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.
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Tips for proper documentation
1.
Write in Black
ink for chart notes, reports etc. (makes copying easier to read)
2.
Sign and date
all chart notes, reports
3.
Include client’s
name and ID # or SS# on all documents
4.
Don’t erase or
white out. Cross out and initial
when necessary.
5.
Write legibly or
type.
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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
