The Daily Note

Documenting Medical Necessity – Daily Treatment Notes

After the initial treatment plan and goals are established, the notes required for each daily visit documentation can be brief - provided they identify key components:

  1. Review of the chief complaint – improvement or regression since last visit
  2. What was the response to previous care?
  3. Indicate findings of pre/post adjustment examination
  4. An assessment of change in the patient’s condition since the last visit
  5. Evaluation of the effectiveness of the care given
  6. Details of exactly what treatment is preformed
  7. Any changes to the plan of care

 By utilizing the Medicare model of P.A.R.T. as part of your S.O.A.P., your notes will be standardized and your documentation sufficient for not only Medicare but commercial, workers compensation and personal injury patients.

The S(ubjective) portion of the daily note records the patient’s description of their problem. It should include the current status of the symptoms, an interim history of how the patient has done since their last appointment and how the pain has changed.  Document how they are following your recommendations and how their activities of daily living have been affected.


The O(bjective) portion of the daily note should contain the PART documentation – or examination findings.


  • P – Pain and Tenderness can be identified using one or more: observation, percussion, palpation, visual analog scale and questionnaire or by asking the patient to grade their pain.
  • A – Asymmetry/Misalignment can be identified on a sectional or segmental level by one or more: observation, static and dynamic palpation or diagnostic imaging.
  • R – Range of Motion Abnormality can be identified as an increase or decrease in segmental mobility using one or more: observation, motion palpation, stress diagnostic imaging or range of motion measuring devices.
  • T – Tissues, Tone Changes can be identify by one or more: observation, palpation, instrumentation or test for length and strength.


Example: Active range of motion measurements in the lumbar region of the spine were observed to be restricted to a marked degree, with pain.  Patient stated pain was 7 on the 0 – 10 scale.


The A(ssessment) should monitor the patient’s progress, and record comments concerning outcomes.

Example: Since starting care two weeks ago, the patient has shown a noticeable improvement in both her symptoms and objective findings. Current treatment appears to be effective and no modification of the treatment plan is required at this time. 


 The P(lan) should identify the treatment done today and to what areas.  If the treatment includes physical therapy modalities, record the type, location and timing of therapy.  While your full treatment plan addresses the reasoning behind the prescribed care, the daily note must contain specific details about what services were provided. 

Example: Patient was adjusted at T8 and T11 with diversified technique.  EMS was applied to the thoracic area for 14 minutes set to patient tolerance.  Home exercises given to the patient on a previous visit were reviewed to ensure thorough understanding of their importance and to confirm they are being correctly performed.


 Your daily notes fill in the details of the visits between your examinations.  They also document the exact care given and the progress the patient is making by following the plan you create with each exam.  Give careful attention to the details you present to insure that your records provide a clear understanding of your patients care.






Responding to Claim Denials - Part 2

In part 1 of this article, we looked at 4 steps to check your billing and coding on denied claims.  Using that information you've checked your coding, your modifiers, your units and your onset dates.  What you submitted meets the generally accepted standards and it was denied!?  It happens every day.  

Most offices don't take the time or have the expertise to appeal denied services.  Insurance companies "bank" on the fact that less that half of denied or bundled claims are ever appealed.  Don't take those denials – get paid for the services you perform!

 #5 - Appeal the decision: Get ready to write! 

Determine the basis for your appeal; incorrectly bundled?  Medical Necessity?  Create an appeal letter that clearly and simply states why this claim should have been paid. Leave your frustration at your office and offer a compelling, fact based, CPT driven reason the claim should be paid. 

#6 – Review the rules for appeal

Review the EOB or the on-line provider resources for the insurance company’s appeal process. Take note of the time frame for receipt of the appeal and the time frame under which the insurance company is required to respond. 

Some carriers require their own appeal form (Blue Cross/Blue Shield, United Healthcare), while others do not.  Keep a copy of the letter/form, documentation you attached, date and address to which the appeal was sent. 

#7 – Appeal the decision.

 Mail the appeal – you can send it certified if you prefer, but document what, where and when you appealed the carrier’s decision.  Be prepared to follow-up if you have not received correspondence or payment regarding your appeal.  Follow-up on these pended claims should begin 4-6 weeks after records are submitted. 


If your office is experiencing a pattern of records requests, a thorough review of your billing practices and documentation might be in order.  For assistance in this and other healthcare related matters, contact us at 888.887.5259.

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Three Areas Impacted by ICD-10

ICD-10 impacts your office in three distinct areas: people, processes and technology.  In order to successfully navigate the changes, let's look at some of the ways I10 will impact your office.


Staff will require training.  Not everyone in your office needs to understand the complexities of I-10, but each person will need to understand a least a little about this coding system. Your front desk personnel will utilize I-10 for pre-certifications and referrals in and out of your clinic.  Staff will need to understand how and what is required under this new environment when they enter new information into your software system.

Your clinic’s billing department will need additional training whether they assign diagnosis coding for you or simply process claims containing these new codes.  They will need to understand the complexities and be ready and able to monitor requests for records, handle appeals and identify trends that impact your cash flow.  Post-implementation, you can expect the need for this expertise to increase as insurance companies process claims more slowly, deny claims more readily and request records more frequently.

The financial management of your office must understand the possible impact of I-10 on the cash flow of your office. They need enough training to assist or manage your billing department when claims are delayed or denied and to facilitate the monitoring of issues and problems post-implementation.  They will need to understand and continue to assess the risks to your practice and know when to implement your risk reduction strategies.

Clinical staff will feel the greatest impact in I-10 as they face the increased scrutiny of medical records documentation.  Understanding the increased documentation requirements for the codes selected is a key element for physicians and other clinical staff members.  Careful consideration of the documentation and code selection pre-implementation can help assure that cash-flow is impacted minimally in the 3rd quarter of 2015 and beyond.


Processes within your office will be significantly impacted by I10.  Revenue cycle processes need to be reviewed and changed. Pre-authorizations, eligibility, charge entry, claims and collection follow-up, and payment posting and denial management all face changes to the processes.  Patient care processes will change as clinical staff will require additional time to document the patient’s condition.  Financial management processes must include monitoring issues, denials and records requests more carefully.


Clinicians may need documentation coaching for improvement and protection of your claim payments.  Paperwork from referrals, superbills, diagnosis “cheat sheets” and more will require review and update. Budget processes will need to be reviewed and modified due to the changes and challenges presented by I-10.


Billing and EHR systems will require updating. Interfaces with outside vendors (payers, clearinghouses, statement processing, etc.) will need to be reviewed and tested.  Changes to templates and/or dictation used to capture documentation may require changes to support the increased need for information.   The use of computer aided coding applications and translation tools to assist your clinical and billing staff may need to be updated, added, tested or changed.

As we prepare for the implementation of ICD-10, we can look to lessons learned from other similar implementations.  For example, in the implementation of the HIPAA 5010 format, although vendors claimed to be ready, there were post go-live adjustments required.  In the migration to a new Medicare contractor, the rules can change and the technology of the payer may not be ready for the new onslaught of charges.  In both instances, cash flow was impacted as everyone scrambled to make corrections and reprocess claims.