A simple chart should consist of four basic sections :
1 . Intake Information
All medical practices are governed by the Health Insurance Portability and Accountability Act ( HIPAA ). Each office must post its privacy policy in a public location and offer a printed version to each person presenting for treatment . Further , each patient must sign a privacy statement acknowledging that they understand the policy . The statement is countersigned by a witness , generally a member of the office staff performing the intake .
The patient ’ s demographic information goes into this section and should include full name , address , birth date , contact telephone numbers and insurance claim numbers .
2 . Insurance Information
If you bill any insurance companies , including Medicare , it is important to have all the most current data in your file and all the appropriate waiver and disclaimer forms in order to process a claim . Whether you do it yourself or use a billing service , you must have all the information . Make a copy of the front and back of the insurance card as it contains policy and group numbers as well as electronic payer number , contact phone numbers and mailing addresses for claims .
When dealing with Medicare , CMS has specific language for the assignment and release statement , and is available on your Jurisdiction ’ s website . The disclaimer and assignment of benefits allows you to bill the patient ’ s insurance and discuss their case with the proper parties . Your practice may utilize additional statements and disclaimers as necessary .
For your Medicare patients , you may need an Advance Beneficiary Notice ( ABN ). The ABN is a statement that Medicare may not cover the patient ’ s services . You must state the service and
Billing and payments are the lifeblood of our practices .
why it may not be covered . Should the ABN be needed and is not signed , the patient cannot be billed for the service you provided . At no time should an ABN be considered a blanket document signed in all cases . It must be used in specific circumstances . The provider manual for your jurisdiction has complete ABN information .
3 . Examination and Treatment Records
The examination is the key to determining a modality and its efficacy . Only after the empirical evidence is gathered can it be synthesized and transformed into a suitable solution . Having a quick reference checklist style examination report gathers the required information and puts it in a very easy to use format . The goal is to recreate in your mind the encounter and give you the opportunity to make notes of the visit along with pathologies , pathomechanics , and supporting information .
Exam documentation also includes a written lab order for the fabrication of the footwear , modalities and / or orthoses . Clear instructions are necessary for producing the kind of device that you envision . This is especially true if someone else is actually doing the fabricating . A separate form is used to delineate modifications on shoes . Once the orthoses , shoes and modifications are dispensed to the patient , report the trial fitting and final disposition of the case . Note any changes you needed to make during this process such as grinding down an area on the orthosis or fitting problems with the shoe .
Many offices use electronic documentation , and some use a combination of written and electronic . Just remember that all your records must be complete , accurate , and are subject to
HIPPA regulations .
4 . Billing Records
Billing and payments are the lifeblood of our practices . Having accurate records is imperative to being paid in a reasonable period of time , and to avoid adverse actions from your billing sources . Billing can be done manually ( by paper ) or electronically . Electronic claims are the preferred method as the claim information is already in a form suitable for processing . Medicare now requires electronic submissions and many private plans prefer it . Consult with the particular plan for their requirements .
Once a claim is processed and paid , the Explanation of Medical Benefits ( EMB or EOMB ) is sent along with your remittance . This form explains what was paid , how much was paid , and references any deductibles , co-payments , or other financial information . Contracted practices agree to accept a certain amount for services , and any decrease from the billed amount is also on this form . The EMB will assess what the patient is responsible for and what amount you must write off , if any .
Documentation can be time consuming , but is time well spent . ■
Dean Mason , C . Ped ., OST , BOCO , CO , BOC Pedorthist , owns North Shore Pedorthics , LLC , in Lorain , Ohio , and is a member of PFA ’ s Board of Directors as co-chair of PFA ’ s Government Affairs Committee and a member of the Marketing , Communications and Editorial Committee .
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