Defensible Documentation for Physical Therapy Businesses

The healthcare insurance industry today is moving toward value-based payments. Auditing systems are being used to ensure that clinics are strictly following CPT (Current Procedural Terminology) and National Correct Coding Initiative (NCCI) rules. To protect your practice and its financial health, documentation is more important than ever. Not only is detailed documentation a legal requirement, it is the only way for case auditors to know the true status of your patient’s treatment.

APTA’s Documentation Recommendations

To start, the APTA has a few recommendations to improve your documentation:

• Provide a brief assessment of the patient’s response to the therapy at every visit
• Document why you are providing the current treatment plan or why you are removing a previous treatment from your plan of care
• DO NOT flow forward a previous note without making significant changes each visit
• Provide clear understanding as to why a skilled therapist is necessary for the treatment by proving complexity and sophistication

PT Clinical Notes

The medical record is a tool that insurers use to qualify their patients for treatments, examine outcomes, and provide financial compensation. In order for the tool to be effective, PT clinical notes must support and justify the level of care, and provide the patient’s story. They do this by:

• Acting as a historical account of the patient’s care for legal purposes such as in disability or workers comp cases
• Communicating about a patient’s care and status of treatment among providers.
• Demonstrating compliance with local, state, and federal law
• Helping third-party payers determine appropriate payments
• Telling all these parties of the valuable services provided by a professional therapist

Defensible Documentation for Physical Therapy Reimbursement

For your own sake and the integrity of the industry, you should be able to answer four questions while documenting, to greatly improve the chances of surviving an audit or winning an insurance appeal for more visits or compensation.

1. If I read this note in three weeks would I know specifically what happened on this date of service?
2. Could I justify this date specifically to an insurer, lawyer, or auditor?
3. Could a non-therapist read this note and understand what happened i.e., what goals were met, which treatments were changed, etc.
4. Is the plan of care apparent?

Making sure these questions are answered, plus completing the following will create defensible documentation for physical therapy.

• Date and sign all dates of service.
• Complete necessary progress reports.
• Document as much information as you can while the patient is still there for their appointment.
• Be sure to note any conversations with the patient, or any reasons for missed therapy,
• Use any standard tests possible to communicate goals and progress.
• Do not use vague phrasing; make sure all documentation is clear and concise.

Although all of this will get you, as a therapist, more clearly defined information on your patient’s therapy and improve chances of additional visits and best compensation, none of it matters if the case doesn’t meet medical necessity requirements. Watch out for our next article on that topic!