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Previous Compliance Matters columns have looked at the keys to effective documentation and at documenting the CPT® code descriptors that took effect on January 1, 2017—97161, 97162, and 97163 for evaluation, and 97194 for reevaluation.1,2 This article takes the discussion full circle by recapping that information, further contextualizing it, and sharing some setting-specific considerations from an updated APTA document.

It's easy to get caught up in terms such as "quality" and "value" when we talk about documentation, without stopping to think about what those words really mean. Sure, there are implications for billing and reimbursement, and, yes, there's even a specific Quality Payment Program under Medicare that has an array of component parts (see "Resources" on page 8). But the bottom line, and best way to think about what documentation is, is this: It should tell the clear and complete story of everything that's been done by the physical therapist (PT) and physical therapist assistant (PTA) to ensure that patients and clients achieve their best possible outcomes.

Documentation is much more than simply the means to a payment end. It's a written record that, properly completed, serves you, your patient or client, and the entire health care system by ensuring continuity of care and contributing data that will facilitate improved future access to physical therapy by chronicling its worth with facts and figures.

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  1. Evans WK. The keys to effective documentation. PT in Motion. 2016;8(7):8-12.
  2. Evans WK. Documenting the new evaluation codes. PT in Motion. 2017;9(2):8-13.

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