisual Course

$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

Kathy Mills Chang, MCS-P, CCPC

Adobe PDF Download
AudioVisual Course

$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

Kathy Mills Chang, MCS-P, CCPC

Adobe PDF Download
AudioVisual Course

$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

Kathy Mills Chang, MCS-P, CCPC

Adobe PDF Download
AudioVisual Course

$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

Kathy Mills Chang, MCS-P, CCPC

Adobe PDF Download
AudioVisual Course

$20.00 USD

Documentation 161

Keys to Clinical Documentation


2.0

  • 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

Adobe PDF Download
AudioVisual Course

$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

Paul Sherman, DC

Adobe PDF Download
AudioVisual Course

$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.

Gregg Friedman, DC

Adobe PDF Download
AudioVisual Course

$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.

Gregg Friedman, DC

Adobe PDF Download
AudioVisual Course

$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

Leanne Cupon and Warren Jahn, DC, DABFP

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

Leanne Cupon and Warren Jahn, DC, DABFP

Downloadable Course in PDF
Text

$85.00 USD

Documentation 103

Medicare Documentation - Part 2


4.0

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 7 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

Adobe PDF Download
AudioVisual Course

$80.00 USD

Documentation 102

Medicare Documentation - Part 1


4.0

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

Adobe PDF Download
AudioVisual Course

$80.00 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

Paul Sherman, DC

Text

$44.00 USD