Tell Your Patient's Story: Tips for Defensible Documentation
By Donna Diedrich, PT, DPT, and Jaclyn Warshauer, PT
As physical therapists (PTs), you've no doubt heard the saying, "The work is not done until all the paperwork is done." However, this often is easier said than done. While you're highly trained professionals who identify with a doctoring profession, you may at times struggle to effectively communicate your expertise. The challenge is multiplied when you consider the components that constitute an accurate and timely record of skilled physical therapist services, as well as the audiences it reaches such as physicians, payers, patients, and consultants if/as indicated.
Effective documentation must provide details related to the therapy episode, outlining the complex factors that necessitate skilled PT services for your patient or client. This includes specific medical necessity and skilled service interventions that require the unique skills of a physical therapist or physical therapist assistant—skills that cannot be provided by other health care providers.
When documenting your services, it helps to consider 2 questions: Why now? And why you?
Why Does This Patient Need PT Services Now?
To address" why now," consider what caused the patient visit and within what timeframe, as well as how the symptoms presented. Did Mrs Chen fall this past weekend with resulting stiffness and new-onset low back pain (LBP)? Or did she fall 3 months ago and is now experiencing exacerbation of chronic LBP secondary to arthritis that is not responding to usual care?
As you gather facts supporting the timeframe, you need to include relevant medical and psychosocial events that may be influencing the patient's presentation. For example: Is Mr Sanchez's hip replacement new or longstanding? Is he recently widowed, and was his spouse his primary caregiver? Is his current functional limitation influenced by both recent hip surgery and underlying complications from Parkinson disease?
Tell the story to relate the functional history to the current limitation of impairments. For example: "Prior to fall and hip fracture, Mrs Davis was independent in community mobility and driving, including attending church regularly with navigation up and down 12 steps without assistive devices. Her current limitations 1 week post fall surgical repair of left hip fracture with weight bearing as tolerated includes need for front-wheeled walker and contact guard to minimal assist of 1 for 25' level ground mobility, minimal assist of 1 and bilateral handrail for 2-3 step navigation and inability to drive."
Why Does This Patient Require Your Skilled PT Services?
Demonstrate the "why you" component with a thorough assessment that captures the patient's goals, uses differential diagnosis to identify the musculoskeletal and/or neurological causes integrating symptom and movement presentation, and aligns interventions with your physical therapist scope of practice. This skill needs to be evident in the written documentation of tests and measures used to rule in—or rule out—causes and how, based on evidence, you determine the most appropriate intervention intensity, exercise dosing, frequency, and duration.
It's critical to remember that "skilled" services must be complex and sophisticated enough, or the condition of the patient complex enough, that the treatment could be safely and effectively performed only by a physical therapist or a physical therapist assistant. Below is an excerpt from a denial-of-payment letter from the Centers for Medicare and Medicaid Services (CMS) (emphasis added):
The progress made does not support the need for ongoing PT. The patient could have been placed on a maintenance program with periodic assessment to determine progress. No new therapeutic techniques, compensatory strategies, or effective cueing were identified or implemented during these service dates. The documentation failed to support that the services provided were at a level of complexity and sophistication that the unique skills of a licensed therapist were necessary for their delivery.
This statement supports progress; however, it emphasizes that the physical therapist failed to justify the "why you?" component of need. Place yourself in the shoes of the reviewer as you write the progress note. Ensure you not only describe what the patient did, but clearly and succinctly communicate what you measured, analyzed, adjusted, fabricated, adapted, facilitated, and/or educated, and that it was at such a level to require your skills and expertise. Make sure to include the tests and measures you use and relative comparisons to normal values for a population similar to your patient.
Payment Is Not Necessarily Linked to Patient Progress
Remember that progress alone is not a requirement for payment. CMS reminded us via the 2013 Jimmo Settlement Agreement that payment for skilled therapy services can be medically necessary not only to restore function but to maintain it or to prevent or slow deterioration. But to justify your services, documentation must state the expertise, knowledge, clinical judgement, and decision making used that only a physical therapist can provide. This is needed whether progress is noted or your skills and analysis are required to maintain or deter decline.
Consider the following examples of documentation to support the restoration of function or maintenance of mobility:
Important, But Unskilled
Demonstrates Skill and Expertise
|Patient ambulated 50' with a wheeled walker and minimal assistance.
||Minimal assist to ambulate 50’ with front-wheeled walker. Required manual facilitation to stabilize right pelvis/hip during stance phase and verbal cueing for right toe clearance during swing phase for safe forward mobility on level surfaces.
Documentation can be daunting, but you know your patient's medical, psychosocial, and environmental story. It's up to you to paint a complete picture of the episode of care for payers.
Donna Diedrich, PT, DPT, is vice president of clinical operations at Aegis Therapies. She is a board-certified clinical specialist in geriatric physical therapy. Jaclyn Warshauer, PT, is the national director of medical review and quality services at Aegis Therapies.
For more information on this topic, visit APTA's Defensible Documentation webpage.