With the increase in notes requested from third party payers, more recently Medicare secondary plans, it is good time to review the process once you receive a request.
First, do not ignore the notes request. You can call the payer acknowledging receipt of their request, or simply print or export the SOAP notes from your practice management program and send them to the payer. It is also highly recommended to include the initial patient intake form, or New Episode patient form, exam form(s), and care plan schedule including treatment goals which can simply be specific ADL functions pre-injury.
I also recommend looking to see what the most current Onset date is in your patient profile. Many recurring notes requests are due to the onset date going back two years and more. If this is the case, the patient is due for a re-exam and more than likely a new set of diagnosis codes, and you can include this information in your response to the payer.
If you need a review on what exactly to include in a SOAP note, click on this link HERE to access the checklist that complies with Medicare documentation requirements.
I use this checklist when I conduct onsite documentation reviews.
Questions? Need help with a documentation audit? Ask Lisa – I can help!
920-334-4561