Physical Therapy Documentation: Essential Components of Compliant

By Nitin Chhoda PT, DPT on December 11, 2012

In order to avoid malpractice and negligence of your practice, make sure that your documentation and management systems meet the required standards. Nitin Chhoda elaborates on the importance of being and remaining in compliant with the laws.

physical therapy documentation compliantPhysical therapy documentation isn’t just a tool for the physical therapists who work with patients, it is also critical to the success of the entire practice.

If physical therapy documentation standards are not set and maintained, errors in coding and billing are likely to occur and the practice will waste money and time on correcting rejected or denied claims.

There are legal requirements as well as insurance and government program requirements that need to be followed to ensure your physical therapy documentation is compliant.

Medicare Compliance

With the increased attention from the federal government, physical therapy documentation practices cannot afford to be incompliant with Medicare regulations.

In an effort to reduce waste and fraud, HIPAA and the HITECH Act give more power to regulation agencies so that the money spent on physical therapy actually goes to programs that are necessary and efficient.

Medicare defines skilled care and has requirements for what is deemed “reasonable and necessary” for physical therapy treatment.

If your practice does not use waivers and modifiers correctly or doesn’t supervise assistive personnel, you may be jeopardizing your Medicare reimbursements. Review of the minimal documentation requirements from Medicare is essential for all physical therapy staff.

Legal Compliance

The legal concerns of a physical therapy practice can be mitigated if physical therapy documentation standards are kept high. The dangers of noncompliance will not be revealed until it is too late. Most legal action against physical therapy offices will be related to negligence or malpractice, and noncompliance falls under both legal categories depending on the situation.

If a physical therapist is knowingly keeping poor physical therapy documentation and that leads to incorrect treatment of a patient, the therapist is liable for malpractice. If the practice management knows about the therapist’s actions and does nothing to avoid the situation, the practice is also liable.

And if records are poorly kept and an issue arises, whether or not the practice or the physical therapist is aware of the problem, either or both can be liable for negligence.

Insurance Company Compliancephysical therapy documentation essentials

Insurance companies seem to be looking for any reason to reject or deny a claim.

In the current system, it is absolutely necessary that your practice follow the particular rules set by insurance companies, otherwise you may find that you are billing and never getting compensated.

Some companies require reevaluations on a regular basis, to determine that care is still required and that the current treatment plan is having a positive effect. Other companies may have different physical therapy documentation policies.

The only way to avoid losing money is to check the rules beforehand and be sure that each physical therapist or staff knows what those requirements are.

Staying Compliant Mean High Standards

The best way to avoid a bad situation, whether to do with legal or healthcare insurance compliance, is to keep high standards of physical therapy documentation as the norm within the practice.

There are a number of ways that staff can be encouraged to learn and improve their physical therapy documentation practices, and it is the management’s role to ensure that standards are maintained.

About Nitin Chhoda PT, DPT

Nitin Chhoda PT, DPT is the CEO of In Touch EMR and In Touch Biller Pro, an electronic medical records and medical billing software system built be leaders in the physical therapy software industry, with thousands of satisfied customers across the world. For more information, please visit www.InTouchEmr.com and www.InTouchBillerPro.com

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