physical therapy documentation

Electronic Medical Records and Its Role in Patient Billing

by Nitin Chhoda PT, DPT | Jul 29, 2013 | Electronic Medical Records, Physical Therapy Billing, Physical Therapy Documentation, Physical Therapy Software

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. Nitin Chhoda discusses how electronic medical records system (EMRs) simplifies billing for both physical therapists and patients in a variety of ways.

Patient income has long been the lifeblood of medical providers. Effective physical therapy billing is a highly necessary procedure for physical therapists in particular, as some patients may have sessions last over a period of several months.

Versatile Billing

Electronic medical records allow patients to make payments on their own time with a push of a button. Today’s consumers are used to online billing for various services.

However, some medical providers still insist on paper bills. Online billing through an electronic medical records system allows patients to make either one-time payments, ongoing payments, and sometimes participate in automatic billing via credit or debit card.

EMRs make it easier for both patient and physical therapist. If a physical therapist would like to move into online billing, electronic medical records system is a logical step.

Instant Transactions

Prior to online billing, physical therapist billing used to involve mailed checks or credit card payments taken over the phone. Both of these practices took office assistants’ time to manage billing, and involved a lot of upkeep.

However, with electronic medical records, physical therapists can receive their funding in as little as 48 hours. Consumers are also able to pay on a variety of devices, such as phone or tablet, without waiting for a paper bill. Providers can increase their income by 23% by adding the ability to receive credit card payments, and EMRs provides that opportunity.

Electronic medical records represent a new wave in improved patient care and physical therapist billing.

Physical therapists who are looking to streamline their practice in income and medical records should consider using EMRs.

As one of the facets of the changing face of healthcare, electronic medical records are an essential tool for the survival of a physical therapist office.

EMR: The Changing Face of Healthcare Management

by Nitin Chhoda PT, DPT | Jul 23, 2013 | Physical Therapy

EMR facilitates office processes, expedites revenues and enhances the quality of client care. These are just some of the advantages why Nitin Chhoda wants physical therapists and private practice owners need to implement an electronic medical record system now.

Throughout the years as technology evolved, healthcare management has adapted to meet the changing capabilities of the system.

Before a new eave of technological advances, offices were forced to rely on paper medical records, handwritten, and susceptible to casualty or loss.

These boxes and file cabinets filled back rooms of physical therapists’ offices. If the documents remained safe in the office, they were still at risk of being read by an individual who could compromise the patient information.

Now a new era of medical records has arrived called electronic medical records (EMRs). It has streamlined every facet of the healthcare practice, no longer forcing offices to rely on paper records

New Flow of Communication
Physical therapist and other private practice offices used to rely on postal system and copier to transfer information to other practices. The ability to fax records helped speed up the process but it still took time. If a patient relocated for employment or family, the patient’s medical records had to be transferred as well, a cumbersome practice that could take weeks or months of sorting, copying, billing for copies, and mailing.

With EMR, records are stored in the “cloud” or a healthcare database from which a physician can easily access a new patient’s previous records. EMR also allow doctors and physical therapists to coordinate treatment of their mutual patients, and the information is updated immediately.

Cost-Saving Procedure
Paying an employee to keep medical records can cost a physical therapist or provider up to $15 per hour. With new EMR software, medical records are kept easier and faster, and readily accessible to any individual in the office with the touch of a button.

Improved Physical Therapy Documentation for Third Parties
In the days before advanced technology, retrieving physical therapy documentation was a tedious practice. Insurance agencies were forced to rely on photocopied records or faxed copies. This delay in processing slowed the entire system. Personal injury attorneys had to retrieve a signed HIPAA from a patient, individually contacting each medical provider for patient records for legal analysis.

Now with EMR, attorneys can simply fill out a request form, and have the information provided within a few a days.

Streamlined Billing Practice
In the pre-EMR days, physical therapist billing used to be a shaky process at best. Providers had to submit individually to each insurance agency, and wait for the results. Few patients had insurance and if treatment was covered by a government agency, the waiting time doubled.

Income was precarious due to the long response time. Now EMR system allows physical therapist and other providers to bill with a few clicks, and insurance agencies are instantly notified with invoices. Gone are the days of billing via mail for insurance and individuals, payment processing is now available online.

EMR opens a new way of communication and billing process for patients, insurance agencies, and third parties. In the evolving body of healthcare, EMR improves the treatment of patients with up-to-date information.

As more providers embrace technology, EMR is also available on tablets and mobile phones, for instant consultation.

Physical Therapy Documentation: Productivity Benchmarks in Your Documentation System

by Nitin Chhoda PT, DPT | Dec 25, 2012 | Physical Therapy

Nitin Chhoda discusses how setting benchmarks will allow your physical therapy documentation and practice to become more productive.

Keeping track of productivity benchmarks should be the priority of any physical therapy practice that wants to make the most of time management strategies.

Efficiency and productivity are not always easy to measure, but with a few benchmarks included in your physical therapy documentation system, you will be able to view reports on how everyone is measuring up to expectations and goals.

Benchmarks for Determining Optimal Operational Levels

One way that benchmarks in physical therapy documentation can serve to improve productivity is to measure the productivity of providers. This can be a difficult line to draw, especially without any basis for comparison.

An EMR reporting system can help determine what the average number of patients per day is, as well as patients per day per physical therapist. But even then, you are relying on numbers without much context.

Because physical therapy documentation is so closely aligned with billing, one way to measure productivity is to track weighted procedures per provider work hour or weighted procedures per visit.

Weighted procedures are used by billing staff to determine which CPT billing codes to use, and those codes give a specific financial value to each appointment.

Using these numbers, you can come up with a much more precise measurement of productivity. Rather than just focusing on visits per day, which may have varying values depending on the visit, you can focus on the amount of billable work that is being done each day or even each hour.

The challenge is to come up with a quick and realistic system physical therapy documentation for collecting the data and measuring them against your goals or expectations.

Visits Per Patient and Cancellation Rates

Another measure of the productivity of a physical therapy documentation practice will be in the success the practice has with each individual patient.

Do many of your patients “self-discharge” before completing their anticipated number of appointments?

How often do you have no-shows or last minute cancellations? Are patients being discharged early because you cannot schedule new patients?

The average physical therapy documentation series will last for 9 appointments, depending on many factors, including diagnosis and affordability for the patient. However, 9 visits is an appropriate benchmark for practice management to anticipate and aim for.

Payments Per Weighted Procedure and Per Visit

Payments per weighted procedure and per visit can be dramatically different depending on where your physical therapy documentation practice is located and the productivity of each visit.

These two numbers should be used together as benchmarks for success. Let’s say you have a goal of averaging $90 per visit. If one physical therapists only bills for three weighted procedures, but another bills for four, the amount per visit will be dramatically different for the two providers.

The physical therapy documentation payment per weighted procedure amount is critical to these calculations. If you know what you can bill for, you can design the treatment plan around weighted procedures that can be billed to the insurance companies you work with. Setting benchmarks will allow your physical therapy documentation and practice to use that information and become more productive.

Physical Therapy Documentation: Web-Based Versus Server-Based EMR Systems

by Nitin Chhoda PT, DPT | Dec 17, 2012 | Physical Therapy

Nitin Chhoda shares the advantages and disadvantages of a web-based and server-based electronic medical records. These two types of physical therapy documentation can be very useful depending on the needs of the practice.

Practices who want to adopt an EMR physical therapy documentation system find out that there are more and more options to choose from.

Many offer similar features but perhaps the interface is better or worse depending on the development.

For most physical therapy documentation and practice management professionals, the decision will take some time to make and there will be a lot of factors to weigh.

One decision you can make up front so that your field of options is narrowed is to decide whether your practice will benefit from a web-based EMR or an in-house server-based EMR.

Pros of Web-Based EMRs

Web-based EMRs offer a number of benefits that help make the decision easy for some practices. First of all, investing in an EMR that has consistency and has been road-tested feels safer and more secure.

Web-based physical therapy documentation solutions will operate from the cloud, meaning that all of the information is stored in more than one place. You never have to worry about the server going down if the EMR company offers the highest quality of services.

Additionally, the cost and headache of maintaining a system is handled by the EMR company. Your physical therapy documentation software is maintained and updated, while the servers are well taken care of by the best IT professionals of the provider.

Pros of Server-Based EMRs

On the other hand, an in-house server gives you the control and comfort of knowing that your physical therapy documentation is right where you want it to be. You can get a back-up server to protect from down time and you can probably find a reasonable IT company that can maintain your server for you. In-house servers will be faster and will never rely on the Internet to be usable.

For large practices, a server-based physical therapy documentation EMR is usually a better option, because the costs of maintaining the system are much more reasonable compared to the benefit of having a slightly faster and more capable system.

Cons of Both Systems

For a smaller office, the cost of maintaining a physical therapy documentation server in-house may seem prohibitive.

Even if you could work out a cheaper system in-house, you still have the stress and headaches of dealing with problems and ensuring that the system is secure and always working correctly.

With HIPAA and the HITECH Act, there are more and more physical therapy documentation regulations that will be enforced, which dictate exactly how secure your server must be. A small office will put in a significant investment for only minor gains with an in-house server.

But a web-based server does rely on the Internet, so there will be infrastructure choices to make. The downside of a web-based solution is that you may end up paying a monthly fee for a slightly slower service that is not as snappy.

But your physical therapy documentation staff may or may not notice the difference, and the convenience of portability cannot be undervalued. Figuring out which system is best for your practice will be the big challenge.

EMR Solutions and Its Importance

by Nitin Chhoda PT, DPT | Oct 24, 2012 | Physical Therapy

Physical therapy businesses are not for healthcare purposes only. In order to easily adapt to the modern technology that private practice owners are experiencing today, Nitin Chhoda shares the importance of using the latest physical therapy software called EMR.

EMR solutions of the first software developers are being created into a simple solution to a simple problem. How can you improve communication between various entities using technology?

Much of the infrastructure already exists; you can send an email in an instant and online security has improved to a standard that can handle sensitive medical information.

But today, rather than just being able to communicate quickly and effectively, EMR solutions are much more complex.

You want to be able to improve efficiency between the medical billing department and the work of doctors or clinicians.

You want clinicians to have easy and intuitive access to patient files. You want insurance claim submission to be smoother and error-free.

What an EMR Should Be

To get all of these benefits from an EMR, the software has to be intuitive, customizable, well integrated, and portable. The best electronic medical records solutions out there can be used by clinicians holding tablet computers at the same time as the medical billing staff is receiving automatic notifications about claims that need to be followed-up.

The reception staff should be relying on the clinicians to review electronic medical records when the EMR sends an alert about the next appointment. Everyone who works in a medical facility or private practice should benefit from an EMR. Efficiency and time management can be optimized with a technological solution like a customizable EMR.

After all, the reason we use technology is so we can reduce the amount of work that the staff needs to do.

If an EMR is doing some of the simple tasks, like storing all medical records in an easy-to-access place, the staff doesn’t have to find and file records all day long.

Is it Really That Easy?

There are plenty of challenges involved in implementing a fully integrated EMR solution. One of the most obvious will be the financial challenge.

How do you budget for this kind of broad, sweeping change throughout the practice?

The good news is that you won’t be the first; others have gone before you and have learned a lot from the process of selecting and implementing medical EMR solutions.

Implementation will be a challenge and there will be an adjustment period. But those temporary inconveniences are nothing compared to falling behind when the rest of the market is moving towards digital records and information management.

Adapt to Modern Technology

If your practice doesn’t put forth an image of modernity and if your practice cannot adapt, the cost of foregoing implementation of an EMR will be much higher.

Unfortunately, healthcare today isn’t just a matter of helping people to improve their health. Healthcare is a competitive industry that is bogged down by an unfair disadvantage. The patients who receive the service your practice provides are rarely the payers.

Medical practices have to rely heavily on the healthcare insurance industry, and health insurance companies are quick to reject or deny claims. Your practice needs an edge to stay afloat, and a portable, customizable EMR solution is that kind of edge.

CPT Codes — from the Medical Coder Perspective

by Nitin Chhoda PT, DPT | Aug 3, 2012 | Physical Therapy

Nitin Chhoda explains how medical billing and coding can be simplified with an integrated electronic medical records and billing system. The importance of communicating with patients and elaborating costs and financial responsibilities is also discussed.

CPT codes are pretty complex to use if you are unfamiliar with the process.

However, because they are so widely used, there have been many improvements in the way that medical coders and billers can access the codes they need.

Especially in an increasingly electronic age, CPT codes are only getting easier to use. Coding speed and accuracy can be increased with special physical therapy software that allows you to search for the right CPT codes quickly.

The most common reasons that insurance claims are rejected or denied have to do with incorrect coding or policy non-compliance. And every claim that has to be re-done makes the medical coding in your office slower and more costly.

With the Internet and software prices going down, these problems are being reduced for medical coding professionals and for the clinics that they work for. The high-end EMR solutions also include coding databases and can help improve efficiency and accuracy.

In order to draw more clients to use EMRs, software developers are learning to provide just what clinics and clinicians need from a complete electronic system.

Not Just CPT Codes – All Medical Coding

And of course, CPT codes are just one aspect of the job of a medical coder. CPT codes for Medicare are the same as certain HCPCS codes. Not every clinic will use all CPT codes, but only a certain sub-set. CPT codes list are only good if they are combined with the appropriate ICD codes when submitted with claims.

These kinds of important requirements keep medical coding staff very busy, which is one reason why many practices prefer to hire certified medical coders.

Communication with Patients

Another important way that CPT codes are used is in communication with patients. After a claim is filed and the insurance company responds with the amount they are covering, if there is any leftover amount it is up to the medical biller to bill the patient.

Patients usually find the medical billing paperwork to be confusing and overwhelming, especially patients who have recently undergone a medical procedure or have been diagnosed with a serious disease or condition.

Medical billing staff have to be able to communicate why certain CPT codes are used, why the insurance company did not cover the entire cost, and what the patient is responsible for paying.

Determining Future Costs

It can also be helpful if patients get an explanation about what future costs to expect due to discrepancies between the amount the insurance company will cover and the amount the patient has to pay.

CPT codes dictate how much a patient will be charged as well as how much the insurance company will pay.

The hope is that with a reasonable agreement between the health care provider and the insurance company, the patient will not be responsible for partial payments all the time. CPT codes can be used to ensure that pricing is consistent with the expected reimbursements from insurance companies as well as programs like Medicare and Medicaid.