Home Health & Hospice Week

Improve your therapy documentation to guard against audits and comply with new rules.

The PPS 2011 proposal to beef up your therapy documentation may place an extra burden on you and your therapists, but it should also help correct a big problem -- poor charting.

While some therapists offer excellent documentation, many therapists in home care have let their clinical notes slide under the prospective payment system, experts say. The problem seems especially pervasive for contract therapists.

"Almost across the board contract physical therapists have been slipshod with paperwork, templates, and overuse of assistants," says Lynn Olson of Astrid Medical Services in Corpus Christi, Texas. In the 2011 prospective payment system proposed rule, the Centers for Medicare & Medicaid Services "is addressing the issue and has taken a giant step towards fixing it," Olson cheers.

New requirements: CMS has proposed a number of new therapy documentation requirements, including use of objective measurements to track the patient's progress, formal functional reassessments at the 13th and 19th visits and every 30 days, and a clinical justification of why therapy should continue if the patient's function isn't improving (see Eli's HCW, Vol. XIX, No. 28, p. 218 for more details about the proposed therapy requirements).

For small agencies struggling to get their contract therapists to toe the documentation line, the proposed requirements from CMS are "a windfall," Olson says.

Home health agencies shouldn't be worried about therapy documentation just starting next year, cautions PT Sparkle Sparks with OASIS Answers. They are at risk right now to audits and medical review -- and reviewers have big financial incentives under PPS to deny therapy visits. For example, knocking a later episode from six to five visits will strip about $800 from the payment rate.

Avoid these common therapy documentation pitfalls to guard your claims against scrutiny and prepare for the new requirements hitting Jan. 1:

1) Vague notes. To stand up to review, your therapists' clinical notes must include meaningful specifics, Sparks urges. It's not enough for therapists to just say "tolerated treatment well" and move on, she tells Eli. Therapists must show payors why the therapists need to be there.

Using the objective measures CMS proposed in the rule should help therapists do that, Sparks expects. CMS suggests OASIS data as one source of the measures.

2) Neglecting function. Citing a patient's im-pairment without showing how it ties to the patient's function is a common mistake. "Link the deficits to something the patient can't do," Sparks advises.

For example: Instead of just saying that a patient has hip weakness, show how that weakness affects her ability to stand up, Sparks suggests.

Always ask yourself, "how does it impact function?" Sparks says.

3) Visits don't stand alone. A reviewer needs to be able to pick up a chart and see from each visit's therapy documentation why the patient re-quires the therapy. "Each and every note needs to be able to stand on its own," Sparks reminds agencies.

This tends to become a problem in episodes with higher therapy visit numbers. Better documentation has been sorely needed for patients with high therapy utilization, says PT Cindy Krafft with Fazzi Associates. That's because therapists often get sloppy for these long-use patients. They get very used to the patient and stop writing down specifics, Krafft observes. "You can watch the attention to detail slide."

Such documentation bad habits make it easy for reviewers to deny the last six or seven visits of a 16-visit episode, for example, Krafft points out. That results in a big financial hit of thousands of dollars to the patient's episode payment.

4) All goals are met in the last visit. A sure sign of sloppy documentation is when "the patient miraculously meets all their goals on the last visit," Sparks notes. "That is just asking for it."

Therapists need to document the ongoing attainment of goals, she stresses. Clinical notes should assess the patient's progress toward treatment goals for every visit, which will show the impact the treatment is having.

"When the patient attains a treatment goal, note it on that day," Sparks instructs. "It doesn't all happen at once."

5) Unexplained data. Some therapists do a good job of including functional data in their notes, but they miss an essential component -- explaining what that data means. You need to show how that data impacts the patient's function, Sparks emphasizes.

"OASIS is quantitative and we need that," she says. "But you still have to explain what that objective data means. Relate the objective measures to function."

6) Canned computer-driven documentation. Using generic check-box computer templates to document therapy visits is asking for trouble. Documentation should be full of patient specifics and explanations of what's going on.

"There is no substitute for a well written clinical narrative," Sparks says. "Documentation is a lost art."