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The Importance of Keeping Proper Patient Records in Your Holistic Practice

Keeping track of treatment codes to ensure accurate medical billing can be a challenge for small holistic practices. Proper billing requires familiarity with all the relevant CPT treatment codes and how they interact with one another. Not understanding how billable units are calculated, for instance, could result in an acupuncture or massage practice not getting reimbursed properly for its services. In addition to billing and coding, however, these practices also need to make sure that they’re keeping accurate patient records to document holistic treatments.

Why is Keeping Proper Patient Records Essential for Your Holistic Practice?

Put simply, keeping proper treatment records is often a necessary step for getting paid for patient services. That’s because many insurance companies request treatment notes to ensure that the treatments being administered conform to the specifications outlined in their policies. Simply providing billing information with the proper treatment codes is usually not sufficient for an insurer to evaluate whether or not the care being administered qualifies as good practice. Without supporting documentation that provides more detail about the treatment, the claim could be considered suspect and subsequently denied.

There is often a tendency among holistic practices, such as acupuncturists or massage therapists, to believe that they do not need to keep the same records as western-style medical practices. While this may have been (somewhat) true when most patients paid for services out of their own pockets, today these practices are submitting billing claims for reimbursement to private insurance providers, all of whom are very concerned with documenting exactly what services they’re reimbursing. For holistic practices that want to start treating these patients, it is extremely beneficial for them to view their practice the same way any other professional healthcare provider would regard theirs. That means keeping detailed and accurate medical records to improve the overall quality of care, provide evidence of treatment to third-party payers, and shield the practice from potential liability.

The Benefits of Keeping Proper Patient Records

In addition to the obvious benefit of helping a practice get its billing claims approved, keeping accurate patient records is extremely valuable for auditing purposes. When a holistic practice is audited, it is typically instructed to prepare certain files for review, but the auditors will then randomly select several additional files at the time of the audit to make sure the documentation process is consistent. If an office has poor documentation, it can be very difficult to explain why treatments were administered or prove that they were necessary.

Accurate documentation is also important when it comes to providing high-quality care to patients. When patients receive multiple treatments over a period of time, there should be a record of what treatments they received, when, and why. The size of the practice should not be relevant when it comes to the extent of recordkeeping. Without accurate documentation, it can be difficult to know whether or not the best possible treatment is being administered at any given time. 

For example, even if an acupuncture practice only sees three insurance patients a day, three days a week, that still means over 450 acupuncture treatments were administered over the course of a year. If a patient returns a year later for additional treatment and there is no documentation of their first visit, the acupuncturist is left to rely on memory when determining what treatment was administered. At best, this will result in highly inefficient treatments. At worst, it could open them up to liability.

3 Tips for Keeping Patient Records

Fortunately, there are a few easy tips for keeping accurate, detailed patient records. Documentation may take a little bit longer to do properly, but the benefits of accurate patient records far outweigh the inconvenience of taking five to ten minutes charting or documenting treatments after patient visits.

1. Remember the 7 Cs

In order to comply with HIPAA regulations, patient records should always follow the same basic guidelines regardless of practice type:

  • Correct
  • Clear
  • Concise
  • Complete
  • Consecutive
  • Comprehensive
  • Confidential

2. Don’t “Carry Over” Electronic Health Records (EHR)

For holistic practices that are documenting treatments with an electronic records system, there is often an option to “carry over” information, or copy one set of medical records into another patient’s chart. While this can sometimes be a time-saving trick, it’s important to remember that copying the same notes across multiple patients is going to look extremely suspicious to an auditor (as well it should). Every treatment should be considered unique, even if the previous five patients received the exact same treatment.

3. Use the SOAP Note Format

Long utilized by medical practices to document patient treatments, SOAP notes provide an overview of the entire patient visit and give context to whatever treatment was administered. Many payers require SOAP notes to be submitted alongside billing claims to ensure that treatments were medically necessary.

There are four characteristics of SOAP notes for holistic practices:

  • Subjective: An overview of the information the patient brings into the visit, including their primary complaint, patient description of symptoms, progress since the previous visit, initial pain scale value, and medical history.
  • Objective: A quantifiable evaluation of the patient performed by a healthcare professional, including measurable data like vital signs, physical symptoms, laboratory results, and other clinical documentation.
  • Assessment: An interpretation of the connection between the Subjective and Objective information available to produce a diagnosis of the patient’s condition.
  • Plan: A description of what treatment will be administered based on the diagnosis as well as recommendations for moving forward. This information should be very specific. For instance, an acupuncturist should indicate what the pain scale value was pre and post-treatment.

Improve Your Record-Keeping with Holistic Billing Services

Keeping detailed patient records in addition to managing billing claims can be quite a handful for many holistic health practices. Every moment spent filing paperwork is time that could be spent treating additional patients and increasing revenue. That’s why partnering with a billing service like Holistic Billing can help your practice focus its attention on the most important aspects of patient care. We can help to streamline your billing process and get your claims reimbursed faster and with fewer denials while you work on expanding your business. To learn more about how Holistic Billing Services can transform your practice, contact our experienced team today for a consultation.

April 29, 2020
 - by Antonio Arias, MBA, CHBME
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