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Documentation

Documentation 200
ICD 10 Documentation

4.0

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

$80.00 USD

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

4.0

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

$80.00 USD

Documentation 198
Routine Visits are Often Far from Routine

1.0

  • 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

$20.00 USD

Documentation 197
The Clinical and Written Diagnosis Process

1.0

  • 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

$20.00 USD

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

1.0

  • 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

$20.00 USD

Documentation 195
Documenting Compliantly for Your Audience

1.0

• 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

$20.00 USD

Documentation 194
1.0

  • 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

$20.00 USD

Documentation 193
Medicare Mastery Part 2 Complicated Compliance in Medicare

1.0

  • 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

    $20.00 USD

    Documentation 192
    Medicare Mastery Part 1 Medicare Fundamental Regulations

    1.0

    • 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

    $20.00 USD

    Documentation 191
    How to Perform a Baseline Documentation Audit

    1.0

    • 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

    $19.00 USD

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

    1.0

    • 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

    $20.00 USD

    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'

    multiple

    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

    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

    AudioVisual Course

    $20.00 USD

    Documentation 186 - 188
    4.0

    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

    $80.00 USD

    Documentation 186
    Medicare Billing Compliance Made Simple

    2.0

    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

    $40.00 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

    Colleen Auchenbach, DC

    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

    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

    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

    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

    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

    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

    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

    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

    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

    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

    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

    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

    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

    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

    April Lee, DC, CPCO

    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

    Colleen Auchenbach, DC

    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

    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

    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

    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

    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

    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

    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

    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

    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 for those Doctors not using an EHR

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

    Text

    $20.00 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, DC, DACRB and Warren Jahn, DC, DIANM (US)

    Adobe PDF Download
    Downloadable Course in PDF
    Text

    $80.00 USD

    Documentation 149
    Avoiding Pitfalls with Evaluation & Management Services

    1.0

    • 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

    AudioVisual Course

    $20.00 USD

    Documentation 105
    Avoiding Medicare ABN Pitfalls Establish a Compliant Process

    1.0

    • 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

    AudioVisual Course

    $20.00 USD

    Documentation 104
    Documenting Medical Necessity

    3.0

    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

    $60.00 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 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

    $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

    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

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    $40.00 USD