physical therapy documentation

CPT Codes: What's In It?

by Nitin Chhoda PT, DPT | Aug 2, 2012 | Physical Therapy

CPT codes and ICD codes are the terms used when discussing medical situations, and are used by the insurance and medical billing companies as guides. Nitin Chhoda describes the categories and roles of these codes as they relate to the physical therapy business.

CPT stands for Current Procedural Teminology. The CPT codes have been set and maintained by the American Medical Association and they are updated every year in October.

One of the easiest ways to understand the CPT codes is to compare them to ICD codes. While ICD-10 codes identify the diagnosis of a patient, CPT codes identify the services rendered.

CPT codes are used by clinicians, medical billing and coding professionals, and patients, as well as accreditation organizations, as a standardized communication tool for talking about medical services.

In fact, the reason that CPT codes are so useful is that everyone uses them when referencing medical services. The most prominent uses are in medical coding and billing, when a clinic needs to bill an insurance provider or government program. Medicare and Medicaid are both billed using CPT codes list along with ICD-10 codes.

Categories and Sections

CPT codes come in three categories, Category I, II, and III. Category I is split into six sections: Codes for Evaluation and Management, such as home services, hospital observation services, or emergency dept services; Codes for Anesthesia, such as obstetric, head, or neck; Codes for Surgery, such as nervous system, digestive system, or general; Codes for Radiology, such as nuclear medicine, diagnostic ultrasound, or mammography; Codes for Pathology & Laboratory, such as drug testing, immunology, or transfusion medicine; and Codes for Medicine, such as dialysis, allergy & clinical immunology, acupuncture, and ophthalmology.

Categories II and III are a little different. Category II are CPT codes that measure performance and are entirely optional. Category III are CPT codes for emerging technology use.

Not Optional

CPT codes are required by health insurance companies, as well as Medicare and Medicaid, in order for medical or physical therapy billing to be successful.

Additionally, HIPAA requires that CPT codes are used as part of a national data standardization and collection effort.

However, the copyright for CPT codes is help by the American Medical Association (AMA). That means that anyone who uses the CPT codes must pay license fees. This usually falls on the shoulders of health care services providers.

Insurance companies and government programs also use CPT codes as a reference for the amount of reimbursement that the clinician or clinic is paid for services. Insurance companies will negotiate with health care service providers in order to determine the precise amount, but once the amount for a service is set, all both parties need to know is which CPT code to use and the payment can be made in the agreed upon amount.

Updates and Improvements

But paying for access to CPT codes isn’t all bad. The AMA maintains the system and ensures that updates are made every year. The resulting system provides all users with a way to share information quickly and in a standardized way. The AMA has workshops to get informed feedback in order to make the system easier to use. The uniformity that CPT codes provide benefits everyone who works in medicine.

Electronic Medical Records and Their Uses

by Nitin Chhoda PT, DPT | Jun 5, 2012 | Physical Therapy

Nitin Chhoda describes the many uses of electronic medical record system, and how it can help streamline the entire documentation process. Starting with the patient’s first appointment, down to the compliance requirements for Medicare.

Medical records are a critical part of any medical practice. It ensure that patients are given the right medications at the right time or that a physical therapy schedule is being followed accurately.

There are very specific rules about how medical records are kept, and in that past all medical records were kept on paper.

But today more and more medical offices, from dentists to physical therapists and physicians, are using electronic medical records or EMR.

Streamline the System

Electronic medical records for physical therapy services is one way to streamline the entire system of tracking patients. Physical therapy electronic medical records is making offices more efficient by decreasing the amount of paper records being printed and the amount of storage space needed to track patient progress.

With a growing and evolving set of physical therapy documentation software options, physical therapists are able to carefully track each patient in a quick and efficient manner.

Specific Benefits of Physical Therapy EMR

One major benefit of electronic medical records for physical therapy is that it maximizes the time that physical therapists can spend focused on their patients. Physical therapy documentation software makes it quick and easy to update a patient record and can make certain documentation as quick as hitting a button or tapping a check box on a laptop or tablet.

PT documentation software is portable, as long as you have an Internet connection and a device that you can access the web from.

Another benefit that will help patients immensely when using electronic medical records is the fact that it is easy to share information between offices when using physical therapy documentation software.

As a physical therapist, this can make your job easier and more efficient. If you have a patient who is in physical therapy due to an injury and they visit their doctor, too, your office and the doctor’s office can transfer pertinent information in an instant if you both use electronic medical records.

And finally, electronic medical records for physical therapy services make compliance with programs like Medicare simple and fast.

You can incorporate all kinds of alerts and schedules into your electronic medical records system so that when it’s time to report outcomes, your “paperwork” is set and ready to go.

PT documentation software offers a lot of scheduling solutions, including billing and reimbursement reminders. Plus the federal Electronic Health Records deadline from the HITECH Act is fast approaching, and getting electronic medical records for physical therapy services is a great way to transition starting right now.

Ease of Use is Key

While there are a lot of reasons to physical therapy documentation software, including the fact that you’ll save money, if it’s not easy to use your physical therapy electronic medical records system, it will feel more like a headache than relief.

Every change requires a transition period, and it might feel difficult while your office is learning to use the PT documentation software. But in the long run, everyone wins. Patient information in an electronic medical record system setting is more readily accessible to all health care professionals who care for them, which makes it easier to do your best for your patients.

Physical Therapy Management: Top Ten Benefits of EMR

by Nitin Chhoda PT, DPT | May 28, 2012 | Physical Therapy

Nitin Chhoda reveals the the top ten benefits to changing over your manual system to electronic medical records. These benefits will help increase your productivity and efficiency within your practice and allow your physical therapy business to thrive.

Top Ten Benefits of EMR

Better Record Keeping
Physical therapy management and documentation software makes it incredibly simple to keep a complete record of everything that your patient has been diagnosed with.

Whether you have prescribed a rigorous physical therapy regimen to help a patient recover from a nasty fall, or whether you are simply checking on a leg, you can keep better records using occupational therapy software.

Easier to Read
Doctors aren’t known for their stellar handwriting. Rather than risk that someone (including you) can’t read your handwriting, opt for a fully digital solution. Physical therapy management of EMR makes this simple, and makes reading the patient’s information simple.

Bill Quicker
Billing is probably not your favorite part of running an occupational therapy practice. But nonetheless, it is an important part of the job. Minimize the pain by minimizing the work. Physical therapy management and billing is made easy when you use physical therapy management software.

All the necessary information is kept on hand; from what the patient’s address is, to how much they owe you, to how long it takes them to pay. EMR can even handle alerts to remind you when to bill next.

Compete Documentation
Physical therapy management documentation is critical to providing thorough care. Make sure that every thought and note about a patient’s visit is fully documented by using physical therapy documentation software that comes integrated with most complete EMR solutions. All relevant information about every patient will be properly filed and easily accessible.

Easy Patient Management
Managing patients with paper records might be easy when you only have a few, but problems will start to arise as your practice grows. Simplify your patient management system by opting for a digital physical therapy management solution.

Send Records Quickly
Electronic records are far simpler to send than paper records. With paper, you will need to send a photocopy in the mail or fax a paper copy to another facility, where it will be printed out on paper. Doing that wastes time, money, and paper. With most physical therapy management EMR systems you can send the information digitally. It is virtually free to do so, and most facilities have at least one computer in the office.

Receive Records Quickly
Speaking of transfer of medical records, you can also receive digital records instantly with EMR software. And with decent EMR physical therapy management and software, you can even add that information to your own records. EMR makes getting information quick and painless.

Don’t Lose Records
Paper records have a bad habit of getting lost, misplaced, or damaged. Don’t let paper destroy your practice. Using physical therapy documentation software, you can keep track of every shred of information you have and store it securely online.

Scheduling Make Simple
Physical therapy management and scheduling is easy when the records are kept in the computer.

You can keep track of all your patients without worrying about the complexities of paper records.

An Integrated Practice
Physical therapy management software simply makes your physical therapy practice run more smoothly.

Look at all the benefits of running occupational therapy software! Your business will be revolutionized as everything is made more efficient with electronic medical records.

Electronic Medical Records System Top Five Tips

by Nitin Chhoda PT, DPT | May 26, 2012 | Physical Therapy

It’s not enough that your practice is switching to an electronic medical record system. The most important thing to remember when choosing a physical therapy software is that it will be able to meet your needs.

Price is not the only factor. Nitin Chhoda reviews the top five tips to choosing the right electronic medical records system for your practice.

Choosing an electronic medical records system for a physical therapy practice can be quite difficult.

There are hundreds of electronic medical records vendors, all vying for your attention. Often there is no clear advantage of one solution over another.

But the evaluation and comparison process is worth the time. Here are five tips to help you navigate the physical therapy electronic medical records (EMR) scene.

Choose Based on Price. For many firms, price is an important consideration. But sometimes the low price means bad design or fewer features. If an electronic medical record is able to successfully compete on price, then that product might just be good enough for your firm, but make sure you’re getting the features you need.

Focus on Design. Remember: you and your team are going to have to use this electronic medical records software every day. It should be intuitive and practical.That means no excessive clicks to get through note taking or record updates and an easy to understand interface.

The interface matters for physical therapy electronic medical records solutions, because if the program isn’t easy and fun to use, it will feel like more of a burden than a solution. A surprising number of electronic medical records vendors don’t focus on design and usability.

If nobody wants to use the electronic medical records (EMRs) software, it’s not worth buying. Oh, and watch out for the phrase “it’s only a click away!” Every click counts. Ideally it should already be on the page you are on.

Analytics are Important. You will be using your physical therapy documentation software to keep track of your patients. That also means that you need to be able to use it to get information back out.

Ideally you should be able to ask your physical therapy electronic medical records solution about your patient. What was prescribed, how many of a given type of injury have you dealt with, how a patient is progressing. Physical therapy documentation software is only as good as its ability to tell you that information.

Don’t Beta Test. You need software designed for electronic medical records of physical therapy. Don’t opt for a product that has seen enormous success in another medical field but hasn’t been tried in a physical therapy setting.

Every field is a little different, and physical therapists’ electronic medical records have different needs than more general doctors.Don’t let a salesmen talk you into PT documentation software that won’t do what you need just because either he or the software is slick.

Be Suspicious of Salesmen. This is probably the best advice that can be offered. The goal of a salesman is to sell you a product. As such, they will gloss over any flaws that their software has.

This isn’t a good thing, especially if they manage to convince you to adopt a product with a user interface your team can’t use.

But we have all dealt with salesmen before. As long as we guard ourselves against slick sales pitches and keep our eyes on the goal of finding the right electronic medical records for physical therapy, there shouldn’t be any problem. Just remember to try the electronic medical records software and have as many members of your team test it out before you decide to invest.

Electronic Medical Records Implementation for a Physical Therapy Practice

by Nitin Chhoda PT, DPT | May 20, 2012 | Physical Therapy

Nitin Chhoda shares several strategies to simplify and streamline the decision to adopt an electronic medical records system in your practice. The objective is to reduce the learning curve and allow your staff members to take full advantage of emerging technology.

The correct balance between hardware and software will allow the entire practice to become more efficient throughout the patient treatment cycle.

You have finally decided to take the plunge: to upgrade your practice with electronic medical records (EMR).

Electronic medical records will revolutionize how you run your practice and make life simpler for everyone who works in the office, from receptionists to physical therapists, as well as for your patients.

There are several benefits of electronic medical records, and their use in a physical therapy clinic is discussed elsewhere in this blog.

Tips on EMR Implementation

Implementing an electronic medical records system can be a little frightening. After all, you will probably be paying a fair sum of money to the vendor, and you need to know that the one you have implemented is right for you. Additionally, any transition can be difficult, as everyone will need to learn new strategies and give up their old habits.

Get your team used to using hardware

Sometimes, the implementation of an electronic medical records system may fail because the team that was supposed to use the system wasn’t comfortable with computer hardware.

If you have doctors, nurses, or any staff that don’t know how to use a computer, or aren’t skilled enough to operate the piece of software that they will be interacting with on a daily basis, you have some work to do.Don’t assume that your staff is ready. Make sure that they are.

Analyze your workflow

There’s no getting around it: an electronic medical records system is going to change how you work. You need to make sure that you – and everyone else in the office – are ready for that.
Analyze how your process currently works and talk about how it will change when you implement the EMR system.

Make sure that the process makes sense and work with the software vendor’s technical staff to make sure you understand how everything is meant to work.

Input all data

PT documentation software is only as good as the users who enter the records. Unless you add all of your paper records, your new EMR software might as well not exist.

You are upgrading to an electronic medical records system for a reason.

It may take some time, but the process of including all your patient information will mean that you won’t ever have to check in the physical records.

Because if you don’t, your staff is still going to have to check the physical records to make sure that all information has been accounted for, limiting the efficiency you are gaining.

Upgrade to the necessary hardware

This is a big one. While you can usually get away with running software on underpowered machines, it isn’t a good idea. You will have very little stability when using your electronic medical records software for your physical therapy clinic, if your computers are ancient and slow.

You will want to upgrade to hardware that will run the software optimally.Unless, of course, you are considering web-based electronic medical records solutions. These are frequently less taxing on the machine than localized PT documentation software. This is one of the major benefits of an electronic medical records system, in addition to the fact that you can pull up the data from anywhere.