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Please also check the
insurance billing manual updates and the
blog for more information.
4. Documentation –SOAP notes, progress reports, narrative reports Your chart notes are the most important part of getting paid for your services. Keep in mind that the work you do with a client will be scrutinized, reviewed and even judged for medical necessity in a court of law. I could write a complete book on the topic, but there is already a good one out there. “Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists” by Diana L. Thompson, is a complete guide to charting.
The key to getting paid by insurance companies is proving that the massage that you are doing is “medically necessary”. We do that through the use of chart notes. There are many ways of taking chart notes. The most common are “SOAP” (Subjective, Objective, Assessment, Plan) notes. To prove medical necessity, we must show that the client’s condition has improved as a result of massage. While some people have said that medical necessity is the responsibility of the referring physician, here in WA State we are being constantly asked to provide chart notes to the insurance companies to prove medical necessity. Some companies will require that you send chart notes with the bill before they will send payment. Call first to find this out before sending the bill. Basically using SOAP charting is the most effective way to communicate what you do in a session. The purpose of SOAP charting is to record the clients’ condition and progress that occurs in each session of bodywork/massage. It is usually required for sessions that will be paid for by an insurance company, whether it is a PIP (auto mobile), L&I (Labor and Industries) or Major Medical. Your records may be requested by physicians to keep them updated on the condition of the client or by lawyers who need them as records of the clients’ injury and progress. Either way, it is important to keep the clients charts updated and complete. See also an alternative to SOAP notes – CARE Notes
Please also check the
insurance billing manual updates and the
blog for more information.
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