Your #1 Goal for 2024: Documentation

This is not the first time I have discussed goals and what we must do if we are truly engaged in advancing this profession. With a new year underway, let’s take a fresh perspective for 2024. It’s the Year of the Dragon; this year brings energy, strength and sometimes, breeze fire.

What Insurance Needs

I frequently hear practitioners say, “Insurance doesn’t pay enough.” I always ask myself, Why doesn’t insurance pay enough or more? I then began asking the question to acupuncturists and getting some answers. I also began to observe the information that was being sent to insurance companies by acupuncturists who bill insurance.

The answers came in slowly, sometimes based on documentation or lack of documentation. Sometimes it was requested by the insurance company in the form of an audit or in response to a malpractice case.

An acupuncturist will sometimes call and ask, “They have requested my notes. Do I have to send them?” The answer is a definite yes. You have to send them, even if you’re helping a patient bill their insurance company. Whether the patient pays cash and you give them a superbill or the patient sends the bill in to their insurance company, documentation is always required.

With that said, let’s take a look at documentation, SOAP notes, charting, or any other name you might call this critical process.

Documentation Basics

I also hear things like the insurance companies don’t pay for history and exams. Well, these are actually evaluation and management codes.

Have you looked at your history / examination procedure recently? Most of the time we call this the intake. This is the health history of your patient. Do you record / write down everything the patient tells you about their health issue(s)? Or do you just write down certain things that seem important to you? Have you ever considered that you might find something that the patient forgets or just doesn’t tell you?

When you conduct a patient history and a physical examination, it is very important to document everything. Please remember that from a documentation / insurance perspective, if it is not written down, it did not happen.

I recently attended a hearing at the 9^th Circuit District Court of Appeals. Of the first two cases I listened to, one was 10 years old and the other was going on five years in the court system. Both cases were based on the documentation presented at the beginning of the cases. 

You may be wondering why I was there in the courtroom. I was actually there to hear the third case, which dealt with malpractice insurance, but as the evidence was being presented, I knew why I was in the audience: to hear the defense present the documentation that would be read and analyzed.

I came away being reminded again of the importance of documenting information as completely and correctly as possible. The first thing I thought about was that this same advice can be given to acupuncturists with regard to every patient encounter.

Most of you know I teach classes at various acupuncture schools. Recently, the students in one of my classes reminded me that their favorite part of the class, the part that they feel they do the best at, is the intake section and the patient encounter. Yes, this is very important; in fact, it is another reason to request patient records from other medical providers. It is important for your acupuncture documentation to be part of the patient’s health history.

There are two more critical areas that must be addressed in your documentation:

• The current treatment, including every detail of the encounter
• The measured and documented progress the patient has made in terms of function, as measured by improved performance in activities of daily living

4-Part Documentation

Looking at documentation for the acupuncture profession, there are four parts that are critical:

1. The illness script. This should include a Western ICD-10 diagnostic code, a traditional medicine disorder, and pattern differentiations. This can include a conversation with other medical providers if necessary. It is why you are treating the patient.
2. All the subjective information a patient shares with you. It also could include other tests that support what the patient says, as well as records from other medical providers. This is also when you formulate your treatment plan, which will be shared with the patient and/or the patient’s family during a special counseling time.
3. The current encounter experience. What did you do? How long did it take? How many needles did you put in? How many did you remove? Document anything else that occurred during the encounter.
4. The patient’s improvement, if any improvement occurs during that visit.

Make 2024 the Year of Acupuncture Documentation

The more we document regarding how we treat our patients, the more insurance companies, other medical providers, and patients will understand and appreciate that we treat much more than just pain.

In 2024, we will begin to teach ICD-11 classification for traditional medicine, and how to support your choice of diagnosis by including the codes in your documentation on each patient encounter. I look forward to seeing you in some of the classes; and hope that you will enjoy creating your documentation to demonstrate the full scope of what traditional medicine offers.