Speaker B, a medical documentation lecturer, warns that clinicians often document cash patients less thoroughly than Medicare patients, but state licensing standards require the same level of detail for everyone. Proper documentation proves you met the standard of care your license demands, regardless of who pays.
So where are practices actually most exposed today and what documentation mistakes create the biggest audit risk?
So with Medicare guidelines, and if we give the example of, let's say, the chiropractic provider, a doctor of chiropractic, that's been laid out pretty succinctly what is required on the initial visit, what's required on the subsequent visit. Now, this isn't just for Medicare, okay? And I lecture across the United States on, on this subject matter. And what I want providers and doctors to know is that when you document, you are documenting to be able to prove that you performed to a standard of care for which you are licensed to perform to. And a lot of docs don't think about it like that. They think about, well, Medicare requires this, so I better put this in there. And oh, this is a cash patient, so I don't have to do that. Well, guess what? You need to perform to your standard of care, which I'm not doubting that they do, but you need to have your documentation reflect that because that's the only way you can prove that you perform to the standard of care that's required for you to be licensed in your state.
