Guidelines for PT Documentation

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Guidelines for PT Documentation

• Introduction to Writing Notes

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Guidelines for PT Documentation

• APTA Board of Directors Policies, BOD
  G03-05-16-41 (pp. 83-92)
• http//www.apta.org/AM/Template.cfm?SectionPolici
  es2TEMPLATE/CM/ContentDisplay.cfmCONTENTID2713
  3

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Purpose of Writing Notes

• Plan and evaluate patients treatment
• Provide pertinent data for other health
  professionals
• Facilitate claims review and payment
• Utilization reviews quality of care reviews
• Clinical data for research and education
• Legal document witness in court

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For Claims Review, Services Must Be

• Appropriate for treating the patients condition
• Medically necessary for the diagnosis

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General Guidelines

• Complete and legible
• Includes patients full name and ID
• Includes referral mechanism
• Dated and authenticated (signed) with appropriate
  designation (e.g. PT)
• If handwritten, must be in ink
• Charting errors single line strikethrough, date
  and initial do not delete the original record

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Types of Documentation

• Initial patient/client management
• Documentation of continuation of care (i.e.
  progress note)
• Documentation of reexamination
• Documentation of summation of episode of care
  (i.e. discharge summary)

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Initial Patient/Client Management

• Includes the elements of examination, evaluation,
  diagnosis and prognosis

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Examination

• The patient/client history
• The systems review
• Tests and measures

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Evaluation

• Diagnosis
• Prognosis
• Plan of care
• Based on examination, evaluation, diagnosis and
  prognosis
• Identifies goals and outcomes
• Describes proposed interventions, including
  frequency and duration
• Includes patient/client involvement
• Includes appropriate coordination/communication
  with other professionals/services
• Includes plan for discharge

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Documentation of Continuation of Care

• Provided for every visit/encounter
• Document
• Intervention or services provided
• Current patient/client status

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Documentation of Continuation of Care (contd)

• Elements
• Patient/client self-report
• Identification of specific interventions
• Include frequency, duration, intensity
• Equipment provided
• Change in patient/client status
• Adverse reactions, if any
• Factors that modify progress (e.g. patient
  compliance)
• Communication/consultation with providers,
  patient, client, family, significant other, etc.

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Documentation of Reexamination

• Purpose of reexamination
• Evaluate progress
• Modify or redirect intervention
• Elements
• Selected components of examination to update
  patients/clients status
• Interpretation of findings and revision of goals
  and outcomes, as necessary
• Revision of plan of care, as necessary

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Summation of Episode Care

• Criteria for termination. For example
• Goals and outcomes achieved
• Patient/client declines to continue
• Patient/client unable to continue
• Patient/client no longer benefits from PT
• Current physical/functional status
• Degree of goals and outcomes achieved with
  reasons for not achieving, as appropriate
• Discharge or discontinuation plan (e.g. home
  program, follow-up PT) that describes written and
  verbal communication.

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Coding Systems

• Used in claims forms in conjunction with medical
  record to identify
• Whats wrong with the patient (diagnosis or
  diagnoses)
• What was done to treat the patient (the
  intervention)
• Two types
• ICD-9-CM codes
• HCPCS Codes
• Used by CMS and also adopted by some third-party
  payers.

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ICD-9-CM Codes

• International Classification of Diseases, Ninth
  Revision, Clinical Modification
• Classification system that reports the diagnosis
  of illnesses, diseases and injuries
• With multiple diagnoses, the reason patient seeks
  treatment is listed first
• Example
• Frozen shoulder 726.0

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HCPCS Codes

• Health Care Procedure Coding System Three levels
• Level I also known as CPT codes (Physicians
  Current Procedural Terminology)
• Level II known as national or HCPCS (pronounced
  hik pks)
• Level III phased out and no longer used

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Examples of CPT Codes

• Evaluation 97001
• Reevaluation 97002
• Gait training 97116
• Therapeutic exercise 97110
• Ultrasound 97035

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HCPCS Level II

• Supplement CPT coding system by including codes
  for
• Non-physician services
• Electrical stimulation as part of PT POC G0283
• Durable medical equipment
• Straight cane E0100
• Underarm crutches (wood) E0112
• Supplies
• Electrodes A4556
• Slings A4565

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Why Mention CPT Codes and HCPCS?

• Typically a clerical person completes claims
  forms using your notes for information
• To get your claims paid promptly and correctly,
  you must the medical necessity and
  appropriateness of the care provided

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Medically Necessary Services Must Be

• Established as safe and effective
• Consistent with the symptoms or diagnosis
• Necessary and consistent with generally
  acceptable medical standards (e.g. Guide to
  Physical Therapist Practice)
• Furnished at the most appropriate, safe and
  effective level

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Documentation that supports the necessity of an
intervention shows

• What service or procedure was rendered
• To what extent the service or procedure was
  rendered
• Why the services, procedure or other item(s) was
  medically warranted

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The Bottom Line Is . . .
No job is finished until the paperwork is done!