Objectives

Objectives of APTA's documentation guidance are to:

1. Raise awareness of physical therapists and physical therapist assistants about the areas of concern in physical therapy documentation.
2. Identify legal, regulatory, and payer requirements for clinical documentation.
3. Provide useable and clinically relevant tools and resources PTs and PTAs need to create documentation that will satisfy requirements.

Note: While it's as comprehensive as we can reasonably make it, this guidance cannot address every aspect of physical therapy documentation. Some specialized settings, practice arenas, regulations, and other areas may require additional types or components of documentation. Check specific compliance requirements of payers, third-party administrators, state laws, and accreditation organizations such as The Joint Commission and CARF.

Appropriate documentation of physical therapist services is crucial because it:

• Is a tool for the planning and provision of physical therapist services and is a communication vehicle among providers.
• Is a record of care provided, including a report of the individual's status, physical therapist management, and outcome of physical therapist intervention.
• May be used to demonstrate compliance with federal, state, payer, and local regulations.
• Provides a historical account of individual encounters that can be used as evidence in potential legal challenges.
• May be used by third-party payers to assess appropriateness of service utilization that is required for payment.
• May be used for policy or research purposes, including outcomes analysis.

Documentation to Reflect Best Practice

Health care consumers trust physical therapists to use their expert training to improve, maintain, restore, and enhance movement, activity, and health for optimal functioning and quality of life. While safety and quality of care is most important when caring for patients and clients, documentation throughout the episode of care is a professional responsibility and a legal requirement. It is also a tool to help ensure safety and the provision of high-quality care and to support payment of services.

To help protect against the risk of fraud, abuse, and waste, physical therapists incorporate evidence-based resources in clinical decision making whenever possible. Evidence-based practice includes the integration of best available evidence, clinical expertise, and the patient's or client's values and circumstances related to patient and client management, practice management, and health policy decision making.

Of course, before therapists can document evidence-based practice, they must first know how to integrate evidence into clinical practice.

Therapists can demonstrate evidence-based practice in their clinical documentation in various ways:

• By documenting tests and measures that are valid and reliable for diagnostic and/or prognostic information.
• Through the use of standardized outcome measures, which are an effective means of evaluating and communicating changes in a patient's/client's impairments and/ or functioning.
• By selecting and implementing an appropriate plan of care and interventions/treatments based on available evidence or clinical guidelines and that reflect patient perspectives and preferences and their influence on the plan of care.

Keeping up to date with current research and expert opinion may be difficult, but there are many tools available to make the process easier. While it is not the intent of Defensible Documentation to teach evidence-based practice, the following are some tools that can get you started:

• Clinical practice guidelines are intended to help clinicians improve patient outcomes and avoid unwarranted variation in practice. Find clinical practice guidelines.
• Systematic reviews compile and evalute the existing published research to determine whether there is conclusive evidence to support the use of a specific treatment or intervention. PTNow also includes Cochrane Reviews and ArticleSearch, a free-to-members source for full-text research articles from clinical and academic publications. Access ArticleSearch.
• Valid and reliable outcome measures, such as data being collected through the Physical Therapy Outcomes Registry, can increase the physical therapist's confidence when making decisions about a patient's or client's plan of care.
• APTA's Choosing Wisely recommendations are designed to spark discussion between the physical therapist and patient about the need — or lack thereof — for many tests or treatments that tend to be done frequently but whose usefulness in some scenarios has been called into question by evidence.

There is a cultural component to best practice that should not be overlooked. The perception of appropriate interaction between the PT and a patient or client and family members will vary among different cultures. These subtle variations require respect and consideration as they impact all aspects of the treatment process, including but not limited to gathering the patient or client history, establishing patient-centered goals, and interaction with the patient or client and family members during the course of care. This is a particularly important to address when treating a patient or client in the home setting.

Documentation for Payment

In most instances, third-party payers cover at least a portion of the cost of your patient's or client's physical therapist services. These payers include Medicare, Medicaid, workers compensation, automobile liability, the ACA exchanges, and private insurers. Prior to initiating treatment, it is essential for the physical therapy clinic to determine coverage limitations and payment policies of the respective payers. The federal government has adopted laws and regulations that apply to federal insurance programs, such as Medicare, and many states have enacted similar laws that apply to private payers. The federal government and other payers rely on physical therapists to exercise sound clinical judgment, provide appropriate services, and submit proper claims for payment with accurate information.

As the US health care system moves toward value-based payment, quality reporting is becoming ever more prominent, and proper documentation of reporting measures will have an increasing impact on adjustments to payments — both upward and downward. While PTs are not yet included in mandatory MIPS reporting within the Quality Payment Program, voluntary reporting and data collection now will help prepare you for the future, when PTs are expected to be subject to MIPS requirements. APTA has resources, tools, and other guidance on QPP and MIPS on the Quality Reporting Program webpage.

Claims Denials

Despite best efforts, claim denials still happen. Here are some steps for handling a denial:

• Establish a system at your facility to ensure immediate notification of any denials received for physical therapist services provided.
• Review the Explanation of Benefits (EOB) voucher. That voucher should have a code with a descriptor that states why a denial was made. Common denial language on the EOB includes “Documentation does not support the claim” or “Medical necessity is not supported by the documentation.”
• Review the claim form and documentation to see if there are grounds for an appeal.
• Appeals should be submitted in writing and not initiated over the phone. Submit in a timely fashion as specified on the EOB.
• Forward your documentation along with the letter of appeal but make sure the documentation supports your case. Rather than sending in documentation of only one day of service, send in documentation for dates of service both before and after the date in question, in addition to the most recent reevaluation or progress report. (Contact the contractor if you have any questions about what service dates to include). Include all supportive documentation to demonstrate the need for skilled services.
• You may choose to support your appeal with your state practice act. Resources to include are APTA's Standards of Practice (.pdf), a copy of the patient's or client's benefit language, and the records of any conversations that the office staff had with the payer's professional services personnel. For more information about Medicare's 5 levels of appeal, review the Medicare Learning Network's Medicare Parts A and B Appeals Process (.pdf).

For further information on managing claims denials and on billing in general, see APTA's Coding & Billing webpage.

Documentation for Risk Management and Compliance

Our health care system is complex. Ensuring compliance with federal laws and regulations is necessary to avoid fraud, abuse, and waste and to eliminate improper payments. Incorporating compliance principles as part of the practice culture can help prevent problems from occurring, speed and optimize payment of claims, reduce billing errors, mitigate the risk of an audit, and avoid conflicts with anti-kickback and self-referral laws. When they submit claims for services, PTs are attesting that the payment requested is accurate and that they are in compliance with all the billing requirements. Therefore, it is important to understand and remain current on the coverage and payment policies of Medicare, Medicaid, workers compensation, automobile liability, and private insurers. 

While the vast majority of health care providers are ethical and provide high-quality care, the few who abuse the system cost payers and consumers billions of dollars each year, and place beneficiaries' health at risk. Furthermore, beneficiaries who have had services billed improperly could later be subject to denials for medically necessary services. The prevalence of health care fraud, abuse, and waste has resulted in the need for laws, regulations, and other policies to prevent their occurrence.