Physical Therapy Documentation & Medical Billing INTOUCHEMR

HIPAA Regulations 101

by Nitin Chhoda PT, DPT | Aug 29, 2016 | Electronic Medical Records, Physical Therapy Documentation, Physical Therapy Management

HIPAA laws are designed to protect unauthorized access to a patient’s personal and medical information.

Nitin Chhoda elaborates on HIPAA regulations and how to comply with them to avoid fines and penalties in your practice, and the role that your electronic medical records (EMR) system plays in the process.

HIPAA or known as the Health Insurance Portability and Accountability Act of 1996 is something with which every therapist must be closely acquainted.

The act sets forth the rules regulating patient privacy and security, and the way personal health records are collected, maintained, used and shared.

Therapists are in possession of sensitive client data each day and clinic owners must take steps to safeguard the security of those documents. Practice owners that aren’t in compliance with HIPAA regulations will find themselves facing harsh and costly fines, along with civil and criminal penalties.

HIPAA Regulations

The HIPAA privacy rule protects patients by prohibiting the release or sharing of individually identifiable health information. It applies to all forms of communication, including oral, paper or electronic.

Protected data includes a patient’s past, present and future medical condition. It includes demographic information such as name, address, date of birth and insurer information. There are exclusions under HIPAA, but therapists must be absolutely sure they’re not violating the law. The parameters are quite narrow concerning the release of client data.

There are unique circumstances in which a patient’s data can be divulged. For example, if the president declares a state of emergency or the Secretary of Health and Human Services declares a public health emergency. The client’s own health information can be released to them if they make the request in writing. HIPAA also makes provision for the release of information to parents and legal guardians of minors.

The usage of unidentifiable information is more liberal. It can be disseminated when used for public health reasons and research. Data can also be included in a wide range of marketing efforts, as long as no data leads back to a specific client, including names, addresses, social security and insurer data.

State Laws and Disclosures

Therapists must also be cognizant of state laws of disclosure, always keeping in mind that HIPAA rules supersede state requirements.

Typically, states can divulge information to prevent payment fraud or abuse, for state reporting on healthcare costs and regulation of controlled substances.

As more clinicians implement electronic medical records, the question of documentation security will continue to grow and evolve to meet the changing needs of electronic medical record systems.

Physical therapy documentation software ensures practice owners are HIPAA-compliant, while providing superior security and safeguards. User login information and verification are required for authorized personnel.

The Connection between your EMR Provider and HIPAA

In an effort to comply with HIPAA requirements, consider the use of an EMR system. With a web-based system, records are maintained in the cloud instead of on local computers, laptops and tablets, where they’re safe from fires, floods and other natural disasters.

Server-based systems are kept and maintained on-site. Therapists run the risk of having equipment stolen that contains personally identifiable patient information. Identity theft and disgruntled employees also place records in danger.

Complying with HIPAA guidelines isn’t optional, it’s the law. It’s one that can cost practices dearly if patient information isn’t adequately protected and is inadvertently made available to unauthorized third parties.

Recent penalties for infractions ranging up to $1 million amply demonstrate this. It highlights the need for clinicians to ensure staff members are trained in privacy regulations and procedures. Even innocent mistakes could lead to penalties that can cripple a private practice.

EMR Adoption, Selection and Implementation Checklist

by Nitin Chhoda PT, DPT | Aug 22, 2016 | Electronic Medical Records, Physical Therapy Billing, Physical Therapy Documentation

If you are switching from one EMR system to another, you need to consider several factors including portability, integration and security.

Nitin Chhoda provides a detailed checklist to help you make the transition to an EMR system that will help you prepare for the future, streamline and automate your practice.

The selection of electronic medical records system is one of the most important decisions a practice owner will make over the next two years. It will affect every aspect of the clinic, from communicating with patients to submitting reimbursement claims.

With hundreds of available EMR options available, selecting a documentation software system can be an exhausting and confusing process without a well-thought action plan and clear expectations of what the system will accomplish. Look for the following features in an EMR.

Evaluation – Decide what the EMR is expected to accomplish within the clinic.
Teamwork – Form a team to evaluate the different EMRs and report back to the final decision makers.
Specialization – Choose a documentation system specifically designed for physical therapy practices.
Privacy and security – To maintain HIPAA compliance, therapists must ensure their EMR meets stringent requirements to safeguard personal health information. Practice owners that fail to do so will find themselves faced with costly fines, along with civil and criminal charges.
Customization – Physical therapy practices have unique need and an EMR should allow clinicians to create custom documents and templates.
Web-based – Select a web-based system that stores information in the cloud to eliminate the dangers of fires, floods, natural disasters and identify theft.
Workflow integration – Some therapists are attached to their existing systems and don’t want to give them up.

Choose an EMR that integrates any existing office software and offers the ability to remove old systems easily should they no longer be wanted or needed.

Portability – iPad compatibility is essential for portability throughout the office, at home and other venues where the clinic offers services.
Electronic billing – An EMR equipped with electronic billing reduces the turnaround time on reimbursement claims and allows for the quick submission of documentation and resolution of denials.
Communication – Interacting with clients can be automated to deliver appointment and billing reminders. Communications can be sent via email, phone, and text and voice messaging.
Patient portal – Clients can schedule an appointment, view test results, complete health histories and provide insurance information with a patient portal. Therapists can easily verify insurer information and contact patients if there’s a problem.
Prescriptions – The ability to submit medication orders to a wide variety of pharmacies saves time for therapists and patients.
Interconnectivity – Tests, x-rays and lab work from outside facilities can all be ordered from the office with an EMR. Therapists should ensure their EMR is compatible with other facilities in the area. Results can easily be returned to the office electronically and posted through a patient portal where clients can view them.

Importation capabilities – EMRs are designed to eliminate voluminous paper files, but the information contained within existing documents must find its way into the documentation software. It’s essential that the EMR offer the ability to import notes, documents and test results for a complete electronic solution.
Online training – Staff must be trained in the use of an EMR, but training provided by vendors often results in an overload for staff. Online training can be accessed multiple times and whenever it’s needed to reduce the learning curve and assist staff in retaining more information.
Customer service – Choose an EMR that provides automatic updates, 24/7 support, regular back-ups, and the ability to upgrade and add new modules as needed.

The idea of implementing an EMR can be a scary thought and has led many professionals to delay the process.

An electronic documentation system must be in place by 2014 and therapists need to initiate the search for a suitable EMR as soon as possible to ensure sufficient learning and shake down time before the deadline.

Physical Therapy Documentation: Productivity Benchmarks in Your Documentation System

by Nitin Chhoda PT, DPT | Aug 16, 2016 | Physical Therapy Billing, Physical Therapy Documentation, Physical Therapy Management

If your practice is still using pen and paper, the thought of electronic medical records can be daunting.

Nitin Chhoda explains how to boost productivity using a web-based documentation system to make life easy for the practice owner, the staff and the biller.

Productivity is a key element in all facets of a physical therapy practice, from obtaining vital patient information to receiving reimbursements.

For a struggling clinic, an increase in productivity can mean the difference between eliminating positions to hiring new staff that can help the practice grow.

Physical therapy documentation software provides automation of tasks for increased productivity for every member of a clinic’s team.

As new treatments become available and reimbursement regulations escalate, an EMR provides better and more elaborate coding and physical therapy documentation options to satisfy third-party payer provisions.

Physical Therapy Documentation

Every therapist has experienced the time consuming process of recording, rebilling and providing explanations to insurance companies, Medicare and Medicaid. EMRs offer multiple coding abilities for practices working with an extensive array of providers to ensure therapists are adequately paid and clients receive ongoing care.

Employee wages constitute one of the largest expenses for a physical therapy practice. Clinic owners can utilize their physical therapy documentation software to ascertain where the abilities of staff members can best be allocated. An EMR helps therapists ascertain if they’re overstaffed, identify time wasters, and where positions can be eliminated for greater overall productivity.

Patient Scheduling

A full patient schedule is one of the goals of a productive practice and a physical therapy documentation system provides essential information therapists can use to market their clinic successfully. Referrals can be monitored and marketing efforts tracked to ascertain methods that work best based on a variety of demographics.

An EMR provides improved patient management, eliminating duplication of testing, prescriptions and treatments. Lost charts and missing information is never a problem with physical therapy documentation software.

A secure patient record is created that can be accessed by numerous medical professionals and quickly updated as surgeries, procedures, prescriptions and treatments are implemented.

Patient care can begin immediately instead of waiting for essential records to be transported by the postal service.

The Advantage of a Physical Therapy Documentation Software

Those in the medical professions have notoriously bad handwriting that’s eliminated with an EMR. Personal notes can be added with no loss of legibility.

Therapists work with a wide variety of incidental documents that includes work and school excuses, referral letters and requests for records. Physical therapy documentation software allows therapists to produce and transmit those and a myriad of other documents with just a few clicks.

There’s no need to maintain copious amounts of physical therapy documentation paper-based records, space to house them, or engage staff in the time consuming task of finding them with an EMR.

‘Patient information is available at a moment’s notice anywhere an Internet connection is available, reducing the time needed to implement a course of treatment. EMRs speak for a patient in an emergency, preventing errors or inappropriate treatment.

Clients like the convenience of patient portals with physical therapy documentation software, but patient portals save significant time and effort for therapists. Insurance information can be validated prior to services and a complete health history can be submitted, allowing practice owners to familiarize themselves with the client’s data and formulate possible options.

The highest level of productivity is necessary for clinics to survive and thrive and EMRs provide practices with the tools to achieve that, along with tools to analyze trends and the productivity of their entire business operation.

Physical Therapy Billing: On-Site Patient Credit Card Processing

by Nitin Chhoda PT, DPT | Aug 8, 2016 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

The ability to accept credit or debit cards as a form of payment for physical therapy services rendered can boost practice revenue.

Presenting patients with simple, convenient ways to make payments and recurring payments if necessary is a way for a practice to minimize accounts receivables and increase cashflow, according to Nitin Chhoda

Credit and debit cards represent one of the most convenient and easy way for patients to pay their bills, while providing practices with a point-of-purchase solution to collect funds before the client exits the clinic.

Physical therapy billing allows patients to make one time and recurring payments at the office and online to boost revenues. Patients are much more likely to relinquish co-pays and fund their healthcare costs if all they must do is provide their credit or debit card information.

Ease of Access

Convenience is the keyword for the 21st century clinic. Today’s population is busy and mobile, with little time left after meeting, work, and family obligations. Few clients carry cash with them nowadays, but virtually everyone has a credit, debit or pre-paid card.

It’s a trend that therapists can utilize to their physical therapy billing advantage. For those who want to move into the electronic age of physical therapy billing,coding and collections, an EMR is the first step. Financial institutions have offered online payment options as a courtesy for their members for years.

EMRs provide the same service through patient portals where clients can make a one-time or recurring payment without the need to enter extensive billing information.

Payments Made Simple With the Help of EMR

EMRs allow patients to make physical therapy billing payments from home or from their mobile devices, and funds can be transferred into the clinic’s account in as little as 48 hours. Practice owners can offer a variety of incentives to patients who pay with their cards, from special discounts to membership programs.

Many credit card issuers offer their own incentives, and when combined with offers from a practice, it provides additional motivation to pay early and often. A physical therapy practice is a business and clinic owners must look at every available avenue to collect for their services.

Therapists can immediately determine if funds from physical therapy billing are available so as to initiate a transfer if payments are made at the office.

An EMR with a patient portal allows individuals to pay their bills and manage their financial obligations to the practice more effectively.

The ability to accept credit and debit cards can increase revenue by as much as 23 percent. Instead of waiting up to 90 days for a check to clear, funds can be deposited directly into the clinic’s account for better cash flow. Credit card processing becomes an automatic physical therapy billing process for savings in time and effort.

The Convenience of Using Credit Card

Accepting credit cards via an EMR is an environmentally desirable solution that saves natural resources and cuts costs for practices. The ability to accept credit cards provides a speedy, flexible and convenient means of delivering a superior level of customer service.

Clinics also gain credibility from established and potential patients. Therapists utilizing physical therapy billing software contained within an EMR are perceived as the most modern and desired therapists. An EMR with physical therapy billing capabilities provides convenience for patients and increased cash flow for clinics.

Credit and debit card processing for one time and recurring payments enables practices to collect quickly for their physical therapy billing services and are perceived better by patients, leading to clients who enthusiastically recommend the practice to family, friends and co-workers. Combined with real time, automatic claim submissions, therapists can significantly boost their cash flow, even in a vexing economic climate.

Physical Therapy Billing: Real Time, Automatic Claim Submission to Boost Cash Flow Reiterated

by Nitin Chhoda PT, DPT | Aug 1, 2016 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation, Physical Therapy Management

Paper-based physical therapy billing not only consumes a lot of time but is also prone to claim submission errors that will affect the practice’s revenue.

Nitin Chhoda shares how an integrated physical therapy EMR can produced automated claim submissions and boost cash flow for your business.

A steady cash flow is a primary concern for any physical therapy practice and it’s one of the most difficult aspects for clinic owners to predict.

Coding errors, claim denials and time spent exchanging correspondence via the postal service reduce the turnaround time on physical therapy billing reimbursements and can quickly place a clinic in the red.

Billing with EMR

The future for physical therapy practices of all sizes is good physical therapy billing through the utilization of an EMR.

They offer superior coding options to reduce denials and errors, while providing paperless electronic claim submissions that reach their destination almost instantly.

Submissions can be transmitted individually as clients are seen or set for a batch submission at the end of the day.

One of the biggest problems facing practices is the need for proper coding and documentation in the claims process to ensure clinics receive the reimbursements to which they’re entitled. Information management is a hallmark of automatic claim submissions, providing crucial physical therapy billing and documentation to facilitate and accelerate the reimbursement process.

Paper Submissions are Reduced

Electronic submissions reduce the need for paper physical therapy billing and invoicing for significant savings and can reduce associated costs by up to 15 percent over traditional methods. Electronic submissions are environmentally friendly, highly efficient and enable therapists to collect for their services in hours instead of weeks.

Funds are automatically deposited in the practice’s account. Coding errors are the bane of a physical therapy clinic and electronic claim submissions offers a wide variety of options to accommodate physical therapy billing by the session, services rendered or treatment setting.

Electronic claim submissions via EMRs are secure and HIPAA-compliant. Claims can be sent virtually to any agency or payer with which therapists work, from private insurance, Workers’ Compensation and TRICARE for veterans to Medicare, Medicaid and clearinghouses.

Software for Physical Therapy Billing

Physical therapy billing software can virtually eliminate coding errors and drastically reduces the number of denials, post-payment audits and requests for clarification.

When an instance does occur, disputes can be handled quickly and efficiently through electronic methods.

EMR documentation software provides a clear record of the patient’s visit so therapists don’t inadvertently submit claims that contradict coding and billing rules or lack specific billing codes.

Electronic claim submission capabilities allow clinic owners to file for reimbursement from any location with Internet access. The system enables payers to deliver crucial correspondence and responses through the same claim submission system.

Automated Physical Therapy Billing

An automatic physical therapy billing record is created of what was filed and when, along with the current status of the claim. Ceilings on payments and reduced benefits for employee insurance programs are costing practices dearly.

Physical therapy billing software enables clinic staff to verify a patient’s insurance eligibility and range of coverage before they arrive at the office. Therapists can utilize that information to develop a treatment plan that falls within the constraints of the client’s available coverage.

Automatic claim submissions provide enhanced coding options to boost reimbursement levels. Submissions can be set to send individually, or as a batch at the end of the day for added convenience.

Physical therapy billing allows therapists to receive payments in hours or a matter of days instead of weeks for better overall cash flow. Superior speed and documentation significantly reduces errors, denials and audits, while placing more cash in clinic coffers where it can do the most good for the practice and patients.

Medical Coding and Its Trends

by Nitin Chhoda PT, DPT | Jul 25, 2016 | Electronic Medical Records, Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

Medical coding can be done by a skilled professional or by a trained physical therapy billing staff. It is important that who ever is assigned this task is knowledgeable and detail oriented because it affects the billing and revenue cycle for the practice.

Nitin Chhoda shares the latest trends in medical coding and the role of ICD-10 codes to the medical practices.

Incorrect medical coding costs small practices thousands in revenues each year. Medical coding can be a tricky process and requires the expertise of a trained professional, even with an EMR.

Physical therapy billing software will significantly reduce the number of errors and denials, but with upcoming changes in billing codes, clinic owners may want to consider hiring a certified medical coder.

Medical Coding and Billing

Medical coding is a complex and demanding environment requiring someone with special knowledge and expertise, and who is detail oriented. Some practices combine their billing and coding departments under the guidance of a single person.

A good physical therapy documentation system will include billing and coding functionalities that makes a coder’s job easier, but then clinicians must decide if they’re going to hire a certified medical coder or train one themselves.

Even with a top of the line EMR, nothing can replace the expertise that comes with an experienced and certified medical coder. They undergo extensive education and training, build upon their expertise with on-going re-certification courses, and are fully able to navigate changes and updates in the coding system as they occur.

They command more money for their medical coding services, but trying to train a new coder is time consuming and can cost the practice thousands of dollars while they learn.

The Coding Process

The introduction of EMRs adds another level of difficulty to the billing and medical coding process.

An EMR greatly facilitates the job of a professional coder, allowing them to maintain a constant rate of concurrent billing and coding procedures, reducing the ebb and flow of payments that can severely interrupt a practice’s financial health.

A factor that will radically affect the billing and medical coding process is the switch from ICD-9 to ICD-10 codes in October 2013 that will introduce 100,000 new codes into the existing system of 13,600.

medical coding trends Correct coding is difficult enough – the on-going educational requirements for professional coders will make it easy for them to handle the many changes and updates.

The medical coding changes will affect every medical provider in the country and represents the first comprehensive update since 1977.

The coding changes take into account new diseases that have been discovered, a better understanding of old ailments, new medications and vaccines, and the effectiveness of those medications in treatment.

With mutating viruses and diseases that can be communicated among species, the coding change is long overdue. Global travel and journeys to under-developed countries sets the perfect stage for pandemics.

Switching to ICD-10 Codes

The switch to ICD-10 codes will help all practices provide medical coding that more accurately reflect treatments and procedures. The result is better patient care, quicker reimbursements and fewer denials.

The future is bright for professional medical coders. Their extensive medical coding training is a distinct advantage for practice owners who benefit from their expertise. Better medical coding means better and faster reimbursements, fewer denials, mistakes and errors, and issues can be dealt with quickly and efficiently. EMRs will help medical coders accomplish those goals in an expeditious manner.

EMRs will soon be a fact for every physical therapy practice. Clinic owners who implement an EMR system with correct medical coding will be ahead of the game when the coding changes take effect. Professional coders will play a major role in ensuring that clinicians are compensated for their time and services.