Please review the important highlights below related to the treatment, documentation, and processes regarding Kaiser Permanente Primary Care Physician (PCP) Referrals. Detailed information can by found in CHP’s Billing Manual, Section 4.1.
- Confine treatment to areas of referral only
- For chiropractors, document all elements of the subluxation as well as the specific level(s) adjusted
- Use standard abbreviations
- Treatment Extension Requests (TER) must be typed
- A fillable TER form is available
- Use consistent outcome assessment tools (OATs) for initial visit, interim/re-evaluation’s to allow for comparing scores and measuring patient response to care
- Use the TER process to request additional visits; do not have patients contact their PCP’s for this purpose
- In the process of recording daily visit notes, clinical records must be visit specific, not “copy-paste”, to demonstrate medical necessity. Additional information on this topic is in the document Best Practices in Clinical Record Keeping: Visit Specific Chart/Progress/Encounter Notes.