The Importance of Documentation

If you haven’t heard, time and time and time again, our therapy documentation is of the utmost importance. Why, you ask? Well, you don’t go out to dinner or buy groceries without receiving a line-item receipt with costs associated. And I’m pretty certain you will not blindly provide your credit card number to a vendor without knowing what will be charged and what you will receive in return. The same principle is true for health care. We are obligated to provide a receipt to our payors and customers for services performedand it must be a very detailed receipt. Our documentation receipt has to be clear, support the services performed, demonstrate skilled service and be medically necessary. Yet many of us expect Medicare and other third-party payors to just trust our judgment and pay us what we think we deserve without providing a clear portrait.

No longer can health care providers be abstract artists. Payors and consumers are demanding improved quality, lower costs and more transparency.

The Centers for Medicare and Medicaid Services (CMS) has started the payment reform march by shifting from quantity/fee-for-service to quality/value-based health care. Therapy services are gradually moving towards the same payment methodology. Beginning January 1, 2017, occupational and physical therapists have new three-tiered evaluation codes. One reason for this is to acknowledge that patients vary due to comorbidities and other personal factors. Instead of just documenting the patient’s severity, intensity and complexity, we now have billable evaluation codes to further support our documentation and represent a clearer, more transparent, picture of our patient. Speech therapy went through similar evaluation code changes in 2014 by creating four new, more specific evaluation codes related to language, speech-sound production, voice and resonance and fluency disorders.

Can documentation and coding changes be burdensome, time-consuming and outright frustrating? Absolutely! So why should we care? Why put forth the effort? Quality documentation is of utmost importance because not only does it drive effective management and success in achieving a positive outcome for our patient, but it will also directly impact our future reimbursement. It is the building block for future payment methodologies. We must work toward consistent, well-written documentation along with accurate coding of our billable services so auditors and reviewers of our therapy claims don’t penalize us for poor documentation that doesn’t demonstrate reasonable and medically necessary care. We don’t want our services denied. We want them to say “Wow, we got our money’s worth! This is quality care!”

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