Physical Therapy Documentation: The Importance of Operational Analysis For Your Practice

Physical Therapy Documentation: The Importance of Operational Analysis For Your Practice

Sometimes, more patients is not the answer, especially if the clinic is not sound from an operational and financial standpoint. To succeed as a practice, it’s important to work ‘smart’ and not just work ‘hard’, and enlisting your staff in your vision is a key component of the process.

In this article, Nitin Chhoda will teach how to improve your practice, operationally and financially by enlisting the help of your most valuable asset – your human capital.

physical therapy documentation operationsBefore you can step into the fray with staff and ask for a change of pace or even different physical therapy documentation procedures, a lot of operational analysis should be completed.

This involves reviewing reception staff efficiency as well as reception area capacity.

The physical therapists may be able to handle higher productivity, but without operational and financial analysis, you may be adding to the workload of other staff and decreasing productivity and efficiency in those realms.

Improving your bottom line should never get in the way of common sense when it comes to managing staff needs and expectations. Billing staff must also be evaluated and consulted about potential changes.

Managing Staff Correctly

If you want physical therapy documentation and billing staff to be able to bill more frequently, maximize claim acceptance, minimize errors, and collect payment more often and at a faster rate, overwhelming them with additional work will not get the job done. What will an increase in weighted procedures mean for coding and billing?

Every physical therapy documentation and management professional who is considering implementing a physical therapy documentation software solution has plenty to think about.

From the cost of the EMR to the implementation of policies and procedures that will actually make the practice more efficient, the job of transitioning a physical therapy practice over to electronic medical records is not simple.

The Staff Can Help

The truth is that physical therapy documentation and management is often quick to take on too much when the staff really can be helpful.

In terms of operational analysis, it will be the staff that bears the burden of operational changes. So it follows that the staff should be part of the process to make those changes logical, effective, and realistic.

Before implementing a new physical therapy documentation solution, the staff should be prepared sufficiently for their new responsibilities. Every staff member will need training to be able to use any new software.

But they will also need to know that the software is meant to make their jobs easier in the long run. The only way you can ensure that the EMR works in this way is to find out what the staff thinks will make their jobs easier.

Communicate Well With Your Staffphysical therapy documentation importance

It may take a one-by-one approach to determine where your operations are sufficiently prepared and where changes need to be made.

The conversation you have with physical therapy documentation and billing staff will be very different from the way the reception staff feel about changing work modes.

Will the reception staff feel good about handing patients an iPad rather than a clipboard? If the task of filing and pulling files is taken out of the job, will they appreciate and use that extra time sufficiently? How many tablet computers do they need?

Even simple questions about the number of clipboards they have now and how often they use them all can give physical therapy documentation and management insights into how the day-to-day tasks in the practice can be better managed using physical therapy documentation software.

Operational analysis is the process of identifying just what you have and what you will need to make things work well with your new system.

Physical Therapy Documentation: Productivity Benchmarks in Your Documentation System

Physical Therapy Documentation: Productivity Benchmarks in Your Documentation System

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

physical therapy documentation templatesKeeping 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 Ratesphysical therapy documentation benchmarks

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 Technological Advantages

Physical Therapy Documentation Technological Advantages

Nitin Chhoda says that by using the latest physical therapy documentation such as EMR, you will bring a lot of advantages to your practice. 

In addition, it can give consistent feedback to your software provider in order to continuously improve the system and reach your goals.

physical therapy documentation technologyEverything about your physical therapy documentation system should encourage the staff to work in a more streamlined and efficient manner. After all, technology is only as good as the users.

That means a lot of training should be part of the implementation process. But once the staff does get up to speed and starts to work seamlessly within an EMR, the improvements within the practice can be incredible.

Let Technology Do The Work

The whole idea behind updating your practice with the latest technological innovations is to improve the way your practice runs and improve your bottom line.

The way this works is that the technology takes some responsibilities away from staff and eliminates some tasks altogether. The EMR system or physical therapy documentation you choose should do the work for you and your staff so that you can focus on making and achieving your goals.

Features to look out for include website integration, instant intake forms, integrated patient portals and time stamping and clinical timer technology.

For improving management techniques and for big picture goals of the practice, look for advanced physical therapy documentation tools, intuitive and useful reporting capabilities, and feedback opportunities.

Feedback and Flexibility Translate to Longevity

Any physical therapy documentation tool should also be deeply flexible for the users from a development perspective. You should always have the option of giving feedback on the way aspects of the system work, and suggestions should be taken into account for updates.

The truth is that with high tech physical therapy documentation tools, the developers can and will improve upon the system regularly.

physical therapy documentation advantagesIf a software system is not going to be updated, and if there’s no way for your practice to give feedback on what works and what doesn’t work, be wary.

Although technology changes rapidly, you should be able to count on the company where you purchase your software from to be around for a while.

Physical therapy documentation software that is no longer being improved and supported will die quickly. Longevity will be key to getting the most from any system you invest in.

Well-Tended Information

The more efficiently you can manage physical therapy documentation information within your practice, the better your practice will perform. Customizable forms and templates for your information will allow you to dictate what will be the best set-up for your practice.

Additionally, a high quality EMR will help you to do as much as possible to avoid non-compliance issues.

Imagine that your physical therapy documentation software can help you to stay compliant with HIPAA and with regulations and policies related to submission of claims to both health insurance companies and to programs like Medicare and Medicaid. You rely on an EMR to not only manage information but to keep it safe and secure as well.

Everyone in the practice can have access to the information they need without compromising security. And of course, the physical therapy documentation and billing staff will be able to improve their claim acceptance rate. Which is where well-tended information creates improvements in the financial security of the practice.

Physical Therapy Documentation: The Importance Of Flexibility In The Documentation Process

Physical Therapy Documentation: The Importance Of Flexibility In The Documentation Process

Even if your practice is using the latest physical therapy software, it’s not enough that it’s automated and meets the standards. It should be flexible to what your practice needs.

Nitin Chhoda imparts the importance of software flexibility in order to maximize the use of your physical therapy EMR, and help your practice continually grow.

physical therapy documentation processWhile it is important to stick to certain standards of physical therapy documentation, your EMR should allow flexibility.

No two practices work in exactly the same way, so high quality physical therapy software will not restrict your documentation options.

To help make the practice truly more efficient, you will need customizable forms as well as integrated systems for the different aspects of the practice.

Platform Flexibility

Making the most of physical therapy documentation software will require that your practice has all the available tools with which to track patient progress, billing, and scheduling. That means investing in technological tools.

At first, you may not want to invest in portable electronic devices, such as tablet computers. You may feel that the staff can only make a few adjustments at a time, and you may want to wait for a bit of a financial shift before investing in these technologies.

However, if you want to make the most of the physical therapy documentation software that you are investing in, eventually you should allow it to be portable, too. Whether or not you’re ready now, the EMR should include options such as iPhone and iPad apps, cell phone alerts via SMS, and an online browser-based platform.

These options will allow scheduling, billing, and patient care to proceed smoothly and in a timely manner. Time stamping can be incorporated into the daily routine, no matter where a physical therapist is caring for a patient.

Reporting Flexibilityphysical therapy documentation flexibility

As you can probably imagine already, without flexible and intuitive physical therapy documentation reporting options, many of the benefits of physical therapy documentation software will be lost.

There are so many benefits to having accurate reports on productivity, claims acceptance rates, and referral rates and success, but if the reports system is hard to work with or requires a lot of time, the reporting capabilities will not be used to their maximum effect.

Reporting should be integrated in a way that allows practice management to cross-reference data.

Time stamping and number of patients should be integrated so you can identify the number of patients seen per day by each physical therapist.

Scheduling should also be linked to reports, so you can determine which patients frequently cancel appointments. Physical therapy documentation and billing claims should be reported so you can identify insurance companies that reject an unusually high percentage of claims.

Patient Interaction

Another way that physical therapy documentation and time management can be improved is through patient options. If you want to integrate a patient portal so patients have the option of entering their information online even before they come to the practice.

Intake forms should be flexible and available online or on mobile devices, so that patients have a more streamlined experience when they come for their appointment.

Customizable templates or forms are one of the most important features of any EMR and physical therapy documentation solution. But the entire physical therapy documentation software should be built with flexibility in mind so that you have the option to expand and grow.

Physical Therapy Documentation: Essential Components of Compliant

Physical Therapy Documentation: Essential Components of Compliant

In order to avoid malpractice and negligence of your practice, make sure that your documentation and management systems meet the required standards. Nitin Chhoda elaborates on the importance of being and remaining in compliant with the laws.

physical therapy documentation compliantPhysical therapy documentation isn’t just a tool for the physical therapists who work with patients, it is also critical to the success of the entire practice.

If physical therapy documentation standards are not set and maintained, errors in coding and billing are likely to occur and the practice will waste money and time on correcting rejected or denied claims.

There are legal requirements as well as insurance and government program requirements that need to be followed to ensure your physical therapy documentation is compliant.

Medicare Compliance

With the increased attention from the federal government, physical therapy documentation practices cannot afford to be incompliant with Medicare regulations.

In an effort to reduce waste and fraud, HIPAA and the HITECH Act give more power to regulation agencies so that the money spent on physical therapy actually goes to programs that are necessary and efficient.

Medicare defines skilled care and has requirements for what is deemed “reasonable and necessary” for physical therapy treatment.

If your practice does not use waivers and modifiers correctly or doesn’t supervise assistive personnel, you may be jeopardizing your Medicare reimbursements. Review of the minimal documentation requirements from Medicare is essential for all physical therapy staff.

Legal Compliance

The legal concerns of a physical therapy practice can be mitigated if physical therapy documentation standards are kept high. The dangers of noncompliance will not be revealed until it is too late. Most legal action against physical therapy offices will be related to negligence or malpractice, and noncompliance falls under both legal categories depending on the situation.

If a physical therapist is knowingly keeping poor physical therapy documentation and that leads to incorrect treatment of a patient, the therapist is liable for malpractice. If the practice management knows about the therapist’s actions and does nothing to avoid the situation, the practice is also liable.

And if records are poorly kept and an issue arises, whether or not the practice or the physical therapist is aware of the problem, either or both can be liable for negligence.

Insurance Company Compliancephysical therapy documentation essentials

Insurance companies seem to be looking for any reason to reject or deny a claim.

In the current system, it is absolutely necessary that your practice follow the particular rules set by insurance companies, otherwise you may find that you are billing and never getting compensated.

Some companies require reevaluations on a regular basis, to determine that care is still required and that the current treatment plan is having a positive effect. Other companies may have different physical therapy documentation policies.

The only way to avoid losing money is to check the rules beforehand and be sure that each physical therapist or staff knows what those requirements are.

Staying Compliant Mean High Standards

The best way to avoid a bad situation, whether to do with legal or healthcare insurance compliance, is to keep high standards of physical therapy documentation as the norm within the practice.

There are a number of ways that staff can be encouraged to learn and improve their physical therapy documentation practices, and it is the management’s role to ensure that standards are maintained.

Physical Therapy Documentation Stages

Physical Therapy Documentation Stages

Nitin Chhoda explains the different stages of physical therapy documentation.  Pointing out important guidelines to follow to ensure a smooth documentation process and avoid redundancy.

physical therapy documentation stagesThe speed of physical therapy documentation with which a patient recovers with physical therapy is determined by many factors.

But one thing that physical therapists have control over is the level of care a patient gets, from one appointment to the next.

If each step isn’t documented well, the patient may end up repeating things or wasting time going over their own history with the physical therapist rather than working on getting better.

Physical therapy documentation is extremely important to the process of helping patients to recover and become stronger.

Initial Evaluations

The first stage in physical therapy documentation is the initial interview and examination of the patient. This is an incredibly important process, as it will determine the rest of the treatment plan for the patient.

Of course, the basic patient information will also be gathered and input, assuming electronic health records have not been transferred by a referring physician, as well as details about the injury or pain that the patient experienced.

Every detail is not only important, but may be vital for compliance. And the entire course of the physical therapy documentation and treatment will be determined from the current state of the patient’s health. Goals must also be established so that the progress of the patient can be measured against those goals.

SOAP and Other Details

While taking care of the patient should be the primary concern of the physical therapist, there should also be attention paid to the way the patient’s insurance company will be billed. Some insurance companies have very specific requirements for continuation of treatment and reevaluations.

Rather than risk a rejected or denied claim due to incorrect or insufficient physical therapy documentation, ensure that all physical therapists follow procedural guidelines for documenting the intake of each new patient.

SOAP, or subjective, objective, assessment, and plan, is the standard system of evaluating a new patient. This standard is important for a few reasons.

First of all, it ensures that there is a standard for all physical therapists. Second, when using SOAP, the most important parts of each initial evaluation will be included in the physical therapy documentation.

Subsequent Visits and Treatmentphysical therapy documentation phase

The actual physical therapy documentation and treatment plan should be on a realistic schedule with various stages and goals worked into the physical therapy documentation plan.

Patients are often helped greatly if they can imagine what their life will be like when they feel better. And to have some intermediary goals will keep them thinking ahead and about improvement.

And of course, each session should be well documented with details about the patient’s recovery and activities. The next session will go more smoothly if a detailed physical therapy documentation account of the current session is in the patient record.

This will help the patient to recover as quickly as possible and to make the most of their time with their physical therapist.

Conclusion of Treatment

Just because a patient is done with their treatment, doesn’t mean it’s okay to forget about physical therapy documentation protocol. The patient’s last visit does not signal the last responsibility of the physical therapist or the practice.

Discharge notes will identify what the billing staff can bill for and the information may be useful for future patients or for the management staff, so assessments can be accomplished with real data.