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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Clinical Documentation Improvement Program

Clinical documentation improvement programs are an important piece of the preparation for ICD-10 implementation.  Documentation details why a person seeks care, what care was provided and may be used as defense in malpractice claims and to support the medical necessity of care. 

Each physician’s records must support both the diagnosis and the procedures performed at every visit.  In order to receive reimbursement from a third-party, documentation must be clear and concise.  Vague documentation may results in questions, error and claim denials.

In the current healthcare environment, CPT coding drives reimbursement and many review are focused on whether the procedure codes are supported within the documentation.  With the introduction of ICD-10, there is an increased emphasis placed on diagnoses becoming an important factor in reimbursement decisions. 


Chiropractic reviews frequently cite “insufficient documentation” as a basis for denial.  Focusing on documentation improvement prior to the implementation of ICD-10 will help to reduce denials or assignment of
unspecified codes.  Although there are times when the use of these less-specific codes is appropriate, routine use will result in decreasing reimbursements.  Physicians must take the time to document the specifics to ensure accurate code selection.

A patient’s treatment plan is dictated by the diagnosed condition.  Failure to properly document and assign ICD-10 codes brings increased risk in reimbursement, not only are the initial CPT codes called into question, but the patient’s entire treatment plan may be denied.   

There are several challenges to a clinical documentation improvement program. 

  • Improving documentation without creating excessing administrative burdens and, physician frustration.
  • Identifying the correct details needed, not creating a volume of detail for each visit.
  • Preparing the documentation without encroaching on time spent on patient care.

Physicians have the unique challenge to try and fit the new coding and reimbursement system into their daily clinical workflow without adversely impacting patient care.  Beginning well in advance of ICD-10 is advised.

There are 4 steps to a Clinical Documentation Improvement (CDI) program.

  1.  Assess.  Evaluate the current status of medical records.  Does it support the ICD-9 codes used today?  Will it support ICD-10 code selection?  Does the record support the CPT codes billed?  The outcome of the assessment phase indicates areas of potential improvement for both diagnosis and procedure coding.
  2. Education.  Physician education, training and tools are vital to a successful CDI program.  Training via classroom, webinar, video, or articles can be used to support providers. 
  3. Implementation.  In this step providers and staff work together to support the creation of EHR templates, worksheets and reference tools to make the changes identified in the assessment step.
  4. Maintain.  A CDI program must be maintainable to provide value.  The changes made as a result of the previous steps should be monitored and assessed regularly to ensure that documentation continues to reflect the requirements of the payers as well as federal and state regulations.

The focus of a CDI program should be on increasing the accuracy and completeness of documentation regardless of the impact to the bottom line.  Don’t focus only on the highest dollar services, but on all procedures performed in the clinic.  The most vital role of the CDI program is completely and accurately reporting both diagnosis and procedure codes.

Cornerstone offers Documentation Readiness Assessments and Chart Audits to help you in your CDI program.  The Chart Audit looks at ICD and CPT coding.   Does the information in the chart support the ICD-9 code and have the elements needed to support the CPT codes billed?  The Documentation Readiness Assessment looks specifically at documentation supporting ICD-10 coding.  Based on your documentation today, what ICD-10 code could be assigned and what details, if added, could improve that code assignment. 



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