Physical Therapy Documentation

Preemptive ICD-10 Documentation – Rewriting Your Notes, Onset and Contributory Factors

by Nitin Chhoda PT, DPT | Sep 28, 2015 | Electronic Medical Records, Healthcare Practice Management, ICD 10, Physical Therapy Billing

One of the biggest challenges for clinicians with the transition to ICD-10 will be coding for items that they would normally include in their notes. In the new world of ICD-10, everything has a code and insurance companies won’t reimburse for anything that’s not coded.

The external causes of injuries should be a focus for clinicians and may be the most difficult to remember. Payers want more intensive information about every aspect of a patient’s visit to their medical professional.Practitioners must code injuries, onset of symptoms, external causes and treatment plans.

It’s absolutely essential that professionals in any branch of the medical profession code to prove medical necessity. In some instances, it may be necessary to rely on records from the referring physician to provide acceptable documentation.

Clinicians should always strive to code at the highest level of specificity and detail that’s possible. Practitioners can no longer code for a probable or suspected diagnosis. Payers just want to know about the facts that can be proven by tests and the clinician’s observation.

The process will be smoother and less troublesome if clinicians identify the codes they most often use and convert them to ICD-10 before the implementation deadline. There are thousands of new codes, but clinicians in private practice will typically only use a small number of those, making it easier to begin converting and using them in dual coding.

Before ICD-10, a clinician’s notes were a tool that was used to create an ongoing record of a patient’s health history. They essentially created a database of knowledge that could be referenced about the client. With the implementation of ICD-10, that same information has been reduced to specific codes that determine what clinicians will receive for reimbursements.

The clinician’s expertise with ICD-10 coding will be a determining factor for practice revenues. The GEMs will assist in those efforts to be more specific, but practitioners will want to engage in some preemptive documentation. It will help medical professionals become familiar with the new coding and facilitate the changeover in patient records.

Professional organizations have predicted a 15 percent increase in documentation requirements. Those entities indicate that 65 percent of clinician notes aren’t specific enough for the new ICD-10 coding and will result in a significant increase in documentation times. The sooner that practitioners become adept at coding with ICD-10, the less time will be required as time progresses.

Payers have always sought reasons to deny claims and place the financial responsibility elsewhere. That’s their job. As comprehensive as the new code set is, medical professionals in all fields should be aware that they may encounter substantial difficulties. Many payers are under the impression that ICD-10 has a code for every possible instance, but that just isn’t true.

The current healthcare environment is one in which the focus is on saving money and ensuring that services are actually being received. Payers are no longer content to reimburse without practitioners without providing detailed to ensure the treatment is appropriate and is actually being carried out.

To accomplish that task, practitioners now have more specific coding, along with additional coding for documenting details about the causes and circumstances surrounding the patient complaint. Notes are no longer sufficient for that purpose and a practice’s revenue stream will directly depend upon the clinician’s ability to locate the appropriate codes to provide proofs in an alphanumeric fashion instead of words contained in notes.

Those who identify their most often used codes and begin rewriting their notes to conform to ICD-10 protocols have a better chance of mitigating denials once the new coding goes into exclusive use. The ICD-10 transition will be difficult enough. Taking the initiative in rewriting notes now will save time in the future.

A Physical Therapy Documentation and ICD-10 Code Preview

by Nitin Chhoda PT, DPT | Aug 31, 2015 | Electronic Medical Records, ICD 10, Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

Coding with ICD-10 will offer some interesting experiences for clinicians. Practitioners must keep in mind that they need to bill at the highest level whenever possible. That means taking extra time if necessary to track down the correct codes for optimal billing. Getting the codes right will mean the difference between getting reimbursed and delayed payments.

The following is an example of the type of coding required to provide premium treatment for the patient and optimal reimbursement for the clinician.

Subjective:
Mrs. Smith was riding her horse through an orchard road adjoining her property. Her two siblings were riding their horse with her. As she neared an irrigation pond on the property, a Canadian goose flew up and startled one of the other horses. The second horse whirled to put his rump toward the “threat” and lashed out with both back hooves. One hoof struck Mrs. Smith on the tailbone causing immediate pain. The injury happened two weeks prior and she still experiences pain, along with numbness at the tailbone, radiating 3-4 inches in all directions from the site of the injury. Over the counter medications offer no relief. Past medical history is unremarkable. She followed up with her primary care physician who referred her to physical therapy. Patient indicates no x-rays or other diagnostic tests have been done.

Objective:
Patient is 5 feet tall and weighs 120 lbs. Blood pressure is 120/70, pulse rate 72 and respiratory rate is 16. She has full strength and function in all muscle groups, but now walks slowly and hunched over. Has pain upon walking, sitting and reclining. Range of movement is normal but patient complains of pain upon movement and examination. Special tests: X-ray.

Assessment:
Exam/x-ray shows bruising, swelling and fracture of the coccyx. Treatment is to rest and to address pain. Postural exercises and home exercise for continued mobility.

Coding:
Y93.52 – Horseback riding, describes the activity at the time of the injury

W55.12XA – Struck by horse, describes what caused the injury

532.2XXA – Fracture of coccyx, initial encounter for closed fracture, describes the anatomical area where the injury is located and indicates this is a first time injury

R26.2 – Describes the symptom of the injury (constant pain and difficulty walking, sitting and reclining)

Clinicians know that ICD-10 codes are much more specific, but part of the learning curve will be wading through massive numbers of potential codes to arrive at the options that best suit the injury or need. The new codes include activities ranging from gardening and pollen reactions to knitting and running into a lamp post, complete with initial and subsequent encounters. It’s unlikely that therapists will require the codes for those potential incidents, but it points out the increased specificity of the new codes.

One of the challenges that practitioners will face is the sheer volume of data contained in the new code sets. GEMs provide a partial solution, but in an effort to stamp out fraud and save money, clinicians are now being inundated with too much information. GEMs, EMRs and other software can sort through data quickly and provide potential solutions, but they can’t make decisions about what to display for a given situation.

The final decision on which codes to utilize will ultimately fall upon the practitioner. GEMs and other computerized solutions can present the possibilities, but it will be the clinician’s practical experience and understanding of ICD-10 to code accurately and profitably.

In Touch EMR and Its Voice Recognition Feature

by Nitin Chhoda PT, DPT | Feb 2, 2014 | Electronic Medical Records, Physical Therapy Documentation, Physical Therapy Management, Physical Therapy Software

There are many myths about the use of voice recognition. In the mid-1990s clinicians began using voice recognition with their EMR systems, but they weren’t very accurate for medical records.

Systems weren’t always able to distinguish from background noise and had difficulty with accents.

Voice recognition systems have come a long way since then and will save clinicians considerable time.

Built In Voice Recognition

The newest computers, devices and operating systems have voice recognition capabilities built in, and most people don’t even know it.

If the computer was built after 2011, voice recognition is built in whether it’s a PC or a Mac, and can be integrated with the In Touch EMR™ software.

Practitioners using an EMR with cloud computing are ready for In Touch EMR™.

One EMR, Multiple Devices

In Touch EMR™ can be used with an iPad, Android tablet, computer or laptop. In Touch EMR can be implemented on Windows, Apple and Android operating systems.

In the beginning, practitioners may feel uncomfortable or self-conscious using voice recognition capabilities.

Clinicians who have never used an EMR before may want to use a computer or laptop when they first begin using voice recognition.

Laptops and computers provide practitioners with the flexibility to type or use their voice when documenting patient records.

For clinicians who are familiar with EMR usage, have little background noise, and are in a semi-private setting, an iPad or other tablet makes sense.

Clinicians can combine voice recognition and typing for documentation.

Implementing In Touch EMR software on mobile devices means practitioners attain greater portability, but typing will be compromised due to smaller screen size.

Accelerated Productivity

Combining the use of voice recognition with In Touch EMR™ increases the speed at which patient documentation can be recorded for increased productivity.

Voice recognition dramatically decreases the time and cost associated with transcription and billing processes.

In In Touch EMR, Practitioners can dictate notes, edit, make referrals, document the entire patient encounter, and monitor follow up measures simply by talking.

It’s much easier, faster and efficient to speak than write/type.

In Touch EMR™ provides the means for clinicians to work more efficiently and quickly complete claims for billing.

Voice recognition capabilities allow clinicians to streamline all the office processes, document faster and spend more time with patients.

In Touch EMR™ provides a powerful tool that integrates easily with virtually any system. Combined with voice recognition usage, it simplifies life, completes documentation in a fraction of the time, and allows practitioners to submit claims faster.

Physical Therapy Documentation Technological Advantages

by Nitin Chhoda PT, DPT | Dec 15, 2012 | Physical Therapy

Nitin Chhoda says that by using the latest physical therapy documentation such as EMR, you will bring a lot of advantages to your practice.

In addition, it can give consistent feedback to your software provider in order to continuously improve the system and reach your goals.

Everything about your physical therapy documentation system should encourage the staff to work in a more streamlined and efficient manner. After all, technology is only as good as the users.

That means a lot of training should be part of the implementation process. But once the staff does get up to speed and starts to work seamlessly within an EMR, the improvements within the practice can be incredible.

Let Technology Do The Work

The whole idea behind updating your practice with the latest technological innovations is to improve the way your practice runs and improve your bottom line.

The way this works is that the technology takes some responsibilities away from staff and eliminates some tasks altogether. The EMR system or physical therapy documentation you choose should do the work for you and your staff so that you can focus on making and achieving your goals.

Features to look out for include website integration, instant intake forms, integrated patient portals and time stamping and clinical timer technology.

For improving management techniques and for big picture goals of the practice, look for advanced physical therapy documentation tools, intuitive and useful reporting capabilities, and feedback opportunities.

Feedback and Flexibility Translate to Longevity

Any physical therapy documentation tool should also be deeply flexible for the users from a development perspective. You should always have the option of giving feedback on the way aspects of the system work, and suggestions should be taken into account for updates.

The truth is that with high tech physical therapy documentation tools, the developers can and will improve upon the system regularly.

physical therapy documentation advantages If a software system is not going to be updated, and if there’s no way for your practice to give feedback on what works and what doesn’t work, be wary.

Although technology changes rapidly, you should be able to count on the company where you purchase your software from to be around for a while.

Physical therapy documentation software that is no longer being improved and supported will die quickly. Longevity will be key to getting the most from any system you invest in.

Well-Tended Information

The more efficiently you can manage physical therapy documentation information within your practice, the better your practice will perform. Customizable forms and templates for your information will allow you to dictate what will be the best set-up for your practice.

Additionally, a high quality EMR will help you to do as much as possible to avoid non-compliance issues.

Imagine that your physical therapy documentation software can help you to stay compliant with HIPAA and with regulations and policies related to submission of claims to both health insurance companies and to programs like Medicare and Medicaid. You rely on an EMR to not only manage information but to keep it safe and secure as well.

Everyone in the practice can have access to the information they need without compromising security. And of course, the physical therapy documentation and billing staff will be able to improve their claim acceptance rate. Which is where well-tended information creates improvements in the financial security of the practice.

Physical Therapy Documentation: The Importance Of Flexibility In The Documentation Process

by Nitin Chhoda PT, DPT | Dec 13, 2012 | Physical Therapy

Even if your practice is using the latest physical therapy software, it’s not enough that it’s automated and meets the standards. It should be flexible to what your practice needs.

Nitin Chhoda imparts the importance of software flexibility in order to maximize the use of your physical therapy EMR, and help your practice continually grow.

While it is important to stick to certain standards of physical therapy documentation, your EMR should allow flexibility.

No two practices work in exactly the same way, so high quality physical therapy software will not restrict your documentation options.

To help make the practice truly more efficient, you will need customizable forms as well as integrated systems for the different aspects of the practice.

Platform Flexibility

Making the most of physical therapy documentation software will require that your practice has all the available tools with which to track patient progress, billing, and scheduling. That means investing in technological tools.

At first, you may not want to invest in portable electronic devices, such as tablet computers. You may feel that the staff can only make a few adjustments at a time, and you may want to wait for a bit of a financial shift before investing in these technologies.

However, if you want to make the most of the physical therapy documentation software that you are investing in, eventually you should allow it to be portable, too. Whether or not you’re ready now, the EMR should include options such as iPhone and iPad apps, cell phone alerts via SMS, and an online browser-based platform.

These options will allow scheduling, billing, and patient care to proceed smoothly and in a timely manner. Time stamping can be incorporated into the daily routine, no matter where a physical therapist is caring for a patient.

Reporting Flexibility

As you can probably imagine already, without flexible and intuitive physical therapy documentation reporting options, many of the benefits of physical therapy documentation software will be lost.

There are so many benefits to having accurate reports on productivity, claims acceptance rates, and referral rates and success, but if the reports system is hard to work with or requires a lot of time, the reporting capabilities will not be used to their maximum effect.

Reporting should be integrated in a way that allows practice management to cross-reference data.

Time stamping and number of patients should be integrated so you can identify the number of patients seen per day by each physical therapist.

Scheduling should also be linked to reports, so you can determine which patients frequently cancel appointments. Physical therapy documentation and billing claims should be reported so you can identify insurance companies that reject an unusually high percentage of claims.

Patient Interaction

Another way that physical therapy documentation and time management can be improved is through patient options. If you want to integrate a patient portal so patients have the option of entering their information online even before they come to the practice.

Intake forms should be flexible and available online or on mobile devices, so that patients have a more streamlined experience when they come for their appointment.

Customizable templates or forms are one of the most important features of any EMR and physical therapy documentation solution. But the entire physical therapy documentation software should be built with flexibility in mind so that you have the option to expand and grow.

Physical Therapy Documentation: Essential Components of Compliant

by Nitin Chhoda PT, DPT | Dec 11, 2012 | Physical Therapy

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 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 Compliance

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.