Is Your Office Looking Into Computer-Generated SOAP Notes? Read This FIRST before you invest your cash!
Thinking that your documentation could use an upgrade? You are probably right, but before you invest in a software generated note system, know that Medicare frowns on most such programs and they could actually hurt you in an audit.
As we have been saying for years, there is no good shortcut out there for doing documentation. You have to follow Medicare’s guidelines and just because your software generates a half page typed SOAP, you may still be missing the mark.
According to ChiroCode Institutes recent alert:
Medicare carrier Noridian Administrative Services recently updated and reprinted a notice on Chiropractic Software-Generated Documentation. Apparently, the piece was generated because Noridian has seen an increase in the use of software-generated documentation for chiropractic services. Here are a few key areas where software can begin to go wrong (according to Noridian):
– In general, most computerized documentation fails to provide individualized information necessary for reimbursement.
– Software-generated documentation is commonly identical to the letter, comma and space for different patients, with only minor word changes; therefore, it does not reflect medical necessity. Services supported by repetitive entries lacking encounter specific information will be denied.
– Software-generated documentation often repeats the same phrases and sentences by simply rearranging the words to make it appear as if new information is being disseminated, but when compared to prior days notes, reflects the same or similar concepts.
You can read the whole article here: https://www.noridianmedicare.com/provider/updates/docs/chiropractic_software.pdf%3f. The article contains some humorous (at least to me) examples of how the software, while randomizing text, generates almost identical SOAPs for different patients on different days.
Getting a Medicare CERT audit? Don’t send in your records without calling us first. See our website for more information on our exclusive Medicare Pre-Audit Documentation Review. LINK