This is the diagnosis. Using the data from the chief complaint, patient subjective, and exam objectives arrive at a diagnosis. This is known as your best guess. It is allowed to be modified as you go along and other data reveals itself. You are not being graded here but it does need to be consistent with the chief complaint, patient subjective and exam objectives. The first diagnosis listed is the one you primarily are treating. However you may also be treating the other. Include the diagnosis in the International Classification of Diseases Volume 9 (ICD-9) code book. Do not include the Traditional Oriental Medicine diagnosis here because it will confuse the insurance company reviewer. If you wish to include diagnoses which are to be ruled out, say that next to the diagnosis. For example: Rule out lumbar spine disc herniation.
This is where you will summarize your initial findings, how the patient has progressed up to the last visit, what therapies where used, your overall strategy for the condition. If you need additional visits, list the number of additional visits over and the time interval these will be used. If the patient has been discharged or sent to another specialist, state this.
Print the progress report on your letterhead, sign and date it. Include a bill for your report, as some insurance companies will pay for it. Send it with a copy of the patient treatment notes. In thirty days, call the insurance company for their decision if you have not yet been contacted. This is not a fool proof, guaranteed payment strategy, but it gives you a fighting chance. More often than not, the reviewer is looking for reasons to pay you. Provide the data and hope for the best.
The following is a sample Insurance Company Progress Report. Use it as a model; copy and paste text into your report template or download this version now.
Copyright 2010 by Dr. Kevin McNamee, DC, LAc. Please do not duplicate in any manner.