Kristy Wikum, Centrex Rehab

Did you know that some of the earliest “medical records” date all the way back to around 1600 BC? Those of us who have either been around long enough or know our history recognize that healthcare providers have always maintained healthcare records to one degree or another.

With the upcoming new Medicare Patient-Driven Payment Model (PDPM) on the horizon, it’s wise to look again at the quality of your documentation and make sure that it supports what you communicate to payers and others. Whether supporting time spent (think group/concurrent rule under PDPM) or supporting functional levels and outcomes, documentation is essential for successful reimbursement.

Documentation offers an accurate representation of services provided to patients, supports services for reimbursement and serves as a medical-legal record.

In 2009, Congress authorized legislation labeled the Health Information Technology for Economic and Clinical Health Act to stimulate the conversion of paper medical records into electronic charts. Our experience at Centrex Rehab has been improved legibility, organization and quality of documentation when we transitioned to an electronic medical record.

As we move closer to value-based payment and a major reimbursement model change in October 2019, it is critical to document the outcomes we report to Medicare and others.

Ensuring quality documentation can also involve clinician support and training when some clinicians are resistant to point-of-service documentation.  Educating clinicians that contemporaneous documentation supports accuracy and subsequent support for functional ratings (think section GG of the Minimum Data Set Form)—and teaching the technique of triangulation (patient, clinician, computer form a triangle vs. a computer wall between patient and clinician) can go a long way toward accurate documentation and relationship building with the patient.

In skilled nursing communities where therapists work in discipline teams, documentation enables accurate intervention reproduction and progressions among different clinicians while educating patients about their interventions and performance.

Documentation may also be required to support a claim for  payer therapy benefits.

Here are steps a clinician can take to facilitate strong documentation:

Demonstrate the purpose of each piece of therapy documentation

Evaluation must demonstrate medical necessity for care; knowing and communicating this is as critical as a strong foundation for a practice

Treatment encounter must demonstrate two things:

  1. Skilled care – i.e. what was done for the patient versus simply a laundry list of what the patient performed
  2. Support accurate billing and time – documentation should support billed time and utilization of proper CPT codes for services

Next, the progress report and recertification notes must demonstrate justification of continued care; describe barriers to goals and plans of overcoming in addition to updating goals.     

The discharge note must update all goals and summarizes the episode of care; documentation supports why a discharge is recommended and provides support for a next level of care when indicated

Finally, Electronic Medical Records (EMR) often have “builder statements” or prefabricated statements that many clinicians will use; because these statements are general, it is often important to edit the statement and customize it to tell the story of your patient’s specific situation

These simple steps will help make life easier for you and everyone you serve, while supporting the advancement to PDPM and a value-based payment system.

Kristy Wikum, MS, CCC-SLP, has more than 25 years of management experience as CEO/ President of Centrex Rehab and former executive director at Augustana Therapy Services.

Clinical Physical Therapy Specialist Matthew Mesibov, PT, GCS is responsible for providing clinical support to the physical therapists and physical therapy assistants at Centrex Rehab.