Bullet number two here talks about functional change. Make sure you're always indicating functional change. Notice while Medicare does talk about pain, they're more interested in the functional change or what I'd like to say in the third bullet here is the objective findings. In other words, give me measurable changes, things that go beyond just statements but something that we can actually touch. Also make sure that the CMT regions are documented. For Medicare it literally requires that you document each vertebra. You must state C1 or C2, C3, C4 and so on. The only time you can state a region would be cervical thoracic or lumbar sacral because those would indicate C7T1 for instance, or L5S1. Make sure also there's a treatment plan. Treatment plans need not be super fancy, but must indicate I want to see this patient two times a week for three weeks. Short term goals are to reduce pain, reduce spasm, with long term goals of restoring normal function, but there's going to be a plan and, of course, that plan can be updated and changed. The other factor is always think along the lines of take a critical moment to look at your own notes and say, is it maintenance care, or does it look like maintenance care? Obviously, it's our patient and with our patients we know a lot more than we always document so you have to look at not what's in your head but what is on the paper. What did I document? Does it appear to be maintenance? If I were to look week to week in graph would I be able to see that this patient is literally improving at a significant enough level to allow care to continue? The last two I have here in red are for Medicare and these are the two most common things that they'll run into problems with, illegible notes. Obviously, doctors notoriously have some of the poorest writing of anyone out there, but what you have to remember is if it's not written very neatly, is it legible, which means write larger, give yourself more space, or if it's not legible, before you send them in on an audit make sure that they're retyped or rewritten because they will not review what they can't read and will automatically deny. The final one is an interesting one. For Medicare it says no signature. Many are unaware but Medicare doesn't allow you to do initials at the end of a claim or end of a date of service but actually your full signature. You do have to sign your notes at the end of each Medicare note, or if you're doing electric records realizing electronic signature whether done electronically or as a statement is acceptable as well, but each visit must have its own separate signature not an initial at the end. If your signature
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