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Smart therapists put it in writing

Rehab Regs, May 28, 2005

Most therapists would rather spend time helping their patients than reading manuals or filling out forms. But part of the job is ensuring that you record the services you provide so that you and your facility can receive adequate reimbursement. for them Documentation doesn't have to be a drag if you keep in mind this expert advice.

Be specific

When therapists complete initial evaluations, they must write down goals for the patient and establish a feasible timeline in which to reach these goals. The biggest mistake therapists make is setting goals that are not objective, quantifiable, or functional enough, according to Ann Lambert Kremer, OTR/L, MHSA, CPC, senior manager at Baker Newman & Noyes in Portland, ME.

For example, if for one patient you have set a goal of improving ambulation, be sure to add you would like her to transition from a walker to a straight cane and walk 150 ft. Add that this is the distance to and from her front door to her mailbox to clearly explain why you chose this goal and how achieving it will increase her independence and improve her quality of life.

When you write your progress notes, if you only write "walked 50 ft," you force a reviewer to look back at the initial evaluation, says Kremer. Instead, write "patient walked 50 ft with a straight cane-one-third of the way to her goal."

"Therapists often write an assessment of where they are on that date but don't compare it to where they were or where they want [the patient] to be," says Kremer.

In addition, though, your daily notes may be brief, Kremer suggests that your weekly notes always hark back to your patient's initial goals. Instead of simply writing that "initial goals continue to be realistic," indicate that, in line with the evaluation, "goals will be met in four more visits" or "treatment will be extended for three more weeks." Also, add information like "the bicycle [exercises] were too painful and had to be eliminated," and go on to explain what activities you will do with the patient instead, says Kremer.

In short, your daily notes need to support the charges, and your weekly notes need to address progress toward the patient's goals.

Reimbursement

When you document, do so in minutes. Instead of converting the minutes you provide therapy to your patients into units, write down the exact minute total and allow one person in your facility-preferably the biller-to convert those minutes into units.

For example, a therapeutic exercise (CPT code 97110) is billed at $29.69 per unit, says Gail Neustadt, NHA, MA, CCC-SLP, a consultant for Flagship Rehab in Cumberland, Maryland. If a patient received 37 minutes of treatment, the charge to Medicare would total $55.38 for two units of service. If the patient received 38 minutes of treatment, the charge to Medicare would increase to $83.07 for three units of service.

To understand why this one-minute translates into an extra unit, you must understand unit calculations, even if you aren't going to be converting minutes to units yourself. According to CMS' Program Memorandum (PM) AB-00-14, therapy services are billable to Medicare in 15-minute intervals.

For example, if you perform eight to fewer than 23 minutes of therapy, you would report one unit. Twenty-three to fewer than 38 units would count as two units, and so on. Remember that if you provide fewer than eight minutes of therapy, you shouldn't report any units.

"Since most PT and OT CPT codes are time-based, it's easy to leave money on the table if you are off by one or two minutes in service delivery," says Neustadt. "Use a timer and do not stop therapy unnecessarily until the buzzer goes off."

Best practices

Here are more pointers that will help your facility get a gold star in documentation:

Know your codes. It's essential that therapists understand CPT coding, says Neustadt. "Take a coding course and keep up with the appropriate codes [with the help of] therapists, billing staff, the rehab director, or the health information management staff member," says Neustadt.

Remember these three questions. If your notes are bare boned, you may want to utilize questions that could prompt more detail, says Kremer. The additional information will increase the probability that your claim is paid.

- Was a licensed physical therapist needed to perform these services?

- Were the services rendered medically necessary?

- Does the documentation support the time that was billed?

Write what's important. Because your notes are actually legal documents, include essential information and leave out subjective observations. "Some therapists just start writing," says Neustadt. "[Instead,] say what you do, do what you say, and write it in the payer's language."

For example, a maintenance program designed by a therapist may be called a "skilled maintenance program" by Medicare, but some HMOs may label it a "functional program" instead. Remember your audience when you are writing your notes.

Watch out for hospital diagnoses. If you work in a hospital outpatient facility, watch the ICD-9 codes entered for services to your patients, says Kremer. "The therapist needs to confirm that the ICD-9 code on the admitting paperwork is the code necessitating her services," says Kremer.

For example, the admissions clerk may know that the patient was admitted to the hospital for uncontrollable diabetes and use the corresponding code, even though the patient is seeing a physical therapist due to numbness in the feet. Choose the correct code on the admitting paperwork for the present illness and the present intervention, says Kremer.

Study your local medical review policy (LMRP). If Medicare reimburses for a particular service, you still must determine whether that service is reimbursable under your LMRP. Save yourself time in documentation and claim submission by knowing what will and will not be reimbursed in your geographic area.

Use a form that fits your needs. "One-size-fits-all fits no one," says Kremer of forms that encourage documentation of OT, PT, and speech pathology on a single sheet. "If you're working on a team and you're all documenting on the same form, there's not enough space for you to write what you need to," she says. Consider using multiple forms or attaching additional sheets that give you room to document properly.

Train your staff. Because there are very few bona fide documentation experts, periodic training can always benefit therapists. "If you've got green staff, send them to a formal training program," advises Neustadt. "For experienced staff, schedule training annually and conduct weekly team meetings." These meetings could include discussions of new guidelines and new CPT codes to help staff members document more effectively.

It may also help to set up a mentoring system for new employees. "Every new employee should have a mentor looking over his or her notes," says Kremer. "In a facility, there's always someone who's really good. Encourage [that person] to train others."

Self audit. Kremer suggests doing a self-audit four times a year. Pull a random stack of charts and compare the documentation they contain with the guidelines you've established in your staff-training sessions.