SOAP Notes that both protect your practice and
improve your productivity
The definitive guide to the most convenient and comprehensive
SOAP Notes at 0 extra cost.
“How to manage audit expert-engineered SOAP notes in less than 15 seconds per patient” Do you dread the moment when a letter from a payer requests supporting medical notes instead of a check or explanation of benefits (EOB)?
Do you skip taking notes for some patient visit? If so, you are making yourself a prime target for insurance audits and resulting payment returns and penalties.
Insurance companies use audits to increase their bottom line. They also have access to leading-edge statistical databases to identify most likely audit targets.
If you do take notes, don't you think that documentation takes outrageously long, often longer than actual patient care?
If you use special SOAP note management software, does it improve or impede your productivity? Does it help you code and prove medical necessity?
Do you really know if your notes are audit-proof?
Justice department recovered $3.1 Billion in false claims in 2006.
Do you think this number will shrink or grow in 2007?
Will your practice be the next contributor to this statistic?
On one hand, ignoring or taking superficial notes saves time but exposes the practice to audit risk. On the other hand, taking good notes using traditional methods slows you down.
- How much better would you sleep at night if you had audit expert-engineered SOAP notes?
- How much more revenue could you add if your notes could justify higher CPT severity?
- How would you reuse your own time savings if you could manage your entire note generation in 2-3 screen touches ?
- How much front office time could you save if your care plan records would be integrated with your SOAP notes?
- How much back office costs could you eliminate if both the superbill and insurance claim would be generated automatically from your notes?
- Think how would you reinvest added revenue and cost savings to grow your practice?
Dr. Ben Lerner, co-founder of MaximizedLiving and author of One Minute Wellness: The Natural Health & Happiness System that Never Fails, which hit the New York Times Advice/How To list, the USA Today Top 50 bestseller, and the Wall Street Journal Non-fiction, enters SOAP notes using Billing Precision station:
Now you can both protect your practice revenue and improve your productivity—and you don't have to pay extra fees for it. Our approach is timed to meet your objectives and to adapt to your evolving priorities. The bottom line is that your revenues improve as a result of rigorous teamwork between your office and our team. Explore our methodology to discover how hundreds of office managers and doctors just like you have been delighted.
The difference between Billing Precision and thousands of other billing services is that all our clients and the entire Billing Precision staff, we all share the same technology platform and processes. Through the shared platform, Billing Precision team becomes a virtual extension of your own office. It boosts your staff and gives you powerful control over your practice workflow and office productivity.
Billing Precision's founders hold advanced degrees in chiropractic, computer engineering, and mathematics, and were awarded several patents in artificial intelligence and information security. Our core team has a deep understanding of the needs of chiropractors and the challenges we all face in the current healthcare environment. We leverage the Internet and integrate practice workflow to combine front office and back office function and to automate multiple services, e.g., automated patient reminder calling. We have developed a uniquely integrated practice workflow, which includes patient appointment scheduling, SOAP notes and revenue cycle management.
Our web browser-based and touchscreen SOAP notes allows the insurance adjuster see precisely what you see of the patient. Documenting patient encounter notes is an integral part of practice workflow starting with patient appointment scheduling, to writing out notes, to medical billing.
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"ANJC pays close attention
to industry leaders who are positioned to help chiropractors
in being more successful with challenges of every day
practice. I am very pleased that Billing Precision
services assist ANJC members with billing and collections,
expediting revenue cycle, helping manage compliance,
and integrating front and back office workflow."
- Sigmund Miller, DC, Executive Director, Association of New Jersey
Chiropractors
|
“Billing Precision gets chiropractors paid. It uniquely embraces the vision and system required for successful high volume practices.”
-Drs. Ben Lerner
and Greg Loman, Founders, MaximizedLiving
|
“Billing Precision's team is obsessed with getting chiropractors paid. Its technology is the backbone of my practice, which is now completely paperless.”
- Charles Majors, DC, Planet Chiropractic, Romeoville, Illinois
1,500 patient visits per week |
"I know
of practices that were asked to return years of payments
after a random audit. Billing Precision pays enormous
attention to every opportunity to reduce audit exposure.
Their performance is outstanding."
- Doug Cassel, MD, Director of Interventional Radiology, Hoag Memorial
Hospital,
Newport Beach, California
|
“In
two months we caught up with my backlog and my 120-day
Accounts Receivable shrank to 4.4%. This translates to
almost 20% in added revenue.”
- Greg Loman, DC, Trinity Chiropractic in Naples, Florida
|
“Billing
Precision delivered. Clean claims, measurement and analysis
yield greater collections.”
- Ben Lerner, DC, Celebration in Kissimmee, Florida
|
"Billing
Precision has uniquely adapted Wall Street methodology
to healthcare claims processing, resulting in dramatic
A/R reductions and new revenue recovery for the medical
practice."
- Bob Ettl, Managing Director, Allianz Asset Management, Newport
Beach, California |
“Billing
Precision is an industrial strength billing solution
for the family size practice. I get paid in 7 days for
what used to take more than 90. It helps me daily to
focus on patient care and grow my profitability.”
- T. Foster Bryant, DC, Jubilee Family Chiropractic, Naples, Florida |
"Billing Precision goes beyond making sure we are paid in full and on time - their leading edge chiropractic billing software has turned my entire office into a completely paperless and compliant operation, so I can focus on my patient health and practice growth."
- Michael Lagana, DC, BackSmart Wellness Center, Edison, New Jersey |
"No insurance offers protection against audit risk, which carries enormous potential penalties. Billing Precision's unique chiropractic
billing software reduces audit risk and streamlines SOAP note
compliance management."
- Jeffrey Randolph, Esq. ANJC Legal Counsel |
"I can not speak highly enough of these guys and their chiropractic
billing software. Billing Precision has revolutionized the way I
practice and my collections have gone through the roof. The more you
embrace Billing Precision technology the more it will do for you. I
do not think there is a better overall chiropractic office management
system available."
- Robert White, DC, True Health Chiropractic, Springfield, New Jersey |
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What price can you put on improving your compliance, reducing audit risk, increasing your coding precision, and improving your productivity?
Contact Billing Precision for a demo to discover how you can start growing your practice.
What is a SOAP note?
The SOAP note is short for Subjective, Objective, Assessment,
and Plan. It is a short method employed by health care
providers to document patient encounter notes.
The Subjective describes the patient's current condition
in narrative form, usually beginning with the patient's
age and gender. It includes all pertinent and negative
symptoms. Document how symptoms impact activities of daily
living; Use the Standard SOAP format modified to SOAAP
by adding an extra “A” for Activities of Daily
Living.
The Objective includes vital signs, findings from physical
examinations, and results from laboratory tests. Document
functional measurements (e.g., Range of Motion), comparison
data, test results, co-morbidities, etc. to paint a picture
of what is going on with the patient.
The Assessment is a quick summary of the patient with
main symptoms/diagnosis including a differential diagnosis,
a list of other possible diagnoses usually in order of
most likely to least likely.
The Plan is what the health care provider will do to treat
the patient's concerns. This should address each item
of the differential diagnosis. Document goals for the
patient and establish a reasonable timeline to reach those
goals; e.g., “Patient will increase tolerance to
sit for up to 60 minutes within the next four weeks.”
Update your treatment plan every 30 days or 12 visits
or any time there is a significant change in the patient’s
condition, i.e., exacerbation, new injury, discharge exam.
Document the patient’s progress toward those goals
in the daily SOAAP notes.
Special notes on
Medicare: |
| 1) |
The treatment must have a
“direct beneficial therapeutic relation to the patient’s
condition” and must provide a “reasonable
expectation of recovery or improvement of function.”
Must be billed with a “AT” Active
Treatment modifier to be reimbursed |
2) |
Maintenance is not covered and must be billed with a “GA”
modifier after having patient sign Advance
Beneficiary Notice. Maintenance is defined
as “seeking to prevent disease, promote healthy,
prolong and enhance quality of life.” |
3)
|
Medicare Modifiers:
| AT: |
Active treatment (acute
or chronic) which does not exceed frequency limit.
(e.g., 98941-AT)
|
GA |
Active care (acute or chronic) which exceeds frequency
limit and ABN signed. (e.g., 98941-AT-GA)
|
GY: |
Items or service statutorily excluded or does not
meet the definition of any Medicare benefit. (e.g.,
99203-GY)
|
GP: |
Services delivered under an outpatient physical
therapy plan of care. (e.g., 97012-GP-GY)
|
GZ: |
Service Expected to be denied as not reasonable
and necessary, but no ABN signed. (e.g., 98942-GZ) |
|
4) |
Full spine adjustments: Prioritize your adjustment and
code for the primary area of concern. |
5)
|
Do not upcode or downcode your services as this is insurance
fraud. Make sure your documentation supports your coding.
|
| Example Plan of Treatment
(Day 1) |
 |
Initial examination (CPT
99201-99203) |
|
X-Ray (CPTs 72010 -72120)
|
CPT 72010 - full
spine |
|
CPT 72020 - single view |
|
CPT 72040 - 2-3 views |
|
CPT 72050 - 4 views
|
|
|
Adjust or not adjust on first day? Some
insurers will not reimburse. |
|
Establish treatment plan |
| Example
Plan of Treatment (Day 2) |
|
Get baseline functional measurements:
| 1) |
ROM testing (CPT 95851)* |
| 2) |
1) Manual Muscle testing (CPT 95831)*
|
| * Findings must be
compared to a standardized grading scale and a
formal, written signed report of findings must
be issued to be reimbursed separate from an E/M. |
|
|
Spinal Adjustment
|
CPTs 98940-98942 |
|
|
Extra-spinal Adjustment
|
CPT 98943 |
|
|
Physical Modalities
|
CPTs 97010-97530 |
|
| Example
Plan of Treatment (Day 3-11) |
|
Spinal Adjustment
|
CPTs 98940-98942 |
|
|
Extra-spinal Adjustment
|
CPT 98943 |
|
|
Physical Modalities
|
CPTs 97010-97530 |
|
| Example
Plan of Treatment (Day 11) |
|
Spinal Adjustment
|
CPTs 98940-98942 |
|
|
Extra-spinal Adjustment
|
CPT 98943 |
|
|
Physical Modalities
|
CPTs 97010-97530 |
|
|
Referral for Diagnostic Testing / Consultation
|
MRI, EMG/NCV, Neuro
or Ortho Consult on ly if patient is not improving
and suspected and you feel referral is medically necessary
|
|
| Example
Plan of Treatment (Day 12) |
|
Re-Evaluation
| |
CPTs 99211-99213
Every 30 days or 12 visits |
|
|
Treatment Plan Review:
| 1) |
Update diagnoses |
| 2) |
Update treatment plan |
| 3) |
Update adjustment regions |
| 4) |
Update physical modality program |
| 5) |
Make sure documentation supports
continued care. |
| 6) |
Use Outcome Assessment Tools. |
|
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athenahealth - December 20, 2006
Indiana’s Hendricks Regional Health Medical Group Selects eClinicalWorks Unified EMR/PM Solution for 50 Providers
System will Help Multi-Specialty Practice Participate in Regional Health Information Organization (RHIO) for Improving Patient Care; Interface with Meditech will Simplify Lab Processes
eClinicalWorks - December 11, 2006
OmniMD launches integrated EMR and Practice Management software
OmniMD - December 6, 2006
Community Health Network Expands Strategic Relationship with GE Healthcare
All-Digital Network to Implement GE’s Centricity Enterprise Solution
Pioneer of Paperless, Wireless and Filmless Healthcare Will Further Advance Digital Healthcare Initiatives for Safer and More Efficient Care
GE Healthcare - December 4, 2006
7 Medical Launches On-Demand Healthcare IT Services in Minnesota, Florida, Georgia, North Dakota and Wisconsin
Healthcare Organizations Employ Cost-Effective, Productivity-Enhancing On-Demand Services for Electronic Medical Records and Digital Imaging (PACS)
7 Medical Systems - November 21, 2006
New York Quality of Care Grant Awarded to SigmaCare
EMR Technology Will Improve Care and Increase Efficiencies in Nursing Homes
eHealth Solutions - November 15, 2006
OmniMD launches integrated EMR and Practice Management software
OmniMD - November 13, 2006
VCU HEALTH SYSTEM DEPLOYS PATIENTKEEPER AS ITS PHYSICIAN INFORMATION SYSTEM
Physicians Embrace PatientKeeper As an Important Tool to Save Time and Enhance Patent Care
patientkeeper - October 31, 2006
OmniMD introduces Patient Portal Services with its Integrated Electronic Medical Record (EMR) Software
OmniMD - October 24, 2006
Per-Se Technologies, MediNotes Expand Relationship to Provide Total Practice Management and EMR Solution
Alliance Enhances Two Best-of-Breed Systems for Small Physician Practices
Per-Se-MediNotes - October 23, 2006
PATIENTKEEPER AWARDED U.S. PATENT FOR ADVANCED DATA SYCHRONIZATION TECHNOLOGY
Ability to Access Current Information from Numerous Data Sources Helps Physicians Make the Most Informed Clinical Decisions
PatientKeeper - October 3, 2006
Elsevier Announces iCONSULT to be Offered as Part of SOAPware Electronic Medical Record
Partnership Puts Integrated Evidence-Based Point of Care Content Directly Into Electronic Medical Record to Improve Quality and Consistency of Decision-Making
Elsevier-SOAPware - September 29, 2006
LARGEST KENTUCKY HEALTHCARE SYSTEM SELECTS PATIENTKEEPER AS ITS PHYSICIAN INFORMATION SYSTEM
Award-Winning Software Delivers Immediate Competitive Advantage to Norton Healthcare, While Providing Financial ROI and Infrastructure for Future Expansion
PatientKeeper - September 26, 2006
MedAppz Unveils Integrated Medical Software
MedAppz iSuite is Web-based; New Advances in Electronic Medical Records (EMR) Automate Paperwork, Protect Physicians from Catastrophes
MedAppz - September 21, 2006
HealthONE(TM) Leading the Way in Electronic Medical Records
Quality Initiative Links 8 Emergency Depts., Inpatient Files
HealthONE - September 19, 2006
emsCharts Software Achieves National Gold Compliance
emsCharts - September 19, 2006
Henry County Medical Center Selects McKesson for Electronic Health Record Initiative
Highly-Rated Paragon System Integrates Financial and Clinical Information to Support Strategic Technology Initiative
McKesson - September 14, 2006
EMR Experts, Inc. partners with Medical Communication Systems, Inc. to offer feature-rich EHR
EMR Experts - September 11, 2006
DigiChart announces the release of digiChart Practice(TM)
Powerful integration of electronic medical record and practice management systems built specifically for OB-GYN practices
digiChart - September 6, 2006
Numerous Picis Customers Ranking Among Most Wired by Hospitals & Health Networks
Paperless Medical Records and Measurement of Process Improvements Contribute to Rankings
Picis - August 14, 2006
Medical Transcription in the Era of Electronic Medical Records
OmniMD - August 9, 2006
Patientrak Electronic Medical Records Smart Card System Integrates Continuity of Care Standard in Personal Health Care Record on New Health Services Industry Website
Portable Health and Electronic Medical Record Pioneer PatienTrak releases new personal health record smart card and electronic health records website supporting healthcare standards and interoperability on several levels
Patientrack - August 1, 2006
athenahealth Introduces Healthcare Industry's First Economically Sustainable, Service-Based EMR Offering for Medical Practices
athenaClinicals(SM) Builds on Company's Proven Web-Based Model to Combine Intuitive Software and Results-Oriented Services to Deliver Improved and Predictable ROI
athenahealth - July 25, 2006
MISYS HEALTHCARE SYSTEMS RECEIVES CCHIT CERTIFICATION FOR MISYS EMR
Misys - July 19, 2006
Misys Healthcare Systems' EMR Successfully Completes DOQ-IT Testing
Misys' Commitment to Providing Quality Solutions Gains Momentum with Industry Recognition
Misys - July 12, 2006
eClinicalWorks and Massachusetts Medical Society Team up to Deliver Electronic Health Records
Alliance Helps Bring Integrated EMR and Practice Management Solution to 18,500 Member Physicians
eClinicalWorks - July 10, 2006
Visionary Medical Systems Has Been Selected by Choice HealthCare and Georgia's Largest FQHCs as their EMR / PM Solution
Visionary Medical Systems - June 29, 2006
Providers Choose Siemens and NextGen Healthcare for Cross-Continuum Access to Longitudinal Electronic Health Records
Siemens and NextGen Healthcare Partnership Builds Solid Foundation For Interoperability
Siemens - June 21, 2006
MISYS HEALTHCARE SYSTEMS PARTNERS WITH RXHUB TO IMPROVE EFFICIENCY AND PATIENT SAFETY
Partnership will Reduce Medical Errors and Increase Quality of Care by Providing Comprehensive Medical Knowledge
RxHub - June 20, 2006
Healthnostics Announces Acquisition of Physician Practice Management System
Includes Integrated Electronic Medical Record (EMR) System
Healthnostics - June 13, 2006
ChartLogic, Inc. Announces the Improved Integration of BillingLogic™ with ChartLogic™ EMR
ChartLogic - June 7, 2006
Cutting Edge Sea Mar Community Health Centers Makes $1 Million Decision to Implement Misys EMR to Improve Patient Care
Mexican President Vicente Fox Visits Federally Qualified Health Center to Personally View Practice's Efforts to Serve Low-Income, Underserved and Uninsured Communities in Western Washington
Misys - June 5, 2006
California Doctors Adopt Electronic Health Records Systems at Nearly Twice the National Rate
Lumetra Salutes DOQ-IT Pilot Practices During National Health IT Week (June 5-8)
Lumetra - June 2, 2006
IMPAC Partners With Rocket Communications to Launch MOSAIQ(TM) Image-Enabled Oncology EMR
MOSAIQ's Chart-Based UI and Vendor-Independent MS SQL Platform Ease Implementation and Empower Customer Choice
IMPAC - June 1, 2006
Misys EMR(R)'s Flexible Products Strengthen Business Performance at Tidewater Physical Therapy
Physical Therapy Clinicians Use Misys' Suite of Solutions to Spend More Time with Patients
Misys - May 30, 2006
eClinicalWorks Rated a Top EMR System for Small, Medium and Large Practices at TEPR 2006
Integrated EMR and Practice Management Solution Also Wins Pediatric Award Challenge
eClinicalWorks - May 26, 2006
Nuesoft Technologies Introduces Electronic Medical Record for College Health Center Market
Nuesoft - May 23, 2006
MedPlexus Offers Introductory Pricing on Integrated Electronic Health Records and Practice Management Solution Through June 2006, and Introduces M+ Methodology Pathway for Incremental EHR Adoption
Solutions Offer Predictable, Affordable Complete or Phased EHR Adoption, Resulting in a Faster Return on Investment, Improved Practice Efficiency, Workflow and Patient Care
MedPlexus - May 22, 2006
50% of EMR Implementations Fail – AdvancedEMR has the Solution
AdvancedMD - May 22, 2006
ACOM Healthcare Business Division Integrates RAPID EMR Documentation and Reporting Solution with RAPID EPM Practice to Create Total Chiropractic Office Solution
AcomRapid - May 16, 2006
AdvancedMD Re-Launches Website and Features New Electronic Medical Records Product
AdvancedMd - May 11, 2006
EMR4Doctors, a Privately Held Software Developer for the Medical Industry, Releases New Software to 'Build Your Own Community EMR'
EMR4Doctors - April 12, 2006
AcerMed Invited by Microsoft to Present its EMR Software
Microsoft's booth at HIMSS hosted AcerMed for its presentation of data mining for Pay-for-Performance
AcerMed - February 17, 2006
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