The Do’s & Don’ts of Documentation: Pitfalls to Avoid
Brennan, C. (2015). The do’s & don’ts of documentation: Pitfalls to avoid. OT Practice, 20(15), 8–11.
By Cathy Brennan
Documentation has become a key component in making payment decisions, and knowing what to write can keep us on
track and increase the likelihood of payment for our services.
track and increase the likelihood of payment for our services.
Limited financial resources for health care have increased the need to justify in writing the medical necessity of providing
occupational therapy. Our documentation needs to support the specific skilled care we offer to achieve the client’s expected
outcome. Documentation has become as important a skill to learn as our occupational therapy practice techniques. Being
clear in expressing the medical necessity of our interventions has become a reimbursement requirement. But how do we
know what to write and what not to write to be sure that payers understand what we need them to know? Telling the story and painting the picture of the client’s problems and expected outcomes require us to be diligent in the way we describe our care. Our mantra should be to write better, not more.
However, the trend has been to write more, hoping that something in that documentation will be what payers need to approve
payment for the case. Documentation has become a key component in making payment decisions, and knowing what to write
and avoiding the following pitfalls of documentation can keep us on track and increase the likelihood of receiving payment
for our services.
occupational therapy. Our documentation needs to support the specific skilled care we offer to achieve the client’s expected
outcome. Documentation has become as important a skill to learn as our occupational therapy practice techniques. Being
clear in expressing the medical necessity of our interventions has become a reimbursement requirement. But how do we
know what to write and what not to write to be sure that payers understand what we need them to know? Telling the story and painting the picture of the client’s problems and expected outcomes require us to be diligent in the way we describe our care. Our mantra should be to write better, not more.
However, the trend has been to write more, hoping that something in that documentation will be what payers need to approve
payment for the case. Documentation has become a key component in making payment decisions, and knowing what to write
and avoiding the following pitfalls of documentation can keep us on track and increase the likelihood of receiving payment
for our services.
Evaluation/Plan-of-Care Pitfalls
The objective evaluation data/score is documented without any interpretation or analysis of its meaning for the client. For example, stating that “the child‘s total motor score is 20 and her motor proficiency is less than 1% of the sample population of children her age” does not address the impact this deficit will have on this child’s function.
Instead, link the data to functional performance and participation. “Based on her test results and performance, this child’s primary challenges involve bilateral coordination and motor planning. Difficulties in these areas result in problems maintaining postural control for classroom seating and the inability to perform developmental skills common in childhood games, such as starting and stopping in running, throwing and catching a ball, and balancing while kicking a ball.”
The initial evaluation lacks pertinent medical and/or therapy history that could impact the plan of care. Co-morbidities can significantly affect the client’s progress in achieving outcomes, even though they may not be the primary reason for an occupational therapy referral. Part of telling the story is to identify and include any co-morbidity that may affect performance in the evaluation documentation. For example, “The client is referred because of her arthritis pain but macular degeneration is also impacting her activities of daily living.”
Identify how co-morbidity could impact the plan of care: “In addition to her painful arthritis, this client has significant vision loss due to macular degeneration, affecting her ability to safely perform household activities, such as cooking hot meals for her family.”
The cognition level is not addressed, which could have an impact on the length and breadth of therapy treatment. For example, “The client is unable to dress and groom himself independently.”
Instead, identify how cognitive deficits impact rate of progress. For example, “This client’s performance is impacted by his diagnosed intellectual disability, affecting his ability to understand concepts of directionality in dressing.” An insurance reviewer would get a clearer picture of the need for a possibly longer duration of treatment due to identification of the cognition level.
The intervention identified in the plan of care does not have the level of complexity that requires the skills of an occupational therapy practitioner. Documentation must differentiate specialized skills from non-skilled service and what the practitioner is doing to assist the client to achieve functional performance outcomes.
Documenting a medically necessary (skilled) therapy statement is a clear way to make the correlation between our skilled intervention and the client’s outcome. For example, “Skilled therapy is necessary to design and fabricate a specialty hand splint to enable the client to write legibly while protecting joints.”
Outcome measures are written without an adequate baseline of function to measure change. For example, the payment reviewer identifies a feeding goal in the progress note, but there is no evaluation of eating or swallowing skills to know where treatment is starting.
Use the baseline of current performance as the first objective measure in developing outcome goals in the plan of care.
Intervention Note Pitfalls
The frequency and/or duration of treatment have changed from the initial plan of care without documentation in the record of when or why this occurred. This can be most confusing for payers, who are looking at the continuity of our treatment and the charges associated with attendance.
To alert the payer and others of a change in frequency and/or duration, provide a statement in the client’s record documenting the change. For example, “The client’s frequency of attendance has been reduced today from two to one session per week, as progress has been good and the reduction will enable the therapist and the client to evaluate whether success can be maintained at a reduced frequency of sessions.”
Documentation is inadequate to determine the client’s status relative to the identified functional goals. For example, “The client continues to actively participate in treatment activities.”
Instead, document the client’s status by identifying the specific outcome being addressed and how the client is responding. For example, “The client is working on independent lower extremity dressing skills and has improved this session from assistance needed for standing balance and verbal cues to stand-by assist.”
Documentation of services for the intervention session does not match the description of the code being billed, or the date of billing does not match the intervention note date. Coding descriptions serve the purpose of clearly identifying the services being rendered and the payment that matches them on the day they occurred.
Make the coding, descriptions, and dates within intervention notes consistent. When coding is inconsistent with the actual services being documented or the billing date does not have documentation to match the intervention date, fraud is suspected.
Non-billable time is included in the total treatment time being documented. Actual treatment time does not include indirect time, such as set-up, rest periods, documentation time, or conferences.
When billing, reflect actual treatment time, not the time the client spent in your facility or indirect services.
Documentation is repetitive for each treatment note and does not indicate a change in the treatment plan of care, despite the client’s inability to sustain gains and show any significant improvement.
Gains toward treatment goals, even goals for maintenance, require a change from the baseline performance within a reasonable period of time, taking into account any co-morbidity affecting care. Electronic documentation has provided the payer with the ability to look at practice patterns and compare providers outside the norm. If treatment is not effective, then payment for the services may be denied.
Treatment notes do not identify that supervision of the occupational therapy assistant has occurred in accordance with any state licensure requirements.
A statement documenting that this case has been reviewed by the therapist and plans should continue as is or changes should be made to goals or intervention will make it clear that supervision of the assistant is occurring. State licensure rules will always take precedence if they require more stringent supervision than that of the payer.
Progress NotePitfalls
The outcome measures (goals) are not client centered or measureable. The goals identify what the therapist has planned rather than what the client will achieve. For example, “The client will complete a cognitive assessment within the next week” is a therapist plan of care, not a client outcome goal.
Outcome measures need to be client centered and measureable. For example, “The client will follow a two-step direction during a board game with no verbal cues.”
Abbreviations are used that are familiar only to the therapist and are not identified on the facility’s list of accepted medical abbreviations. For example, the abbreviation “NCGF” is used in a progress report. The therapist meant “No Caregiver Follow Through,” but this would hardly be a commonly understood abbreviation. Use of texting abbreviations is also not acceptable in the medical record.
Use approved abbreviations so that all are able to understand the written record.
Intervention activities are used as outcomes rather than functional performance. For example, “The child will walk four steps forward on a lowered balance beam without falling” is the intervention activity, not the functional outcome.
Indicate how your intervention activities achieve the functional performance outcome. For example, “The child will put each leg into shorts during morning dressing routine, maintaining balance with minimal assist.”
Documentation indicates a lack of coordination and duplication of services. For example, the client is being seen by two different therapy disciplines, and the goals and treatment appear to be the same. Therapy coordination and discipline-specific goals will prevent the payer from discontinuing services of one provider because of perceived duplication of services.
Each of our therapy disciplines exists in different paradigms; make that evident in your documentation.
Documentation does not address each original goal in the progress report, and it is unclear which goals are current and which have been met or changed. Address the status of treatment goals in the progress note.
Do not drop or change goals without identifying why this has occurred.
Skilled treatment is not routinely evident in the documentation. Skilled therapy statements written throughout the record justify the continued medical necessity of treatment.
Use verbs such as evaluate, fabricate, analyze, tailor, grade, develop, design, optimize, stabilize, and educate to describe skilled service in progress notes.
Discharge Summary Pitfalls
Documentation does not identify appropriate carryover training for the caregiver.
Include comments in the documentation about what carryover training has occurred and the caregiver and client’s response to this training. The continued success of therapy after discharge is often aided by family members who have been trained in assisting the client to maintain such things as an exercise program or cueing needed for successful participation in daily activities.
Progress toward all goals is not documented.
The discharge summary is the last opportunity to justify the necessity for the skilled services that were provided and the progress toward each goal. Case reviewers will often compare the initial evaluation and plan of care with outcomes identified in the discharge summary.
Conclusion
Effective documentation is the key to reimbursement. All payers are looking at whether the outcome was cost effective in light of limited health care dollars. Documenting the skilled service we offer and successful client outcomes in a succinct and descriptive manner will enable clients and payers to clearly see the benefit of their spent dollars. Understanding the do’s and don’ts of what should be included in our written documentation will enable occupational therapy practitioners to decrease time spent on documentation and facilitate payment of the claim.
Cathy Brennan, MA, OTR/L, FAOTA, is a private consultant specializing in documentation and coordinates the Peer Review System for the Minnesota Occupational Therapy Association.
- See more at: http://www.aota.org/publications-news/otp/archive/2015/8-24-15/documentation-pitfalls.aspx#sthash.k0WyyXOE.dpuf
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