Rehab

Rehab providers: Five tips to better documentation

Rehab Regs, May 28, 2003

Accurate documentation is essential to ensure that your reimbursement is just right-not too low and not too high. Of course, everyone wants to "maximize" reimbursement, but if you receive more than you're entitled to, as you probably know by now, that can get you into trouble. And the proof is in your documentation.

"Documentation has become the methodology to determine whether a rehab clinic has to send money back or has committed fraud," says Nancy J. Beckley, MS, MBA, president of Bloomingdale Consulting Group in Brandon, FL.

"If you review all of the published fraud cases that are on the Office of Inspector General's Web site, [you'll see that] every single one of them has built a case, in part, on poor documentation," she says.

The success or failure of your facility hinges on the documentation habits of your therapists. Use the following five tips to ensure that your therapists have all the tools they need to document effectively, efficiently, and with great accuracy:

Review your documentation process. Every year take a look at your documentation system and make sure it is still relevant. The process can be streamlined by cutting the fat accumulated over the years. For example, continuously adding forms may lead to inefficiencies bogging down your facility. Beckley says this is the biggest problem of one of her clients. "The best way to develop an efficient documentation system is to sit down, figure out your payer sources and what their documentation requirements are."

Ask yourself what you need to document in relation to your treatment plan. Your payer may not need to know this information, such as the results of patient tests and their measurements, but you might want to have this be a part of your treatment records.

This leads to the question, "What things, clinically, do you want to have in your medical records that will create a clear picture of the patient you are treating?"

There is no easy answer to this question. Different therapists and payers want different things. There are three essential questions to consider: What do you (the therapist) need in the documentation? What does the payer need? Is the documentation relevant to the patient's treatment? Based on the answers to these questions, think about the most efficient way of pulling this information together.

Know the regulations. Bad documentation and wasted time often occur because people just don't know what to write.

David Perry, PT, MS, owner of Perry Therapeutics of Detroit says boning up on federal regulations as well as local medical review policies are great ways of making sure you stay current with the law. He stresses that keeping current with the "little guys" is also important.

"We tend to only think of Medicare, because it's such a big piece of the puzzle, but when you are dealing with private insurance companies, they may have additional requirements over and above what the Medicare requirements are," he says. "You have to be in tune to how you are documenting for making sure of the rules and regulations."

For example, Perry says, Blue Cross of Michigan re quires a summary of patient progress every fifth visit, which is more stringent than the Medicare requirement.

"Private insurers are probably the worst because they can set the rules up any which way, so you have to make sure you have the most recent local medical review policies," he says.

"With Medicare, [documentation] can be a little less specific, as long as you make sure the progress and change are functional in nature. Don't forget your documentation needs to be specific, to have measurable goals, and be patient-focused," Perry adds.

Know your payer. Realize what types of reimbursement drives your clinic and tailor your documentation to that. Are most of your patients reimbursed through Medicare? Or is it private insurance companies?

It is important that Medicare can see the information on your forms. It doesn't do anyone any good for the information to be buried. A person who reviews your documentation would be less apt to question your methods if he or she can easily see what you are talking about.

Reviewers, like most people, can get frustrated if they are hunting and pecking around for the meaty parts of your notes. Keeping it simple saves time for you and your reviewer.

Perry has seen instances where some therapists feel that long documentation means better documentation. This is not always true. If you use multiple forms and have several pages of documentation, you probably have a lot of unnecessary duplication.

Although shorter is better, make sure you use proper language and terminology, Chris Pollastrini, PT, of Chicago says. He cites the following as examples of good documentation:

  • Set a solid foundation and clear picture of why the patient needs skilled intervention and where that client is going
  • Clearly define short- and long-term goals in functional terms and identify patient/caregiver goals and methods
  • Document patient/caregiver training and education, include repeat performance back and ability to follow home exercise program
  • Incorporate a defined plane with skilled techniques and appropriate frequency and duration
  • Document any communication with the patient's other caregivers
  • Continually assess the patient, document, and plan as needed

Document in measurable, quantifiable terms. Don't waste your time and the time of the reviewer by being too vague. You have to demonstrate functional change and identify any specific things that may be out of the norm. These justify why the person is in therapy.

An example of an "out of the norm" patient may be one who has multiple diagnoses with complications related to pain or shortness of breath, which is a limiting factor in their participation of treatment.

Computers can be your friends. Although most facilities use computers to keep their documentation straight, there are still some that don't.

If you're old-fashioned about your note-taking, and feel better about writing them down before you put them in your computer, remember to use the same charts. This will make it that much easier for you to transfer data from a written chart to the computer because you won't be jumping around.

If you are billing Medicare, make sure that you have enough space online for your PT and OT notes, be cause Medicare wants to see that.

Pollastrini is also a proponent of technology. He says a wide range of computer gadgets, such as hand-held devices, wireless components, voice activation, and PC-driven applications have hit the market in recent years, making it easier for therapists to document more efficiently.

"Always continue to investigate existing and new products to help enhance documentation efforts," he says. "Advanced technology has driven down the front-load costs and improved the financial viability and cost-effectiveness of adopting technology in the therapy marketplace."



Save time when seeing patients

"Therapists always complain about documentation time," says Nancy J. Beckley, MS, MBA, president of Bloomingdale Consulting Group in Brandon, FL. "It's a universal complaint. We spend a lot of time on documentation and there is a perception that we don't get reimbursed for it."

She says this type of thinking is wrong. When a payer reimburses you for your work, the money reimbursed for documentation time is automatically included in the payments. Because they are so busy, often a therapist will not do his or her documentation until the end of the day.

Beckley says this way of doing business has to stop. To be more efficient, try concurrent documentation, which means writing about your patients as you see them. That way you won't have to remember every single detail about 10 or 12 different patients at 6:30 in the evening.

"Think about when you go to a physician's office," she says. "By the time the doctor says goodbye to you, he has already dictated his notes. When he sees you, he opens up your chart and writes notes as you discuss with him what is wrong with you. A therapist should practice this too."

It's not just a matter of having the correct forms and the correct information, it's also using your documentation time efficiently.

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