Physical Therapy Software | Making Work Easier and Less Aggravating
Documentation and Compliance
Documentation errors have been called out by the CMS (Centers for Medicare & Medicaid Services) in the past. The three big problem areas were found to be:
- Medical necessity not established
- Inconsistent clinical records
- Signature problems in documents
The following steps should move the needle forward:
- Taking advantage of goal tracking would make documentation more efficient and compliant, this would include functional goals and clinical goals as well as short-term goals and long-term goals. Relating functional limitations to short-term and long-term functional goals along with clinical evidence of issues should make it possible to establish medical necessity.
- The description of the patient procedure would need to match the intent of the procedure code. Reviewing and revising prior documentation would be another useful step. Quickly being able to view the patients prior documentation in the EMR while in the process of treating the patient to occasionally/frequently update it should be a time saver.
- Including a signature line would take care of illegible signatures. Adding a date for the signature on the EMR record should address this issue, especially for the all-important plan of care approval.
In general, documentation expectations in PT are much higher than in other healthcare disciplines.
- Meeting the minimum expectation in documentation, but not going overboard with copious documentation, should probably be the path forward.
- The idea would be to stay clear of common documentation errors while following some important documentation practices, resulting in compliant, complete, and efficient documentation.
- Being able to document at the point of care would be a productivity booster and frustration reducer. Also, well-constructed clinical content should address compliance stipulations.
The goal would be to measure productivity meaningfully and fairly, so that the entire team is onboard with no surprises.
- A measurement and tracking plan would be a good place to begin while setting targets and making improvements over time. Metrics could include key ones like visit count (per day/per hour), units per visit, eval count, and average collections per visit.
- A KPI dashboard that displays selected metrics in real-time should add value. This would be a platform where everyone could understand, influence, see progress, and view where they are at in a transparent manner. Metrics expectations would need to match up at the provider level with case load type and billing efficiency.
Unfortunately, the key metrics are still volume related as we continue to be in a fee for service environment. Financial incentives around value are not where they need to be. Even small changes in dollar per visit could have an outsize impact on overall performance.
Physical therapy practices are under pressure to deliver more care at lower budgets. The need is to have an efficient program that meets the needs of patients and addresses therapist concerns while remaining cost effective.
Challenges from a clinic management perspective include:
- Recruiting and staffing. Hiring and retaining qualified therapists and other staff members could be difficult, especially with budget crunches.
- Performance management. Managing therapists and getting them to meet productivity and efficiency goals could be tough.
- Compliance. The regulatory and documentation requirements that we talked about in this blog should not need further discussion.
- Marketing. Attracting new patients to the practice either directly or through a physician referral would require additional attention.
Overcoming these challenges to drive patient satisfaction and revenue while making work easier for therapists is the priority. What could help is a robust physical therapy software/practice management system with seamlessly integrated billing and clinical processes.
- One patient record for scheduling, documentation, and billing would provide 360-degree visibility into practice operational data and performance analysis against clinic benchmarks.
- Interactive tasks and worklists for the front desk, therapists, and billers would deliver prioritized alerts and notifications on urgent items as well as case tracking from referral to discharge.
- A real-time view of clinical, patient, and claims data along with integrated referral tracking, management, and reporting would serve as an effective platform for collaboration.
- Upfront collection of patient financial responsibility with complete, compliant documentation that automatically captures charges and automated claims processing would enable getting paid faster.
Business process inefficiencies, documentation challenges, pressure to raise billable units, and compliance requirements have been working in tandem and creating a perfect storm. Technology would be a level setter with automation and data capture alleviating many of the key issues. The solution is at hand!