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Introduction Objectives of APTA’s Defensible Documentation for Patient/Client Management In light of the importance of documentation in patient/client care and in response to many of the current issues related to physical therapy documentation, APTA has developed the Defensible Documentation for Patient/Client Management resource as a companion guide to the Association’s existing documentation guidelines. The objectives of Defensible Documentation for Patient/Client Management resource include: 1) Raising awareness of physical therapists (PTs) and physical therapists assistants (PTAs) on clinical documentation issues. 2) Providing useable and clinically relevant information about defensible documentation in patient/client care. 3) Identifying legal, regulatory, and payer requirements for clinical documentation. 4) Providing tools and resources PTs and PTAs need to create documentation that will satisfy all the aforementioned requirements. Please be aware that there will be specialized settings, practice arenas, regulations, etc. that may require other types or components of documentation that are not addressed in this resource. Please check payer, state law, and specific accreditation organization (i.e., Joint Commission, CARF, etc) requirements for compliance. Medicare and many third party payers have established minimal standards for documentation. Medicare’s minimal documentation standards vary between practice settings and benefit. Many state practice acts define what is expected of its licensees in clinical documentation. For the clinician, it can be challenging to determine which standards might apply to their situation. There are several resources for the clinician:  Medicare’s internet only manual system for setting specific and Part A vs Part B guidelines (  Medicare Administrative Contractor’s Local Coverage Decisions (  Payer specific websites (e.g. Aetna, Blue Cross-Blue Shield, Cahaba, Noridian, Palmetto, Trailblazer, United Health, as well as others)  State practice acts  APTA Guidelines for physical Therapy Documentation  Employer policies It is the therapist’s responsibility to be aware of any payer-specific, setting specific, employer/organization specific, and/or state specific documentation requirements.


Why is Documentation Important? While safety and quality of care is most important when working with patients and clients, documentation throughout the episode of care is a professional responsibility and a legal requirement. It is also a tool to help ensure safety and the provision of high-quality care and to support payment of services. If you ask PTs or PTAs what they like least about their clinical practice, you are likely to hear “paperwork” or “documentation” as a frequent answer. Many therapists feel it is difficult to document effectively while providing patient/client care. In addition, documentation time may not be included as reportable time thus significantly impacting therapists’ productivity standards. As a result, therapists often view documentation as an onerous, irrelevant, and unwarranted adjunct to patient/client care. However, appropriate documentation of physical therapy services is crucial because it: 1) Serves as a record of patient/client care including a report of the patients/client’s status, physical therapy management, and outcome of physical therapy intervention. Is a tool for the planning and provision of services, and is a communication vehicle among providers. 2) Tells others about our abilities, our unique body of knowledge, and the services we provide as PTs and PTAs. 3) May be used to demonstrate compliance with federal, state, payer, and local regulations. 4) Provides an historical account of patient/client encounters that can be used as evidence in potential legal situations. 5) May be used to demonstrate appropriate service utilization and reimbursement for many third-party payers. 6) May be used for policy or research purposes including outcomes analysis.


Current Concerns in Physical Therapy Documentation Physical therapists and physical therapist assistants should not underestimate the importance of complete documentation or the implications of deficient documentation. Today’s health care system relies on documentation to measure patient outcomes, the need for services, and justification of the plan of care. Insufficient or absent documentation can negatively affect reimbursement, communication among providers, risk management, and most important, the care of the patient/client. This section will highlight some of the current issues affecting physical therapy services, all with important documentation implications.

I. Medicare Reports and Documentation Standards RAC’s: The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) directed the Secretary of the HHS to implement a demonstration project using Recovery Audit Contractors (RACs) under the Medicare Integrity Program (Section 306). The goals of the project were to identify underpayments and overpayments made to providers and to recoup those moneys for the Part A and Part B programs. The demonstration project was launched during 2005 to 2008 in the states of California, Florida and New York since those states were identified as having the largest Medicare expenditures. However in 2007 it was expanded to Massachusetts, South Carolina and Arizona. RACs look for incorrect payment amounts, non-covered services that were paid for in error, incorrectly coded services, and duplicate services that were paid for. RACs are paid a contingency for each underpayment and overpayment they find. During fiscal year 2007, RACs found $371 million of improper Medicare payments. Most of these related to lack of medical necessity & incorrect coding. Section 302 of the Tax relief and health Care Act of 2006 made the RAC program permanent and required the Secretary of HHS to expand the program to all 50 states by the year 2010. More information can be obtained at CERT Program: As part of its Improper Payments Information Act (IPIA) compliance efforts, the Centers for Medicare and Medicaid Services (CMS) has established the Comprehensive Error Rate Testing (CERT) program and Hospital Payment Monitoring Program (HPMP) to randomly sample and review claims submitted to Medicare. The main objective of these programs is to determine the degree to which CMS and its contractors are meeting the goal of “Paying it Right,” meaning paying the right amount to the right provider for covered and correctly coded services. The HPMP monitors Prospective Payment System (PPS) shortterm acute-care inpatient hospital admissions; the CERT program monitors all other claims. 3

The most recent reports are available on CMS’s Web site. For CERT Report Trends, go to Appendix D. For the CERT Comparison Chart, go to: TE=/CM/ContentDisplay.cfm&CONTENTID=40118 In a report released in November 2007, CMS summarizes error rates from randomly sampled claims submitted in a 12-month period ending March 31, 2007, by the following categories: no documentation errors; insufficient documentation errors; medically unnecessary service errors; incorrect coding errors; and other errors. This report shows a high error rate for certain services provided by physical therapists and indicates that the error rate for physical therapy services is primarily due to problems with documentation.

1. Insufficient Documentation: In the CERT report, therapeutic exercise (CPT code 97110) was included in the list of the top 20 services with insufficient documentation. The paid claims error rate for 97110 was 5.3%, and the projected improper payments for this service were $33,972,936. Manual therapy (97140) also appeared in the most recent report; with a paid claims error rate of 7.8% and projected improper payments in the amount of $16,571,551. 2. Medically Unnecessary Service: Physical therapy was not included in the top 20 list of medically unnecessary services. 3. Incorrect Coding: Incorrect coding can result in underpayments or overpayments. None of the physical therapy CPT codes appeared in this category. 4. Paid Claims Error Rates by Provider Type: Physical therapists in private practice (PTPP) had a paid claims error rate of 6.2% and a projected improper payment amount of $63,633,089. While details of the report cause great concern regarding physical therapy documentation, there is agreement among all stakeholders that some Medicare and Medicaid documentation and coding standards are cumbersome and at times inconsistent. To guide clinicians to improved documentation, Medicare, with input from APTA, developed minimal documentation guidelines for outpatient physical therapy services for


payment purposes. These minimal standards are available in the Medicare Benefit Policy Manual (100-2), Chapter 15, Sections 220 and 230 Additional Medicare and Medicaid Transmittals/Information:    

Medicare Program Integrity Manual (100-8), Chapter 3; Section Medicare Claims Processing Transmittal 88 – Therapy Personnel Qualifications and extension of the plan of care recertification time frame (includes change that no longer allows stamped signatures) Medicaid Resources - Medicaid Information

II. Expectations of Others Related to Clinical Practice As the science and technology of rehabilitation and other clinical fields progress at an ever increasing rate, health care providers must continue to seek out and integrate the latest evidence. This new information can come in the form of new theories of disease pathology, better tests and measures, new equipment, or more effective and efficient interventions. Third-party payers, other health care providers, and consumers expect the physical therapist to use evidence in patient/client management. In fact, therapists may be surprised to learn that many third-party payers have research divisions or contract with private companies to perform research reviews. These reviews are then correlated into clinical guidelines or approved protocols for patient/client care. Likewise, many other government and private agencies are pooling research and expert opinion to establish “best practice” principals or other performance criteria. Because of these expectations, the content of the physical therapy documentation becomes increasingly important. Physical therapy documentation should reflect the thought process and decision making of the physical therapist. As such, documentation of patient/client care needs to be more than a litany of patient/client procedures related to a date of service. Physical therapy documentation must include evidence of our unique body of knowledge and skill. It also should provide verification of our professional judgment. This concept of clinical decision making can be incorporated into clinical documentation. Due to the limited resources in today’s health care environment, physical therapists need to promote our unique role in improving patients’/clients’ function, independence, and quality of life. We need to demonstrate through evidence-based practice and patient/client outcomes measurement the importance of physical therapy services to all stakeholders (patients/clients, families/caregivers, payers, regulators and other providers). Appropriate


documentation that focuses on patient/client function can better demonstrate patient/client outcome and can facilitate this appropriate recognition of physical therapy services. III. Pay for Reporting/Performance/Quality Reporting There has been considerable discussion among policymakers regarding differentiating among providers when making payments. Currently, Medicare and many other third-party payers reimburse the same amount for providers regardless of the quality of the services. Recently, federal regulators including the Center for Medicare and Medicaid Services (CMS) and private payers have undertaken various activities to promote quality and cost effectiveness of health care. One activity, pay for performance (P4P), refers to financial incentives that reward health care providers to achieve predetermined targets or measures of quality and cost. These measures are typically in four types: structural measures or measures that refer to the specific attributes of the settings (e.g., use of information technology, professional expertise); process measures or measures that assess what is actually done with patients/clients (e.g., standards of practice that have been demonstrated and accepted to lead to better outcomes); outcome measures or measurements of the result of the intervention (e.g., clinical and functional measures); and patient satisfaction with the care provided. In many cases, clinical documentation is the vehicle for quality measurement. . As part of HR 6111, the "Tax Relief and Health Care Act of 2006," Congress authorized a bonus payment for eligible professionals who submit quality data. For more information on the quality reporting program (PQRI), click here. A few years ago, the American Physical Therapy Association (APTA) determined a need to collect outcomes data to answer questions about the effectiveness of physical therapist services. As a result, APTA CONNECT was developed in partnership with Cedaron Medical of Davis, California. APTA CONNECT is an electronic patient record system designed for physical therapy and built upon a database system. Hence, all patient/client data can be displayed and analyzed to assist in clinical decision making and for outcomes assessment. In addition, selected data from all users of APTA CONNECT will be de-identified and aggregated to establish a national outcomes database for physical therapy, providing a rich source of information for use in research and advocacy of physical therapy services. For more information about APTA’s national outcomes database and APTA CONNECT, click here.

Nursing Home Value-Based Purchasing Demonstration

Background: The Nursing Home Value-Based Purchasing (NHVBP) Demonstration is part of the CMS initiative to improve the quality and efficiency of care furnished to Medicare beneficiaries. Under this demonstration, CMS will offer financial incentives to nursing


homes that meet certain conditions for providing high quality care. The demonstration will be open to free-standing and hospital-based facilities and will include beneficiaries who are on a Part A stay as well as those with Part B coverage only. CMS intends to conduct the demonstration in up to five states. Basic Approach: Each year of the demonstration, CMS will assess each participating nursing home’s quality performance based on four domains: staffing, appropriate hospitalizations, MDS outcomes, and survey deficiencies. CMS will award points to each nursing home based on how they perform on the measures within each of the domains. These points will be summed to produce an overall quality score. For each State, nursing homes with scores in the top 20 percent and homes that are in the top 20 percent in terms of improvement in their scores will be eligible for a share of that State’s savings pool. Financing: The demonstration will be budget neutral to Medicare. CMS anticipates that potentially avoidable hospitalizations may be reduced as a result of improvements in quality of care. The reduction in hospitalizations and subsequent skilled nursing facility stays is expected to result in savings to Medicare. These savings would be used to fund the savings pool from which payment awards would be made. A separate savings pool will be estimated for each state in the demonstration. Nursing homes that volunteer to participate in the demonstration will be stratified and randomly assigned to experimental and control groups. After each year, CMS will compare total risk-adjusted Medicare expenditures between the experimental and control groups in each state. The actual savings pool for each state will be determined based on the difference in the growth of risk-adjusted Medicare expenditures between the two groups. Status: CMS is conducting a two-stage solicitation process. First, CMS will select up to 5 States to host the demonstration. We have sent a letter to all State Medicaid Directors asking them to express their interest in hosting the demonstration, and we will select from among those States that express interest. We plan to announce the selection of host States by the end of February 2009. Next, we will solicit nursing homes within those States. We anticipate that the demonstration will begin in summer 2009.

Components of Documentation within the Patient/Client Management Model


What follows is a description of the main documentation elements of patient/client management: 1) initial examination/evaluation, 2) visit/encounter, 3) reexamination, and 4) discharge or discontinuation summary.

I. INITIAL EXAMINATION/EVALUATION Components of an Initial Examination/Evaluation (from APTA’s Documentation Guidelines) Documentation of the initial encounter is typically called the “initial examination,” “initial evaluation,” or “initial examination/evaluation.” Completion of the initial examination/evaluation typically is completed in one visit but may occur over more than one visit. Documentation elements for the initial examination/evaluation include the following: examination, evaluation, diagnosis, prognosis, and a plan of care.

A. Examination The examination component of the patient/client record documents pertinent findings from the patient’s/client’s history and the systems review along with findings from various test and measures. It is the findings from these three sections that the physical therapists will use to evaluate the patient/client and determine the diagnosis, prognosis, and plan of care, including goals, selected interventions, and discharge planning. Each section of the examination is described in further detail below: 1. History The history section of the examination is a collection of information that can be gathered through a patient/client or family/caregiver interview and includes a review of past and current medical and social information. The medical history may include pertinent medical diagnoses, surgical history, previous and/or current interventions, and a list of current equipment, environmental modifications, and medications. It may contain information about previous clinical tests (X-rays, CT scan, etc) and a general review of current health status. For pediatric patients/clients, the medical history may also include history of the mother’s pregnancy and complications, birth history, neonatal complications, and age when developmental milestones were achieved. The social history may include information on the patient’s/client’s premorbid and current living environment, education/work status, and cultural preferences, including preferred language. In addition, information on a patient’s/client’s previous level of function and comorbidities that could affect the rate of recovery and/or rehabilitation should be included. For pediatric patients/clients, the social history also includes information on the family. This includes information on the child’s parents/guardians/caregivers, siblings, and other important people in the child’s life. Family history documents the resources, priorities, and needs of the family including information on the child’s daily routines, activities, and interests. The social history also includes information on child


care, school, and other community activities including play, leisure/recreation, and socialization. For patients in a skilled nursing facility, a patient’s history may be gathered from the hospital discharge summary, current and past facility assessments, previous Minimum Data Sets (MDS) if applicable, and the nursing/consults section of the patient’s medical record. Also, the physical therapist should review documentation of the patient’s previous functional maintenance program or restorative nursing program if applicable as this will alert the therapist to an understanding of the patient’s prior level of function. It is critical for the therapist, through comprehensive record review and patient/caregiver interview, to obtain an accurate social history and anticipated discharge disposition, including current and potential support structure available upon discharge. This information is needed for appropriate goal setting and discharge planning to any setting, including long term placement. It is important for all providers to provide a complete and thorough history that highlights pertinent information relevant to the patient’s/client’s or family’s/caregiver’s reason for seeking physical therapy services. The history should clearly identify the patient/client and family/caregiver concerns. A patient’s/client’s medical and/or social history provides essential details used in the physical therapist’s evaluation and determination of prognosis, goals, and the plan of care. For example, a patient/client with a wound who also has a history of diabetes may require increased intensity, frequency, and duration of services. Likewise, a patient/client with a history of a traumatic brain injury may require increased duration of services due to cognitive deficits or loss of short term memory. Similarly, physical therapy management of a pediatric patient/client with cerebral palsy who is living in the foster care system may require coordination of services across multiple agencies and providers. The impact that these histories have on the current problem should be identified and clearly explained in the evaluation and the plan of care.

2. Systems Review A systems review is a necessary component of any initial examination. It is a brief or limited examination of the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems and the communication ability, affect, cognition, language, and learning style of the patient/client. Information gathered from a systems review is imperative as it assists the physical therapist in determining conditions that may affect the current chief complaint. During this review, the physical therapist collects and records information regarding a patient’s/client’s ability to initiate, sustain, and modify purposeful movement as well as communication skills, cognitive abilities, and other important personal factors that might influence care or the performance of an activity that is pertinent to function. For the pediatric patient/client, the systems review may also


include consideration of the child’s safety and well-being, nutrition, behavior/attention, and self determination. Because patients/clients are able to access the services of a physical therapist without a referral in many states, it is important to include a comprehensive systems review to assist the physical therapist in identifying potential conditions that would require consultation with or referral to another provider. The APTA Guide to Professional Conduct states that if findings are outside of the scope of the physical therapist’s knowledge, experience, or expertise, the physical therapist shall refer to an appropriate practitioner. While the systems review is a very important element of the initial examination, this can be completed in a relatively short period of time by experienced clinicians. In many cases, it may be the physical therapist who first recognizes a problem that requires further examination by another clinician. In addition, some patients/clients may not have seen a primary care physician recently. Failure to perform a complete systems review can put your patients/clients and you at risk. Consider the following three examples: Case 1: A 38-year-old male with a complaint of knee pain presents to your clinic for an initial evaluation. As part of your initial examination/evaluation you record his blood pressure at 160/ 98. After a discussion with the patient/client, you call his family medicine physician regarding these findings concerned that the patient/client may have undiagnosed high blood pressure. The patient/client returns a week later, on a new medication to lower his blood pressure. Case 2: A 47-year-old female with a recent left ankle sprain presents for an initial evaluation. In addition to weakness in her left ankle, you note weakness throughout her left side when compared with the right side. This finding along with others from the patient/client history and examination may lead you to contact another provider in consideration of a more systemic cause of her symptoms. Case 3: A 3-month old infant with past medical history of prematurity is referred to physical therapy with a diagnosis of torticollis. As part of your systems review, you note that the infant is unable to visually fix or track an adult face or a toy. You discuss a referral back to the child’s pediatrician or ophthalmologist. Case 4: An 85 year old male status post left hip replacement with prior level of function listed as independent presents for an initial examination. In performing a systems review, the patient presents with moderately impaired cognition that significantly varies from the patient’s current and prior level of function as documented in the nursing portion of the assessment. The therapist alerts the nurse and refers the patient to the patient’s primary care physician for reassessment prior to initiating treatment. Case 5: A 72 year old female with past medical history of hypertension, anemia, GI bleed, wrist fracture, and degenerative joint disease (DJD) is referred for gait training, pain


management and strengthening status post thoracic compression fracture. During chart review the therapist notes the patient has been prescribed an anti-hypertensive medication, a SERM (selective estrogen receptor modulator), and a non-steroidal anti-inflammatory (NSAID). After patient interview and initial review of systems, the therapist asks to see the patient’s medications. The patient reports the previously known meds, but also states she is taking an antidepressant and aspirin daily. Due to the fact the patient has a history of GI bleed and anemia, you question her regimen of aspirin and NSAID, and call her primary physician to insure he is aware the patient is taking both. He is not aware, and gives you a verbal order to discontinue the aspirin. You advise the patient of the verbal order, document the order, document the consultation with the physician, and communicate the exchange to a nurse manager.

3. Tests and Measures From the information gathered in the history and systems review, the physical therapist determines a hypothesis for a diagnosis. The physical therapist then determines which tests and measures are required to further prove (or disprove) the hypothesized diagnosis or diagnoses. In the documentation of tests and measures, a physical therapist should clearly identify the specific tests and measures and any associated finding or outcome. There is no specific recommendation for how tests and measures are ordered or displayed; however, the record of findings should be easy to follow. PTs may choose to document certain systems together, they may follow a natural progression of an evaluation by patient position (e.g., from seated to supine to prone to standing), or they may have the patient complete simple tasks before complex activities. In pediatrics, the physical therapist may decide to present the tests and measures related to participation and activity (function) before the tests and measures related to body structure and function. In addition to more traditional tests and measures (ROM, strength, balance, edema, etc), the physical therapist should rely on standardized tests and measures. These standardized tests can be specific to a diagnosis (knee, low back) or a more general measure relating to disability (OPTIMAL, SF-36) or patient satisfaction. OPTIMAL (Outpatient Physical Therapy Improvement in Movement Assessment Log) is a patient self-report instrument designed to assess a patient’s self-reported difficulty and confidence level on 21 actions that describe movements. You may access the OPTIMAL tool and related literature at the following link: PLATE=/CM/ContentDisplay.cfm Patient/client satisfaction has been shown to influence the outcomes of care. The Physical Therapy Patient Satisfaction Questionnaire has been shown to be reliable and valid. You may access the literature on this tool at the following link:


Choosing standardized tests and measures requires careful thought and consideration, including patient/client factors such as tolerance of testing, time involved, environment, and the psychometrics of the test. Some will quantify pain or function, while others measure the degree of impairment or disability. In addition, some tests are diagnostic while others are more prognostic in their intent. Physical therapists should use tests and measures that produce data that are accurate and precise enough to allow the therapist to make correct assumptions about the patient/client’s condition. Appropriate use of standardized tests and measures are valuable in determining the patient’s/client’s progress and outcomes through the episode of care and can provide a standard measure of comparison for clinical outcomes. In pediatric practice, outcomes are often documented by achievement of behavioral objectives; thus, documentation of initial test and measures should be precise to record the child’s current status on identified priority tasks, including the conditions and criterion under which the behaviors are demonstrated. When documenting the results of standardized tests and measures therapists are encouraged to follow the test’s guidelines related to accurate reporting of test scores. In addition, therapists should document any variation of the standard protocol that was needed when administering the test as well as any qualitative findings that are relevant to interpreting the test results. It is also important to take into account the environment when considering tests and measures. For example, testing related to ergonomics may be best performed in the client’s work environment. In a pediatric practice, when appropriate, tests and measures at the participation level should be conducted in the child’s natural environments, at home, school, or community. Observations made during key routines and activities such as negotiating from the bus to the classroom or negotiating playground equipment should be documented. APTA’s Catalog of Tests and Measures is an essential tool that describes available tests and measures that physical therapists may use in their patient/client examinations. It contains approximately 500 specific tests and measures used by physical therapists and approximately 2,000 citations on reliability and validity of measurements obtained using those tests and measures. You can access information about the Catalog of Tests and Measures at the following link: e&template=/ECommerce/ProductDisplay.cfm&ProductID=844 As an additional reference for practice in pediatrics, the Section on Pediatrics has a list of pediatric assessment tools available on their website at: An additional resource is CanChild Centre for Childhood Disability ( This site provides a variety of resources on pediatric outcomes and assessment tools.

B. Evaluation An evaluation is a thought process that may or may not include formal documentation. This evaluation process is a synthesis of all of the data and findings gathered from the


examination and collaborative decision making with the patient/client. The evaluation process leads to documentation of such items as impairments, activity limitations, and participation restrictions. It should guide the physical therapist to a diagnosis and prognosis for each patient/client. In pediatrics, consistent with family-centered care, the documentation of the evaluation reflects a strength-based approach. An evaluation would typically include the child’s strengths, readiness to learn a new skill, and areas of concern, priority or need. Areas of need would include the child’s participation restrictions in the home, school, and community, activity limitations, and body structure and function impairments. The evaluation should also note the child and environmental characteristics hypothesized to be facilitators or barriers to the child’s activity and participation. The documentation of an evaluation can use formats such as a problem list or a statement of assessment with key factors (e.g., cognitive factors, comorbidities, social support) influencing the patient/client status. While the documentation of an evaluation may come in different formats, the record should convey to the reader what examination factors are relevant to the current complaint. The evaluation process should arrive at a physical therapy diagnosis and a prognosis for a functional outcome(s) at the conclusion of physical therapy services. Narrative example: Clinical Impression: Pt is a 68-year-old female with significant limitations in right knee AROM, strength, weight bearing tolerance. Pt also limited due to pain and edema in the right leg. Pt requires assistance for transfers, bathing, dressing, grooming, and gait at this time. Pt was independent in all activities prior to admission, is otherwise in good health and has good family support. Pt requires physical therapy intervention to resume normal activity. Pediatric Narrative Example: John is a three year old boy with significant developmental delays. He is able to communicate to show his likes and dislikes, walks independently, feeds himself finger foods, and manipulates toys with both hands. John can attend to structured learning activities and remembers routines and activities. He has a very supportive family and two playful siblings. John is ready to learn to use his motor abilities during play activities and games with other children. Currently John does not spontaneously initiate play with peers or siblings and has limited verbal communication. He has difficulty with jumping and ball skills. John requires supervision on stairs, assistance for eating with utensils, dressing, and bathing and occasionally falls on outdoor terrain. He requires physical therapy intervention to promote his strength, balance and motor planning, especially considering weakness on his left side. A consistent team approach for communication and positive behavior support is recommended. Problem list example: Impairments: Edema, impaired balance, impaired gait, impaired joint mobility, impaired muscle strength, and pain Activity Limitation: Inability to stand without minimal assistance, inability to ambulate greater than 20' with moderate assistance, requires set-up for bathing and minimal assistance for dressing. Participation Restrictions: Environmental barriers and home barriers


C. Diagnosis To best understand the scope of practice of the physical therapist related to diagnosis, one must first understand the concept and use of a disablement model. The concept of disablement refers to the “various impact(s) of chronic and acute conditions on the functioning of specific body systems, on basic human performance, and on people’s functioning in necessary, usual, expected, and personally desired roles in society.” (Jette AM, 1994; Verbrugge L, 1994) Thus, the disablement model is used to delineate the consequences of disease and injury both at the level of the person and at the level of society. The disablement model provides the conceptual basis for all elements of patient/client management that are provided by physical therapists. The International Classification of Functioning, Disability and Health (ICF) was developed by the World Health Organization in 2001 and was endorsed by the APTA in 2008. The ICF, with a focus on human functioning, provides a unified, standard language and framework that facilitates the description of the components of functioning that are impacted by a health condition. It enables the collection of data as to how people with a health condition function in their daily lives rather than focusing on their diagnosis or the presence or absence of disease. The ICF describes the situation of the individual within health and health-related domains and within the context of environmental and personal factors. A diagnosis is determined by the physical therapist after the examination and evaluation process. The objective of the diagnostic process for the physical therapist is to identify discrepancies that exist between the level of functioning that is desired by the patient/client and the capacity of the patient/client to achieve that level. Hence, diagnoses made by the physical therapist are typically made at the impairment, activity, and participation levels. The diagnosis by a physical therapist should be clearly documented and can take different formats. In most cases, physical therapists select the corresponding ICD code that reflects the results of the examination and evaluation process. In addition, the selection of the appropriate Preferred Physical Therapist Practice Patterns as outlined in the Guide to Physical Therapist Practice will provide additional insight. A thorough description of the Preferred Physical Therapist Practice Patterns is available in the Guide to Physical Therapist Practice, but some examples include:    

Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation (4E) Impaired Motor Function and Sensory Integrity Associated With Progressive Disorders of the Central Nervous System (5E) Impaired Aerobic Capacity/Endurance Associated With Cardiovascular Pump Dysfunction or Failure (6D) Impaired Integumentary Integrity Associated With Partial-Thickness Skin Involvement and Scar Formation (7C)


For billing purposes, diagnoses are coded according to ICD coding. While the practice patterns are also numbered (i.e., 4E—see example above), this numbering is not the same as ICD coding. When coding diagnoses by ICD for reporting purposes, you may be required to use codes that relate to the impairment for which you are treating the patient/client. In fact, some payers have specific policies for reporting medical and treatment diagnoses, e.g., Medicare’s Local Coverage Determinations (LCDs), so it is important to be familiar with the specific payer policies. For example, if you have a patient/client with a cerebral vascular accident, the medical diagnosis code may be 434.9 (artery occlusion, unspecified). But the reason that you are seeing the patient/client may be best coded as Gait, spastic (781.2). It is best to include more information and incorporate codes specific to function so the reviewer knows why the patient/client is receiving therapy. It is recommended that the primary diagnosis on the claim form be the impairment-based diagnosis. The secondary ICD code could be the medical diagnosis. Some payers prefer as much specificity in ICD coding as possible. There are opportunities to include two numbers after the decimal point for some diagnoses. Therefore, it is recommended that you have a current ICD book. To meet requirements of various pediatric practice settings, medical diagnoses may also be noted, i.e. in Early Intervention, medical diagnosis is included secondary to medical diagnosis being one criterion for eligibility of services under the Individuals with Disabilities Education Improvement Act (IDEA, 2004). In school-based practice, one of the disability categories under IDEA is similarly reported to document eligibility of services. In both early intervention and school-based practice, physical therapy diagnosis may not be noted on multidisciplinary Individualized Family Service Plans (IFSPs) or Individualized Education Programs (IEPs); however, the selection of the Preferred Physical Therapist Practice Pattern can be noted in supplemental physical therapy documentation. Traditionally, IFSPs and IEPs are team documents to guide early intervention and school services under IDEA; however they may not include a physical therapy diagnosis but only a medical diagnosis. Note 1: Certain state practice acts contain specific regulations regarding physical therapy diagnosis. The following link will direct you to information about your state practice act: edPage/TaggedPageDisplay.cfm&TPLID=201&ContentID=21791 Note 2: Third-party payers also may specifically identify ICD-9 codes paired with CPT codes that it considers to be medically necessary. D. Prognosis/Plan of Care 1. Prognosis Documentation of the prognosis conveys the physical therapist’s professional judgment for the patient’s/client’s predicted functional outcome and the required duration of services to obtain this functional outcome. It is important to differentiate between the patient’s/client’s medical prognosis and his/her rehabilitation prognosis. It is also recommended to consider the prognosis for the entire episode of care and not just one


specific timeframe (i.e., during the acute care stay) as this may significantly affect options for continued physical therapy and/or skilled care. In pediatrics it is recommended that therapists document the clinical reasoning that supports the stated prognosis. As an example: “The child’s prognosis for independent walking is positive secondary to the child presenting with a Gross Motor Functional Classification System level of I and a supportive family who provide appropriate movement opportunities.� 2. Plan of Care Documentation of the plan of care includes the following components, all of which are further described below: 1) Overall goals stated in functional, measurable terms that indicate the predicted level of improvement in function. These goals are made in collaboration with the patient/client and other appropriate stakeholders. 2) A statement of interventions/treatments to be provided during the episode of care. 3) Duration and frequency of service required to reach the goals. 4) Anticipated discharge plans (May be part of the prognosis or written separately). 5) The physical therapy plan of care for a child from birth to three can be embedded in the IFSP. The plan of care for a child of school age (3-21) can be embedded in their IEP, or documented in a 504 plan as a supplemental service to support modifications and adaptations within the school environment. Both in early intervention and school based services, the IFSP/IEP plan of care is developed through team collaboration inclusive of the family and when appropriate, the child. In early intervention the plan of care includes plans to prepare the child for transition out of early intervention. In school based services, when the child reaches the age of 16 the plan of care includes plans to transition the child to adulthood. *Note: Medicare includes diagnoses within their documentation requirements for the plan of care. See, Section 220.1.2.B.

Goals Physical therapists develop goals with the patient/client and/or family/caregiver at the onset of care for a variety of reasons. Goals provide an opportunity for the patient/client and/or family/caregiver to describe what functional changes they hope to accomplish through physical therapy services. The goals established during an initial evaluation, while dynamic, should provide the foundation on which the plan of care is directed. Furthermore, the physical therapist can demonstrate progression (or lack of progression) and ongoing communication of expected outcomes and discharge planning, through updates, changes,


deletions, and additions to these initial goals in subsequent documentation (daily notes, summaries and re-examinations). Goals can be written to address impairments, activity limitations, participation restrictions, and prevention. To utilize goals effectively to direct the progression of physical therapy services, physical therapy goals should be objective, measurable by reevaluation, related to the impairment, activity limitation, and participation restriction and include anticipated timeframes. In addition, most physical therapy goals should be stated in functional terms related to the patient/client rather than the physical therapist. Writing goals in functional terms is important because they support both the medical necessity of the physical therapy services and the need for the skilled intervention of the physical therapists or physical therapist assistants. The functional goals are a PT’s means of conveying to external stakeholders why this patient/client requires physical therapy services, rather than simply a checklist of what needs to be accomplished. Consider the following examples of goals: 1. Increase shoulder flexion to 150 degrees 2. Decrease pain 3. Improve safety The above goals do not identify the specific needs of a patient/client. It is important to go one step further and express why the patient/client needs to increase their ROM or level of assistance. For example, the therapist could document the above goals more functionally: 1. Increase shoulder flexion to 150 degrees to enable overhead activities. 2. Decrease pain to 2/5 on VAS with reaching activities. 3. Patient/client will walk with a standard walker independently within the home to complete activities of daily living. Medicare and third-party payers determine the physical therapy benefit or continuation of physical therapy services based on evidence of a significant functional change in a reasonable amount of time. In other words, payers want to see progress. In certain circumstances, therapists may need to communicate very clearly what this means for the patient/client. For example, for some patients/clients, progressing from a maximum level of assistance to a moderate level of assistance may not appear to be a significant change in their status. However, if that degree of change represents a patient’s/client’s ability to go home with caregiver support, this must be conveyed in the documentation. Time frames for the achievement of anticipated goals and expected outcomes are determined by the physical therapist to maximize the effectiveness of care but must be realistic. They may be written in terms of time (i.e., days, weeks, months) or in terms of visits in which the goal will be achieved. PTs also can clarify if the goal is short term or long term. A short-term goal implies that the patient/client will achieve the activity in the near future (e.g., in a day, within a week, etc.) or may indicate a change that needs to occur before long-term or outcome goals can be met or exceeded by the patient/client.


Finally, goals should be designed based on collaboration with the patient/client and/or family/caregiver. The documentation should reflect both collaboration and agreement on the goals. Updating goals during a physical therapy episode of care is important to clinical practice and should be documented clearly and frequently. Documentation of goals after the initial evaluation will be discussed in later sections. Components of well written goals include: 1. Identification of the person who is receiving therapy and will carry out the program. This is generally the patient/client, but may also be the caregiver or family members. 2. Description of the movement or activity that the patient/client will perform such as stand-pivot transfer from bed to chair. 3. A connection of the movement/activity to a specific function such as to eat breakfast or to perform dressing. 4. Specific conditions in which the activity will be performed such as with full weight bearing on both lower extremities or with the use of a walker. 5. Factors for measuring performance such as with contact guard assistance or with 2/5 pain on VAS. 6. The time frame for achieving the goal.1 1 Physical Therapy Reimbursement News, Volume 13, Number 3 Examples: 1) Short-term goal: Patient/client will walk from his bedroom to the bathroom with a walker in 2 minutes within 1 week to prevent accidents which may lead to falls. 2) Short-term goal: Patient/client will report a decrease in pain in the right shoulder after exercise to 2/10 within 5 visits to enable her to move walker in home. 3) Short-term goal: Patient/client will demonstrate ambulation with a standard walker x 100' with contact guard and stable vital signs in one week. 4) Long-term goal: Patient/client will ambulate independently with a straight cane greater than 500' for community activities in 4 weeks. 5) Pediatric long term goal: In 6 months, the child will walk with one hand held from the family room to the kitchen, a distance of 25 feet, at dinner time.

Interventions for the Plan of Care The physical therapy plan of care should include an intervention plan or a description of the planned treatment. It is important that physical therapists consider a number of factors when they write the plan of care for each patient/client. Factors to consider include, but are not limited to, the following:


1) The patient’s/client’s status, including physical, cognitive, and emotional factors (i.e., acuity, prognosis, learning barriers, language barriers, etc.); 2) The patient’s/client’s expected progression; 3) Discharge disposition/plan (see below); and 4) Whether or not additional staff, either another PT or a PTA, will provide some of the interventions during the episode of care. 5) The physical therapy plan of care in early intervention and school-based practice is often incorporated into the child’s general team intervention plan provided in the IFSP or IEP, respectively. The general plan may also include general methods or strategies that will be used by the team to assist the child and family in early intervention or child in school-based practice in meeting their goals. More specific details regarding the intervention strategies are contained in the therapist’s supplemental intervention plan or daily visit documentation notes. 6) The physical therapy plan of care in a skilled nursing facility is incorporated into the patient’s individualized, interdisciplinary comprehensive care plan which reflects problem areas documented through data obtained on the MDS. The therapist should initiate and document patient and caregiver training in addition to providing the results of the initial evaluation to the interdisciplinary team. When a physical therapist is providing care in conjunction with a physical therapist assistant, the documented plan of care should be a clear communication tool for coordination of care. It is this documented plan of care, (along with verbal communications as indicated) that guides the PTA in following the therapist’s plan during the episode of care. Consider the following two examples: Plan of Care Example A: Gait training, therapeutic exercises, modalities prn Plan of Care Example B: 1) Gait training with standard walker—progress distance up to 100' with stable vital signs. 2) Therapeutic exercises for both lower extremities—avoid flexion past 90 degrees; add up to 5 pounds of weight once AROM is within 15 degrees of normal limits. 3) Pulsed ultrasound to bilateral knees 1.5 W/cm2 X 5 min per knee after therapeutic exercise. Plan of Care Example B, by providing more information, is a much better tool for communicating with other staff in directing the care of the patient/client than Plan of Care Example A. Writing a more detailed plan of care can improve patient/client safety and quality of care. Consider a scenario in which a PT and a PTA are not often in the same vicinity (home health, skilled nursing facility, or acute care). A plan of care that contains the level of detail shown in Plan of Care Example B, in conjunction with the patient’s/client’s anticipated goals, can ensure much better


coordination of care. Written communication should provide the details of when the patient/client should be reevaluated by the PT before the plan of care is progressed. In summary, providing increased detail in the initial goals and the treatment plan identifies the expected progression of the patient/client. The PT/PTA team can follow the patient’s/client’s progression more closely and identify any unanticipated problems or red flags more readily. A detailed plan of care allows patient/client progression (or lack of progression) to be easily identified.

Discharge Disposition/Planning It is considered good practice to anticipate discharge planning from the start of every episode of care. This is particularly important in settings in which a physical therapist’s evaluation assists in determining discharge disposition or when discharge planning takes time and coordinated effort with other health care professionals. In other circumstances, a discharge disposition/plan may be included in a prognosis statement. In certain pediatric settings, discharge and discontinuation may include additional factors. In early intervention and school based practice disposition planning is referred to as transition planning and will be documented in the child’s IFSP and IEP respectively. The transition plan to discontinue physical therapy services should be collaborative and are based on the child’s needs. Individual students may not require skilled physical therapy every year they attend school. They may be discontinued from skilled PT service one year, but referred again, the next year as their individual needs and the physical environment changes.

II. DOCUMENTATION OF A VISIT/ENCOUNTER Documentation of a visit or encounter, often called a daily note or treatment encounter note, documents sequential implementation of the plan of care established by the physical therapist. It includes changes in patient/client status, a description and progressions of specific interventions used that may be documented in a flowsheet format, and communication among providers. It also may include specific plans for the next visit or visits. Documentation of a visit or encounter may include: 1) Patient/client or caregiver report 2) Interventions provided including frequency, intensity, time, duration, and level of physical &/or cognitive assistance provided as appropriate (see discussion of support for timed interventions below). Examples include:  Right knee extension, three sets, 10 repetitions, 10# weight, full range with 100% manual cues to facilitate use of medial quad and 50% verbal cues for timing


Transfer training bed to chair with sliding board; required moderate physical assist of 1 and 100% verbal cues for placement of board  Description of equipment provided (sliding board, long handles sponge) for home use  Description of education/training provided (Pt educated in proper lifting technique from floor to chest height and able to demonstrate technique with up to 25 pounds)  Ultrasound at 1.5 W/cm2 for 5' to the L medial knee joint 3) Patient/client response to treatments/interventions. 4) Communication/collaboration with other providers/patient/client/family/ significant other as applicable/indicated. 5) Factors that modify frequency or intensity of intervention and progression within the plan of care. 6) Plan for next visit(s) including interventions with objectives, progression parameters and precautions, if indicated within the plan of care.

A. How to Convey Skilled Interventions in Daily Notes It is important to convey in the documentation of a visit or encounter (i.e., daily note) that the interventions provided require the skills of a physical therapist or physical therapist assistant under the direction and supervision of a physical therapist. Many therapists consider the daily note to be just a ‘listing’ of what treatments took place. While it is important to include the interventions provided, this does not demonstrate skilled care. Demonstration of skilled care requires documentation of the type and level of skilled assistance given to the patient/client, clinical decision making (PT) or problem solving (PTA), and continued analysis of patient progress. This can be expressed by recording both the type and amount of manual, visual, and/or verbal cues used by the therapist to assist the patient/client in completing the exercise/activity completely and correctly. It can also be illustrated by documenting why the therapist chose the interventions and/or why the interventions are still necessary. Some ways of documenting skilled care include documenting what the therapist observes before, during, and after an intervention, the patient’s/client’s specific response to the intervention, determining functional progress, etc. The interventions provided by the physical therapist/physical therapist assistant should correlate to the impairment, activity limitation, participation restriction, and the goals stated in the plan of care. For example: “Patient required verbal and manual cues to complete shoulder flexion and abduction exercises without substitution. Therapeutic exercise and right shoulder mobilization resulted in increased flexion from 90° to 110° allowing the patient/client to reach overhead and complete activities of daily living. Patient still unable to perform overhead activities needed in performance of job duties.” Another example is “Patient required moderate verbal and manual cues to control movement of right leg in swing phase of gait. Therapeutic exercise to hip flexors/extensors and knee flexors/extensors at 50% of one repetition max has resulted in increased strength. Patient still demonstrates inability to clear right foot 100% of the time during gait increasing her risk for falls”.


When a clinician documents an assessment as “patient/client tolerated treatment well,” it does not provide evidence of skilled services. In addition, it does not give enough information regarding your clinical decision making or problem solving to demonstrate what actually happened if this visit were to be called into question in a legal case. In pediatrics, especially school based practice there may be some misconception that daily notes are not required. However, skilled physical therapy intervention should be documented for each visit. In skilled nursing facility settings, there may not be payer specific requirements for daily notes. However, it is best practice for clinicians to have a system in place to track what skilled interventions were provided in daily treatments and why those treatments required the skills of a physical therapist or physical therapist assistant so that when the weekly note/progress report is written, there is enough factual evidence to complete the documentation efficiently and completely. B. How to Communicate Progression of Care and Ongoing Assessment in Daily Notes At its most basic level, a daily note serves as a record of all treatments and skilled interventions provided along with the time of the services so there is justification for what services are billed on the claim form. For each daily note, there could also be a notation as to whether there were changes in the impairments, activity limitations and participation restrictions as a result of the interventions and if there is progress toward the goals and ultimately toward discharge. (As noted earlier some payer guidelines restrict a physical therapist assistant from documenting this information) If any measurements are taken, they should be recorded and relate back to the achievement or lack of achievement toward the functional goals. When a physical therapist is completing the daily notes, and the ongoing assessment is demonstrated, frequently with this level of detail, a progress summary or progress report may not be required.

C. Progress Reports A progress note or progress report/summary is often referred to in third-party payer, state, and facility regulations. The progress report/summary is similar to a daily note but includes more detailed information on the patient’s/client’s current status as compared with a previous date(s) (i.e., date of initial evaluation, last reexamination, or last progress report). In most cases, important changes in examination findings are described. Note that the daily notes and progress reports/summaries work together. If progress is described in daily notes then a progress report/summary may not be necessary. This is particularly true for shorter or less intense episodes of care. Physical therapists may choose to title certain daily notes as progress reports/summaries and include this level of detail at one time. Progress reports/summaries should be


performed regularly on all patients to substantiate the ongoing need for physical therapy services. The report should provide an update on the patient’s/client’s status as it relates to the physical therapy goals and plan of care. Keep in mind that any note that requires assessment of the patient/client and his/her progression or lack of progression can only be written by a physical therapist. Physical therapist assistants cannot write this type of assessment as noted in APTA policy, Medicare regulations, other third-party payer rules, and state law. While the physical therapist is responsible for progress reports/summaries, the physical therapist may use data gathered by PTAs. In early intervention, a team progress report is provided on a six month basis when the team reviews the IFSP. In this review, the family and child’s progress toward their outcomes and objectives are noted and the plan of care is revised as indicated. In school based practice progress reports to parents are required on the same frequency that parent’s receive reports on academic progress. In the Home Health setting, a progress report is required as part of the recertification process if services are going to continue beyond the current 60 day episode of care. Recertification is required to be completed in the last 5 days of the current certification period. There is also a requirement of individual notes for every patient encounter. In the Skilled Nursing Facility setting, a weekly progress note may be the only required documentation. The physical therapist and physical therapist assistant should collaborate on the information presented in the weekly note to insure the information supports the skilled nature of the services provided during the week and provides objective evidence of progress towards goals. Any further assessment of what changes to the plan of care might need to be made should be completed by the physical therapist. D. Support for Timed Interventions Physical therapists and physical therapists assistants are required to support the reporting of timed procedure and modality codes in their clinical documentation in many settings. This requirement derives from the Common Procedural Terminology (CPT) PageDisplay.cfm&TPLID=59&ContentID=16527 code definitions for procedures and modalities reported by physical therapists. The time reported should reflect direct one-onone contact time with the patient (e.g., Medicare requires documentation of total treatment time spent on timed codes). If the setting does not use CPT coding, such as Home Health and Part A Medicare skilled nursing facilities, then the documentation must substantiate the total visit time. For Medicare regulations on timed codes and documentation of time, please refer to For more information about the Skilled Nursing Facility setting: ageDisplay.cfm&TPLID=174&ContentID=18289


Medicaid regulations may have specific language on documentation for each state. Refer to the following web site for more information: TaggedPage/TaggedPageDisplay.cfm&TPLID=251&ContentID=27388

E. Caution: SOAP Notes and Flow Sheets Many therapists choose to document in a standard SOAP note format for their daily notes and progress notes. While commonly used in clinical practice, SOAP notes are often incomplete. If a physical therapist utilizes the SOAP format, the following guidelines are recommended: S: Subjective: This should reflect the patient’s (and at times caregiver’s) self report of status and response to previous treatment(s). Some tests and measures that are subjective may be included in the subjective portion of the SOAP note (e.g., self report such as the SF-36). O: Objective: This should reflect the physical therapist’s objective findings made through observation of the patient, as well as measurements and tests, such as circumferential measurements for edema, range of motion measurements, or heart rate before and after exercise. The treatment provided to the patient and the response to treatment on that specific date also should be included in this category, but it should not be in place of objective data. A: Assessment: This should reflect the physical therapist’s clinical decision making or the physical therapist assistant’s clinical problem solving, including their professional assessment of the patient’s progress, response to therapy, remaining functional limitations and possible precautions. It should never say “treatment tolerated well.” P: Plan: The physical therapist should provide specific information related to the plan for future services including patient/caregiver education and any possible changes in the treatment program. Do not simply say “continue.” Flow sheets are another common form of documentation for daily notes. While they may be a useful format to note specific interventions such as exercises, and parameters such as repetitions and weights, flow sheets often lack space for the physical therapist to include the elements that made those interventions skilled treatment as well as the assessment of the patient’s status and plans for ongoing care. Evidence of skilled decision making and other critical factors should be included in the daily documentation. APTA’s Guidelines: Physical Therapy Documentation of Patient/Client Management (BOD G03-05-16-41), state that “… other notations or flow charts are considered a component of the documented record but do not meet the requirements of documentation in and of themselves.” SOAP Notes: Pros and Cons




Simple format that is well understood and frequently used by physical therapists. Prompts (S, O, A, P) remind physical therapists to include specific information.

Does not easily offer a category for treatment on a specific date of service. Physical therapists might not know what information to place in a specific category or fail to include useful information because a category does not exist. For instance, the SOAP format does not clearly indicate where they should document a conversation with a physician or case manager.1 1 A Payer’s Guide to Physical Therapy Documentation for Patient/Client Management, Alexandria, VA: Department of Reimbursement, APTA; 2006. III. REEXAMINATION/ REEVALUATION Reexamination is the process of performing selected tests and measures after the initial examination to evaluate progress and to modify or redirect interventions. The tests and measures may be repeated from the initial examination and/or include new elements of tests and measures in order to evaluate the patient/client’s status. Reexamination may be indicated more than once during a single episode of care and for a number of reasons. A reexamination might be indicated for a number of reasons. However, due to certain payer regulations, many therapists confuse a clinical reexamination with a billable reevaluation code. In general, a billable reexamination of a patient/client should occur whenever there is an unanticipated change in the patient’s/client’s status, a failure to respond to physical therapy intervention as expected, the need for a new plan of care, and/or requirements based on state practice acts or other requirements ( In clinical practice, a reexamination and reevaluation can serve many purposes. One of the most important objectives of the reexamination is to determine the patient’s/client’s progress or lack of progress toward the established goals and prognosis. The reevaluation compares similar data at two points in time and determines whether or not the plan of care needs to be updated or changed and how this will affect the expected outcomes and timeframe of care. Physical therapy goals should be addressed noting where progress has (or has not) been demonstrated. If appropriate, new timeframes and new goals should be established, as well as confirmation of the clinical evaluation or impression, prognosis, and discharge recommendations. If progress has not occurred as expected, reasons for the lack of progress should be included (i.e., illness, comorbidity, etc). In addition, any changes to the interventions should be documented. Reexaminations can be performed and recorded only by the physical therapist. In the case of the geriatric patient/client, it is recommended to document vital signs (e.g. blood pressure, heart rate, respiratory rate and pulse oximetry), as well as to record any medication changes with implications for functional recovery. This information may contribute to the information gathering for the Minimum Data Set (MDS). 25

In most cases in pediatric early intervention practice, the comprehensive team reexamination report is required annually as part of the annual formal team review of eligibility for services and review of the IFSP. In school based practice, comprehensive team reexamination, reevaluation and reassessment for the integrated educational assessment are performed every three years or as mandated by state and federal regulations (Individuals with Disability Education Improvement Act, 2004). This is a minimal requirement and may be done more frequently as indicated either by child’s change of status, parent request and team decision or any requirements of individual state practice acts. IV. DISCHARGE/DISCONTINUATION SUMMARY Documentation is required at the conclusion of physical therapy services. The purpose of the discharge summary is to summarize a patient’s/client’s progress toward goals, status at discharge, and future plans for self-management. Essentially, this is the last opportunity a therapist has to convey the outcome of physical therapy services. It is also a time to justify the medical necessity for the episode of care. Medicare requires that discharge summaries include all progress report elements. It is the position of APTA and many state policies and payer regulations that only physical therapists can complete the discharge summary. Discharge occurs based on the physical therapist’s analysis of the patient’s/client’s achievement of the predicted goals and expected outcomes. Important concepts to include in the discharge summary include current patient/client status; attainment of goals; goals that have not been attained; and recommendations and instructions that were provided to the patient/client, such as home program, equipment provided, and any patient/client or caregiver training/education. When a patient/client is discharged to another level of service (i.e., from an acute setting to home health or another inpatient setting), evidence of coordination of care should also be included. Issues related to patient/client compliance also may be noted as well as the number of completed visits. A discharge summary should comment if the patient/client stops coming to therapy against recommendation of the physical therapist. If the patient/client is discharged prior to achievement of goals and outcomes, there should be documentation as to the status of the patient/client and the rationale for discontinuation. In pediatric early intervention, a discontinuation summary is typically written in the format of a Transition Report which provides information on the child’s status and progress during birth to three services as they transition to preschool services under Part B of the Individuals with Disabilities Education Improvement Act, 2004. In school based practice, the closure of physical therapy intervention is termed discontinuation of services. This terminology is consistent with IDEA legislation. The decision is reflected in the IEP. Written documentation of the discontinuation should include a summary of the student’s progress, the current status, and the rationale for discontinuing services. Discontinuation summaries in both early intervention and school based programs typically also provide recommendations for community resources to support the child’s continued health, fitness, development, and well-being. In both early intervention and school based practice settings, a decision to discharge/discontinue physical therapy services is decided between the 26

physical therapist and the team. The decision is related to whether physical therapy services are needed to support the child’s and family’s outcomes on the Individualized Family Service Plan in early intervention or on the child’s goals on the Individualized Education Program in school.

General Documentation Guidelines  Documentation is required for every visit/encounter.  Documentation should include indication of a patient’s/client’s cancellations of appointments and/or refusal of treatment.  All documentation must comply with the applicable jurisdictional/regulatory requirements.  All handwritten entries shall be made in ink, dated, and properly authenticated. Legibility is critical in clinical documentation. If an entry cannot be read, it cannot be understood.  Electronic entries are made with appropriate security and confidentiality provisions.  Documentation must include adequate identification of the patient/client, the physical therapist, and/or physical therapist assistant:  The patient's/client's full name and identification number, if applicable, must be included on all official documents.  All entries must be dated and authenticated with the provider's full name and appropriate designation (license number and printed name if required by state law)  Charting errors should be corrected by drawing a single line through the error and initialing and dating the error or through the appropriate mechanism for electronic documentation that clearly indicates that a change was made without deletion of the original record. Example: Pain in the right shoulder will decrease to 2/10 VAS within 5 ABD 11/2/06 visits. 4  Documentation of examination, evaluation, diagnosis, prognosis, plan of care, progress report, and discharge summary must be authenticated by the physical therapist that provided the service.  Documentation of physical therapist service in pediatrics is aligned with familycentered care. Documentation should emphasize the functional abilities of the child rather than highlight the deficits and should be written in a respectful manner. Therapists often collaborate with the family, child, and other team members on the documentation and record their involvement in the physical therapy services.  Abbreviations should be minimized.  Documentation must be clear about who is providing the service whether it is the PT, the PTA, or both when the PT may perform mobilization and the PTA may perform therapeutic exercises with the same patient/client.  Documentation of intervention in visit/encounter notes must be authenticated by the physical therapist or physical therapist assistant that provided the service.


 Documentation by physical therapists, physical therapist assistant graduates, or others pending receipt of an unrestricted license shall be authenticated by a licensed physical therapist, or, when permissible by state law, documentation by physical therapist assistant graduates may be authenticated by a physical therapist assistant.  Documentation by students (SPT/SPTA) in physical therapist or physical therapist assistant programs must be additionally authenticated by the physical therapist or, when permissible by state law, documentation by physical therapist assistant students may be authenticated by a physical therapist assistant. The following links will provide information regarding student documentation/billing requirements: LATE=/CM/ContentDisplay.cfm&CONTENTID=31946  Documentation should include the referral mechanism by which physical therapy services are initiated. Examples include:  Direct access when permissible by state law.  Request for consultation from another practitioner.  Referral from practitioner authorized to refer per Medicare regulations or state practice act.

Improving Your Clinical Documentation: Reflecting Best Practice

A. Evidenced-Based Practice APTA’s position on Evidence-Based Practice (HOD P06-99-17-21) states: “To promote improved quality of care and patient/client outcomes, the American Physical Therapy Association supports and promotes the development and utilization of evidence-based practice that includes the integration of best available research, clinical expertise, and patient/client values and circumstances related to patient/client management, practice management, and health policy decision making.” Of course, before you can document evidence-based practice, therapists must first know how to integrate evidence into clinic practice. Therapists can demonstrate evidence-based practice in their clinical documentation in various ways: 1. By documenting tests and measures that are valid and reliable for diagnostic and/ or prognostic information.


2. Through the use of standardized outcome measures, which are an effective means of evaluating and communicating changes in a patient’s/client’s impairments and/ or functioning. 3. By selecting and implementing an appropriate plan of care and interventions/treatments based on available research or clinical guidelines and that reflect patient perspectives and preferences and their influence on the plan of care. Keeping up-to-date with current research and expert opinion may be difficult, but there are many tools available to make the process easier. While it is not the intent of this Defensible Documentation for Patient/Client Management Resource to teach evidence-based practice, the following are some tools that can get you started. A) Guide to Physical Therapist Practice. A resource that defines scope of practice; guides patterns of practice; improves quality of care; promotes appropriate use of health care services; and explains physical therapist practice to insurers, policymakers, and other health care professionals. Commerce/ProductDisplay.cfm&ProductID=1332 B) Catalog of Tests and Measures. Describes tests and measures and links to available research on their validity and reliability that physical therapists may use in their patient/client examinations. The catalog is only available on CD combined with the Guide to Physical Therapist Practice. Available at: Ecommerce/ProductDisplay.cfm&ProductID=844 C) Hooked on Evidence. A resource on the APTA Web site that represents a "grassroots" effort to develop a database containing current research evidence on the effectiveness of physical therapy interventions. D) MEDLINE®. The National Library of Medicine's electronic bibliographic database of health care research. Find articles published recently or as far back as the early 1950s. MPLATE=/CM/ContentDisplay.cfm E) Open Door. Provides members with free access to full-text journal articles and other resources relevant to clinical practice whenever and wherever they need it. cfm&ContentID=32354#a

B. Demonstrating Progress


As stated previously, the therapist should carefully consider how the goals, in conjunction with the treatment plan, provide a roadmap for communication and patient/client progression. The initial goals are written after the physical therapist evaluates the findings from the initial examination and determines the patient’s/client’s prognosis in specific terms. Consider the following: What will the patient’s/client’s mobility be like when he or she completes the episode of care? Is it likely the patient/client will be able to return to his/her prior level of functioning? Will he or she require an assistive device or other equipment to promote safety and independence? Will he or she require assistance from a caregiver or community service? What is the potential for improvement in the patient’s/client’s strength, balance, and endurance? What is the impact of a child’s home/family situation on his/her developmental progress? After determining the anticipated outcomes the next step is to establish specific criteria for each outcome. These should be written in terms of function whenever possible and include specific parameters. Parameters are the objective statements of a goal that make it “measurable” and ensure that anyone who reads the goals will have a clear picture of what outcome is expected. Physical therapists can specify the anticipated patient/client goals by a variety of methods including timeframes, expected outcomes (distance, level of assistance, etc). “Measurable goals” are further clarified by the examples below: Example of a short-term goal: Patient/client will perform stand-pivot transfers from bed to chair with full weight bearing on both lower extremities and contact guard assistance within 1 week in order to decrease risk of falls with transfers. Example of a long-term goal: Patient/client will walk 200 feet independently on level surfaces with a straight cane so he can attend the dining room for 3 meals/day within 1 month. Example of a pediatric long term goal: Child will sit independently on the floor with both hands free to play with a toy within 6 months. After the initial evaluation, updating the goals shows others how the patient/client is achieving (or not achieving) the predicted outcome. If a patient/client achieves a goal, this should be documented so others may also know what the patient/client has achieved. This is important in all settings so other health care providers (i.e., nurses, physicians, case managers, etc) will know that the patient/client has achieved the goal. These changes will then drive the subsequent care of the patient/client. Clearly documenting updates of a patient’s/client’s physical therapy goals communicates to third-party payers any functional changes in a patient’s/client’s status and the benefits of the service along with the need for continued services, if indicated. Consider the following: To what extent was the evidence considered prior to developing and implementing the intervention plan that has resulted in less than optimal progress?


The goals should be updated regularly depending on the length of the episode of care. The goals should be updated whenever there is a change in the patient’s/client’s progress or medical status. When goals are initially set by the physical therapist in conjunction with the patient/client and/or family/caregiver, the achievement of the goals is dependent on many factors that may affect the patient’s/client’s progress toward the goals. The physical therapist makes the best prediction of when a patient/client will accomplish the goals, but this can change for a variety of reasons. For example, if the goal is to transfer from bed to chair with minimal verbal cues within 3 days, but the patient/client has more difficulty with bed mobility than expected (an essential component of the goal achievement), then the goal would need to be revised in terms of timeframe or level of assistance. Note: State laws and certain third-party payers may have specific expectations on how often goals are updated. What if a patient/client does not demonstrate the expected progress toward his or her goals? In this case, the physical therapist must analyze/consider any factors that may have prevented progression. For example: Was there a medical issue that prevented progression? Was the patient/client unable to participate in physical therapy as expected? Whenever there is little or no progress toward the anticipated goals, the reasons for the delay should be clearly documented and discussed. The physical therapist should also indicate what measures are being taken to overcome the problems over the next treatment period. Documentation of these clinical decision-making processes indicates the physical therapist’s involvement in the overall care management of the patient/client.

C. How to Convey Medical Necessity and Skilled Care Unsubstantiated evidence of medical necessity and skilled care are two of the most common reasons for payment denial in physical therapy. According to most third-party payers, every patient/client visit must be both medically necessary and require skilled intervention. To effectively establish medical necessity, the documentation must clearly indicate WHY intervention is indicated at the current time. Evidence of skilled service must reflect why the skills of a therapist are required to deliver the necessary intervention versus another provider. Evidence of these two elements is expected in the patient/client records. Documentation of skilled services is also discussed in the section on “Visit/ Encounter Notes.” Suggestions for how a physical therapist might support these two elements in clinical documentation include: 1) Provide a brief assessment of the patient’s/client’s response to the intervention(s) at every visit or event. 2) Document your clinical decision making process. For instance, explain why you changed the patient’s/client’s exercise program, added or discontinued a modality, or progressed a functional activity.


3) Make sure documentation is not repetitive, re-stating the same thing day after day. 4) Make sure that when you re-read your own documentation, there is no doubt that only a skilled physical therapist could have provided the treatment. Suggestions for how a physical therapist assistant might support these two elements in clinical documentation include: 1) Document how the patient/client tolerated the intervention(s) at every visit or event. 2) Document how specific exercises or activities will help the patient/client achieve a goal. 3) Make sure documentation is not repetitive, re-stating the same thing day after day. 4) Make sure that when you re-read your own documentation, there is no doubt that only a skilled physical therapist assistant could have provided the treatment. Lastly, when a payer requests documentation for a particular date of service, review the note(s). It may be necessary to send supporting documentation for additional dates of service, such as the most recent summary of progress or reevaluation, so the payer can fully appreciate the context in which that date of service was provided. For more detailed information on skilled care and medical necessity, go to Appendix E.

D. Documentation as a Risk Management and Compliance Tool Thorough documentation is both a benefit and protection for the patients/clients and the therapist. It serves the patient/client well because it gives all providers involved with the patient’s/client’s care the information they need to make informed decisions and render the best possible care. High-quality documentation serves you well because it is the one thing that provides a real-time, historical account of your encounters with patients/clients and can be an important source of evidence in the event your care is called into question. Documentation is often used as evidence during litigation. If your documentation is nonexistent or incomplete, there is no evidence to support your recall of events, and an attorney can call it into question. If your documentation is solid, it can help support your oral account of events and demonstrate that you met or exceeded the standard of care. With this in mind, when considering documentation from a risk management perspective, it is important that you: 

Follow facility/practice policy regarding documentation. Ensure that documentation meets minimal payer/regulatory requirements.

Record information only on proper forms, and write legibly. If your handwriting is illegible, the note may be considered as not having been written at all.

Date, time, and sign every note. Often, there will be questions regarding the timing of events within the course of a day. If you include the time, there will be no question as to the chronology of events.


Record information as close as possible to the time that you deliver care. Don’t document in advance, and don’t leave important notations for the end of the day or the end of the week.

Use only common abbreviations that are approved by your facility/practice.

Do not change the documentation after the fact. Make identified revisions in documentation according to your facility/practice policy to eliminate any questions about authenticity.

Describe the patient’s/client’s symptoms as they are elicited and offered. Use quotations properly. If a patient/client reports an adverse situation, make sure you respond accordingly and document your response or assessment of the situation.

Be objective and factual—never allow opinions or emotions to become a part of the medical record.

Report the facts in an organized and systematic manner with adequate detail and in chronological order.

Document all telephone calls involving pertinent patient/client information. This includes cancellations, conversations with other care providers or referral sources, etc. Also document any handouts, instructions, or follow-up information that you give the patient/client and/or caregivers with parameters and date. Include the patient’s/client’s name/identifier on each page.

If interpretive services are required in order to communicate with a patient/client who speaks a different language or has a hearing loss or other disability that makes communication difficult, document the method of interpretation that was provided (e.g., face-to-face or telephone interpretation), the name of the interpreter and his/her credentials, what instruction was given, and the result of the instruction (e.g., “patient/client and/or family verbalizes their understanding or can demonstrate…”). Be certain that a HIPAA Business Associate agreement is in place if the interpreter is not part of the workforce or provided by the patient/client.

Follow both internal protocol and external regulations (including HIPAA privacy and security regulations) and policies relative to patient/client confidentiality. These regulations and policies may come from the federal, state, or local government and/or reimbursement sources or other entities. It is important to be mindful of this issue when handling incoming calls related to a patient’s/client’s condition and/or when using electronic documentation.

When using electronic documentation, take steps to protect the confidentiality of the record and alert authorized users to their responsibility to maintain the confidentiality of the record at all times. 33

Document all attempts to contact the referral source and/or payment source (e.g., the insurer). In addition, document any communication with anyone.

Release records only upon consultation with your risk manager and in accordance with organizational/practice policies and laws.

Provide documentation for each physical therapy visit.

Report any information regarding a patient/client incident separately from the medical record, using the proper incident report form.

Information in bulleted list is adapted and excerpted from APTA’s Risk Management in Physical Therapy: A Quick Reference, 2nd edition (Alexandria, VA: APTA; 2005) and Spanish for Physical Therapists: Tools for Effective Communication (Alexandria, VA: APTA; 2006).

Setting Specific Considerations in Documentation Clinical settings influence many aspects of patient/client care documentation. Depending on the setting there may be additional regulations by payer, state, local facility, or accrediting organizations. In addition, various clinical settings have different norms, processes, and influences often outside the control of the physical therapist or physical therapist assistant. For example, in an acute care clinic, patients/clients are often discharged without the knowledge of the treating PT or PTA. In a sub-acute or skilled nursing facility, the Minimum Data Set (MDS) may include specific instructions for therapists related to documentation. For more information related to Medicare in these settings, you can go to the corresponding chapter of the Medicare Benefit Manual found at: For Inpatient Hospital Services, Chapter 1 For Home Health Services, Chapter 7 For Extended Care (SNF) Services, Chapter 8 For CORF Services, Chapter 12 For Outpatient Rehabilitation Services (i.e. any therapy provided under the Part B Medicare benefit), Chapter 15. To search for the local coverage decisions by your Medicare contractor, go to: The following sections are meant to raise awareness of specific regulations by practice setting (additional practice settings will be added in the future). The intent of this


section is not to be inclusive, but instead to 1) raise awareness that additional regulations may exist, and 2) provide suggestions to therapists on how to improve documentation given certain unique problems may that occur in a specific setting. A. Acute Care Hospitals Physical therapists and physical therapist assistants in an acute care hospital contend with many factors that may complicate the provision of physical therapy services and emphasize the need for consistent documentation. For instance, varying patient/client care loads and frequent cancellations due to tests can be challenges when a PT or PTA is attempting to establish and carry out a consistent frequency and duration of patient/client care services. The short length of stay and shifting or unknown discharge plans coupled with increased cancellations due to testing or other activities increase the difficulty of predicting the expected outcome within a defined timeframe. Because multidisciplinary communication and collaboration is so important in the care of patients/clients with acute health needs, the physical therapy documentation is the critical vehicle that will ensure that the goals and outcomes of the care that the PT or PTA gives is communicated among all disciplines working with the patient/client. In cases in which the PTA is the last provider to treat and document treatment of the patient/client, the PT will need to write a discharge summary that outlines the status of the patient/client at evaluation and hospital discharge and assess the achievement (or lack of achievement) of the predicted goals and the expected outcomes. In addition to the standards established under professional guidelines, there are also accreditation standards such as those established by the Joint Commission. This includes documentation of “hand-offs� (i.e., transferring the care of the patient/client to another therapist) to ensure continuity of care, patient/client safety event reporting, multidisciplinary documentation of goals, processes for receiving/transcribing verbal orders, and patient/client education, to name a few. In addition, there are certain abbreviations that may not be used and are included in the Joint Commission "Do Not Use List". You may use this link to learn more about the Joint Commission standards: For more helpful information related to physical therapy in the acute care setting, visit the Acute Care Section’s website at B. Health, Wellness, and Fitness When providing physical therapy services to address physical fitness for individuals or groups in either traditional or non-traditional settings, it is important from a professional and liability perspective that you document the services you provide. The level of detail in your documentation should be based on the complexity of the patient or client, the intricacy of the plan of care, and the frequency of change. More complex patients/clients or settings may necessitate significantly more detail while some community settings and less complex patients or clients may require shorter and less detailed notes. Regardless, all services provided as physical therapy to patients or clients should address the five components of 35

patient/client client management: examination, evaluation, diagnosis, prognosis, and intervention. For more information visit the Physical Fitness for Special Populations web page at: C. Home Health Providing physical therapy services in the home health setting involves creativity, flexibility, and solid documentation skills. Physical therapists need to employ their full scope of assessment skills in order to manage a medically complex individual without the support of a medical facility or quick access to additional staff. Home health services under Medicare Part A are subject to 60-day episodes of care. Due to the relationship between therapy visits and reimbursement under the home health Prospective Payment System (PPS), therapy documentation is under significant scrutiny to determine if services are medically necessary. Attention to detail and use of the various assessment and intervention tools available to physical therapy must be very clear in the documentation. In addition, documentation of impairments, activity limitations, and participation restrictions and strategies to improve functioning is essential. More information on home health PPS can be found at: For payers other than Medicare, it is important to determine whether there are payer-specific physical therapy documentation requirements. The OASIS (Outcome Assessment Information Set) instrument is a documentation tool specific to the home health setting. It is designed to be a discipline-neutral tool that is part of a comprehensive assessment of the patient. It is used at various time points in the 60-day episode of care—the start, the end, when a significant change in condition occurs, and when the patient has ongoing needs into another 60-day episode. The tool measures patient characteristics in clinical, functional, and services domains. OASIS data is used to determine the payment for the episode and to measure outcomes of care by comparing initial answers with final ones. Physical therapists can be called upon to complete the tool at any of the time points. Only physical therapists, speech language pathologists, and nurses can complete the form. More information on the OASIS tool can be found at e. The need for physical therapy alone ensures program eligibility under the Medicare program for home health, thus allowing the physical therapist to assume primary responsibility for care. In these cases, the admission to service is completed by the physical therapist and involves agency-specific consent forms, the OASIS tool, and the comprehensive assessment. This assessment must include therapy-specific items, an overall view of health status and risk factors, and a medication regimen review. All aspects of physical therapy in the home health setting require integration of good documentation practice to support the delivery of clinical care. In cases that involve the services of a physical therapist and a physical therapist assistant (where allowed by law), routine communication is critical to ensure appropriate direction, supervision, and implementation of the plan of care. Clearly written documentation is an


effective tool for communication and evidence of verbal interaction must be reflected in the medical record. Both the physical therapist and the physical therapist assistant share the responsibility in documenting that the supervision requirements are being met. Home Heath physical therapists and physical therapist assistants may have access to electronic health records and documentation systems which include patients’ personal health information (PHI). It is important that appropriate safeguards to protect the organization’s data are implemented. This would include physical safeguards which are physical measures, policies, and procedures to protect electronic information systems and equipment from natural and environmental hazards, and unauthorized intrusion. For more information on privacy and security of personal health information, go to the following link: dPageDisplay.cfm&TPLID=183&ContentID=18513 For more helpful information related to physical therapy in the home health setting, visit the Home Health Section’s website at D. Outpatient Services Payment sources for outpatient physical therapy services are varied, which offers many challenges. Third-party payment is when an entity outside of the physical therapist/patient relationship pays the bill. Examples are private payers, managed care organizations, provider networks, direct contracts with employers, Medicare, Medicaid, public school systems, and workers' compensation programs. First-party payment is when the patient pays the bill for treatment and then may choose to submit the claim to his or her insurance company. For all payment systems, it is important to understand CPT and ICD- 9 CM coding. It is also necessary to understand the difference between billing and payment policy; each payer may implement its payment systems differently, regardless of the coding on the claim. For more information, please follow the following link: nly.cfm&ContentID=27185. Many payers have specific documentation requirements, such as established frequency of documentation and/or forms to use in order to get authorization for treatment. It is best to check with each patient’s/client’s insurance company to determine its requirements. To decrease the risk of denials, you may need to use the insurance company’s specific forms, include certain demographic or diagnostic coding information, and/or send more information than requested to demonstrate the need for continued care. The most important thing you can do is to give the payer’s reviewer a total picture of the patient/client in the documentation Documenting in functional terms and defining the patient’s/client’s functional limitations goes a long way toward making the reviewers understand what you are trying to accomplish for the patient/client. For other helpful information related to physical therapy in the private practice outpatient setting, visit the Private Practice Section’s website at


E. Skilled Nursing Facility / Long Term Care Patients residing in a skilled nursing facility (SNF) can receive physical therapy treatment under the Medicare Part A (inpatient) benefit or the Medicare Part B (outpatient) benefit. Medicare Part A services are paid for using a prospective payment system (PPS) methodology, while Part B services are paid for under the Physician Fee Schedule. To qualify for Medicare Part A services, a patient must require daily skilled nursing and/or rehabilitation services, and have had a 3-day qualifying stay in a hospital. For more information, follow this link: ageDisplay.cfm&TPLID=174&ContentID=18289 The Minimum Data Set (MDS) is the assessment instrument that determines the Part A per diem payment in the SNF PPS. The information on the MDS classifies residents into resource utilization groups (RUGs) to determine payment to the facility. The treatment you provide in a SNF must meet the same standard of being “skilled services” as in any other setting; therefore, it is critical that the documentation illustrate this. The information you record on the patient’s chart must support the MDS level being billed. Because SNFs also provide outpatient services, your documentation for Part A services must meet criteria as explained in The Components of Documentation section. The combination of therapy documentation and nursing documentation should support the skilled services provided at the RUG level being billed. Services provided to patients in the long-term care setting under Medicare Part B follow the same guidelines as other outpatient physical therapy settings. For treatment under either Part A or Part B, there was a revision in the Medicare Benefit Policy Manual, Chapter 8, Section, which clarifies that the initial therapy evaluation of a SNF patient must be performed in the SNF; you cannot use an evaluation that was performed in the acute care or rehabilitation hospital settings. You may find more information about SNF-related therapy evaluations by going to the following link: Finally, the effective delivery of physical therapy services, and the documentation of such, has an impact in the state and federal survey process. It is important to understand the survey process and the role of physical therapy in the facility. For more helpful information related to physical therapy in the long-term care/skilled nursing facility setting, visit the APTA Section on Geriatrics’ Web site at

F. Inpatient Rehabilitation Facility (IRF)


Patients admitted to an inpatient rehabilitation facility (IRF) receive physical therapy treatment under Medicare Part A, which is paid for using a prospective payment system (PPS) methodology. To qualify for Medicare Part A services, a patient must require at least 3 hours of rehabilitation services 5 days per week. For more information, follow this link: TaggedPageDisplay.cfm&TPLID=172&ContentID=18287 The Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF_PAI) is used to determine the per diem payment in the IRF PPS. The information on the IRF-PAI classifies residents into case management groups (CMGs) to determine payment to the facility. Thorough documentation to explain why the patient required 3 hours of therapy is necessary to justify why the patient could not have been treated in a less-expensive setting. The treatment you provide in an IRF must meet the same standard for “skilled services” as in any other setting. The information you record in the patient’s chart must support the CMG level being billed. The inpatient rehabilitation prospective payment system has a ‘built-in’ outcome component to it. When a patient is discharged from the IRF to a home health agency or to outpatient rehabilitation services, the IRF receives 100 percent of the patient’s CMG payment. However, if a patient is discharged to a skilled nursing facility the IRF receives only 75 percent of his or her CMG payment. Therefore pre-admission screening of patients admitted to IRFs is important to ensure they can tolerate the level of rehabilitation and have an adequate discharge prognosis before they are admitted to the IRF.

G. Long Term Care Hospitals (LTCH) A long-term care hospital (LTCH) has greater than 25 days as an average length of stay. A facility also may be considered a LTCH if the length of stay averages 20 or more days, and 80 percent or more of its annual Medicare discharges have diagnoses that reflect a finding of neoplastic disease in the 12-month cost-reporting period ending in 1997. LTCHs usually provide extended medical and rehabilitative care for clinically complex patients who frequently suffer from multiple chronic and acute conditions. Services typically include comprehensive rehabilitation, respiratory therapy, head trauma treatment, and pain management. The LTCH system uses the same Diagnosis Related Groups (DRGs) for payment as are used under the inpatient hospital PPS. However, they are weighted to reflect the greater complexity of the cases.

H. Pediatrics 1. Early Intervention Physical therapist practice in early intervention (EI) incorporates unique features that may alter the typical physical therapy documentation process. Physical therapy services


provided to children from birth to age 3 years are part of a child’s and family’s Individualized Family Service Plan (IFSP) under Part C of the Individuals with Disability Education Act (IDEA) (2004). Early intervention services are family centered and typically provided in the child’s natural environment. Documentation is family friendly, written in lay language with minimal medical or technical terminology so that it is meaningful to all team members, including the family and nonmedical professionals. In early intervention documentation, the physical therapist (PT) refers to the child as a “child” rather than as a “patient” or “client,” as reflected in the Guide to Physical Therapist Practice. In addition to state physical therapy practice acts, compliance with the delivery of physical therapy as part of EI services is regulated by IDEA federal legislation and its corresponding state legislation on early intervention. Also, in some states payment for a portion of early intervention physical therapy services may be through the state’s Medicaid plan or other payer sources. Documentation, therefore, needs to meet the standards established by each of these specific payers. All physical therapists documenting services to children need to be aware of both federal and state requirements for how long medical records are to be maintained. Initial Examination In early intervention, a multidisciplinary team conducts and documents the initial examination, referred to as an evaluation and assessment. The physical therapist contributes to the process but also may need to maintain supplementary documentation not required for the early intervention team report. Such information may include detailed information related to the child’s musculoskeletal or neuromuscular status. The team report is to represent the child’s functioning in 5 developmental areas: 1) physical, 2) cognitive, 3) communication, 4) social or emotional, and 5) adaptive. The report also serves to document the child’s unique strengths and needs in these 5 areas. In some cases, the physical therapist may be requested to conduct a separate evaluation and assessment for a child in early intervention who was not previously receiving physical therapy services. In early intervention, physical therapists collaborate with other team members, including the family, in the development of the IFSP. This plan documents the child’s current levels of development; information voluntarily provided by the family on their resources, priorities, and concerns related to enhancing the development of their child; measureable results or outcomes (child and family); early intervention services to be provided (including length, frequency, intensity, duration, and method of delivering services); natural environment in which services will be provided; identification of service coordinator; and plan for transition (components listed in IDEA 2004, Sec. 636). A physical therapist may elect to provide additional documentation in the form of a supplemental intervention plan that delineates more specifically the physical therapy intervention strategies to be used in providing early intervention services for the child. Visits In early intervention, physical therapists typically document their visits (also known as daily encounters) on a standard form developed at the county or state level for early


intervention services. In many cases, the family receives a copy of the form, and so it is structured to be family friendly. This form also is shared with other early intervention providers who serve the child. The documentation usually is structured to capture what interventions were performed during the visit to address the outcomes on the IFSP, progress towards achievement of the outcomes, family input, suggestions for the family, and follow-up plans of the provider. In addition, in some counties or states, a more detailed progress note may be required periodically, such as bimonthly. Reexamination In early intervention, formal documentation related to reexamination occurs at a minimum of every 6 months and takes the form of a team review of the IFSP. During this review, the team documents the child’s and family’s progress toward achieving their outcomes and any required revisions to the outcomes or services. At least annually the review is more comprehensive, based on a reevaluation in order to document the child’s continued eligibility for early intervention services and to update the service plan. Discharge/Discontinuation IDEA, in early intervention, does not require formal physical therapy “discharge summaries” because the entire team, of which the PT is part, makes the decisions on discontinuing services. However, it is important that the physical therapist check his or her state practice act and physical therapy board regulations to determine if there are requirements for the completion of a discharge summary. To find information on your state practice act, click here. The physical therapist may document what is referred to either as 1) a discontinuation summary, if the child is “graduating from” or leaving early intervention service, or 2) a transition summary if the child is transitioning to preschool services under Part B of IDEA (if applicable in the state). Physical therapists working in early intervention also may be required to contribute to documentation related to the IDEA Part C state monitoring program (State Performance Plan) of global child and family outcomes for accountability to the federal government (Office of Special Education Programs). Typically the status of the child and family on set outcomes is documented at entry and exit from the early intervention system (Early Childhood Outcomes Center). Resources McEwen I. Providing Physical Therapy Services Under Parts B & C of the Individuals with Disabilities Education Act (IDEA). Alexandria, Va: Section on Pediatrics of APTA; 2000. Public Law 108-446, Individuals with Disabilities Education Improvement Act of 2004, 118 Stat. 2647-2808.


Building the Legacy: IDEA 2004. U.S. Department of Education. Part B of this Web site, services for children 3-21, is currently available and provides general information on the legislation that is also relevant to early intervention. Part C of this Web site is under development and will provide resources on implementation of Part C IDEA regulations. The Early Childhood Outcomes Center.

2. School-Based

Physical therapy is provided in the school system as a related service for a student qualifying for special education under IDEA (Individuals with Disabilities Education Act, 2004). Physical therapy services also may be provided to individuals under Section 504 of the Rehabilitation Act of 1973 if the student does not meet the eligibility criteria for inclusion in special education but has a disability as defined under federal law. Under Section 504 physical therapy may provide specific accommodations, modifications, and adaptations enabling students to access and participate in the educational environment (see Section 504 below). In addition, there are school-based services that are covered under the Medicaid program. IDEA, Part B and the Individualized Education Program Physical therapy is a related service under Part B of IDEA; a supportive service to assist a child with a disability to benefit from special education services. Special education provides specially designed instruction to meet the individual needs of a student with a federally recognized disability. An Individualized Education Program (IEP) team develops an educational program for each identified student based on his or her unique needs. Members of the IEP team include the student’s parents/guardians, a regular education teacher, a special education teacher, a representative of the public agency, someone who can interpret the instructional consequences of the evaluation results, other individuals who have knowledge and/or expertise relevant to the child (such as the physical therapist), and the child, if appropriate. The IEP team collaborates to develop the IEP document. The IEP document outlines current levels of educational performance (this includes physical functioning), measurable annual goals (in most states, objectives), specific special education, related services and supplementary aids/services to be provided, how the child will participate with their non-disabled peers, modifications necessary for state or district assessments, projected dates for services, modifications, frequency, duration, a description of how the goals will be monitored and progress reported, as well as appropriate transition plans.1 Physical therapists are a part of the IEP team; however, educational goals are discipline free, meaning the goals are developed by the team to meet the needs and priorities of the student. The IEP team decides if physical therapy services are necessary as part of the student’s educational goals or their access and participation in the educational


environment. The IEP team determines the frequency and duration of relevant physical therapy services, based on the recommendations of the PT. As a related service, a physical therapy examination for a student receiving special education services is required initially and again at least once every 3 years as part of the integrated educational assessment, when a physical/motor concern has been identified for that student (check your state practice act because it may differ). The evaluation and assessment of the student reflects how the student is functioning in the educational environment. Observations may be necessary in the classroom(s), cafeteria, school bus, playground, and other locations throughout the school. Input from the educators as well as other school personnel is essential. Unlike more traditional medical model assessments, the IEP assessment must be presented in a format all members of the IEP team can understand. As part of the IEP team, after each interaction, physical therapists document all:  Strategies, 


Staff/student training and education, and

Communication with the student’s parents/guardians or community based services.

IDEA requires that progress be reported to parents at the same frequency that is provided to children who do not have a disability, concurrent with the issuance of report cards. Discontinuation of Physical Therapy Services Physical therapy services may be discontinued in the school system if the IEP team decides the services are not necessary to the student’s educational goals or their access/participation in the educational environment. Based upon the recommendations of the IEP team, physical therapy services are available at any time during the student’s participation in the educational system, usually through the age of 21. It may be appropriate to discontinue physical therapy services one year but later resume the services as the student’s needs and priorities change. The IEP team can determine from one year to the next whether physical therapy services will be necessary during the upcoming school year based upon the planned educational objectives and the student’s ability to access/participate in the current educational environment. Although the discontinuation of physical therapy services would be noted in the IEP document, the physical therapist needs to summarize the student’s current status as part of a final summary to close the current episode of care. Transition Planning Appropriate transition planning is a necessary component of the IEP document. For students aged 16 and older transition means there is a coordination of services to prepare for opportunities when the student leaves school. Physical therapy can ensure the student is functioning at an optimal level in a variety of environments to enable the student’s full potential. The physical therapist may assist in identification of appropriate assistive


technology or training necessary for a student’s successful integration in new environments. Documentation for school-based physical therapy services that follow IDEA regulation and philosophies are similar to procedures described in the Guide to Physical Therapist Practice. There are a few differences in terminology and procedures. School-based PTs use the terms “child” or “student” instead of “client” or “patient.” These PTs collaborate with IEP team members for instructional objectives, compared with the typical approach for the establishment of discipline-specific goals. Physical therapists need to be familiar with their individual state’s practice act and regulations related to school services to ensure that documentation required by the local school district for the IEP is sufficient to meet all aspects of professional documentation in their state. Supplemental documentation of daily visits, specific procedures and assessment time frames may be indicated to ensure compliance with professional documentation standards. All therapists documenting services to children need to be aware of their state requirements for how long documents are to be maintained. If services are billed through Medicaid additional documentation may be necessary. Section 504 of the Rehabilitation Act of 1973 If the student does not meet the eligibility criteria for inclusion in special education, Section 504 of the Rehabilitation Act of 1973 entitles people with disabilities protection under civil rights law. Children or students with a permanent or temporary disability, a physical or mental impairment that limits one or more major life activities, might need physical therapy at school to accommodate for the disability. The local school district may have a written 504 plan with the type of accommodation along with the frequency and duration of physical therapy services; however, individual physical therapists must also ensure that their own documentation follows the requirements and criteria of their individual state practice acts. For more helpful information related to physical therapy in the pediatric setting, visit the Pediatric Section’s website at Reference Building the Legacy: IDEA 2004. Washington, DC: US Department of Education, 2004. Available at: Accessed on March 26, 2008. 1

Resources McEwen, I. Providing Physical Therapy Services Under Parts B & C of the Individuals with Disabilities Education Act (IDEA), Section on Pediatrics, APTA 2000. Public Law 108-446, Individuals with Disabilities Education Improvement Act of 2004, 118 Stat. 2647-2808.

44 Special Education & Rehabilitative Services, The Rehabilitation Act.

I. State Physical Therapy Practice Acts References to state laws governing physical therapy services are found throughout this document. Every state has different language in their state practice acts, and many include specific language related to documentation of patient/client services. They may include issues of specific types of documentation required, minimum timeframes for documentation, and even scope of practice issues. In determining what is required by your state, you must review your state law. edPage/TaggedPageDisplay.cfm&TPLID=201&ContentID=21791

Additional Topics in Documentation of Patient/Client Care A. Abbreviations Abbreviations can be a quick and efficient way of documenting information. However, use of unknown or confusing abbreviations can be the source of communication breakdown. APTA does not endorse any particular set of abbreviations and recommends that physical therapists use abbreviations sparingly. Facilities/agencies should clearly define what abbreviations are allowed in clinical documentation. Improper and excessive use of abbreviations also can cause frequent denials in payment. A clinic may wish to develop a key of frequently used abbreviations on most documentation forms or request that therapists completely spell any word the first time it is written with the shortened form in parentheses; for example, American Physical Therapy Association (APTA). In addition, you should send your approved abbreviation list with any requested documentation that will be reviewed by payers. This will assist the payers in their review process.

B. What to Maintain in a Patient/Client Record Specific content of medical records may vary from clinic to clinic depending on state law, survey/accreditation standards, payer regulations, and local facility policy. Content also can vary according to specific patient/client related needs, events, and activities.


Below is a list of documents and forms that may be included in patient/client records (this list is not inclusive): Signed consent for treatment Referral, if indicated Privacy notice receipt acknowledgement Insurance verification (authorization/signed certification/recertification, etc) Evaluations/reevaluations (including special reports or results of objective tests or measures) Plan of care if not contained in the evaluation/reevaluation Daily visit/encounter notes and summary of progress (including copies of patient education/home exercise materials) Progress reports Equipment information Discharge summary Letters/communications Flow sheets/exercise forms No-show/cancellation documentation Service / Billing / Activity logs Other examples: letters of medical necessity C. Claims Denials Related to Deficient Documentation Common denial language on the Explanation of Benefits (EOB) may read: a. b.

“Documentation does not support the claim.” ”Medical necessity is not supported by the documentation.”

How to Handle Denials: 

• In the skilled nursing facility, establish a system to insure you are notified immediately of any denials the provider might receive for physical therapy services provided to its residents.

Review the Explanation of Benefits (EOB) voucher. That voucher should have a code with a descriptor that states why a denial was made.

Review your claim form and documentation to see if you have grounds for an appeal.

Appeals should be submitted in writing and not initiated over the phone. It is recommended that you mail the appeal with a “return receipt requested.” Submit in a timely fashion as specified on the EOB.

Forward your documentation along with the letter of appeal but make sure that the documentation supports your case. Rather than sending in documentation of only 1 day of service, send in documentation for dates of service both before and after the date in question, in addition to the most recent re-exam or progress report. (Contact the


contractor if you have any questions about what service dates to include). For appeals of a claim for therapy provided in the SNF, send all supportive documentation (including nursing notes and the MDS) to demonstrate the need for skilled services. 

You may choose to support your appeal with your state practice act, APTA’s Guide to Physical Therapist Practice, APTA’s Standards of Practice, a copy of the patient’s/client’s benefit language, and the records of any conversations that the office staff has had with the payer’s professional services personnel. For more information about Medicare’s five levels of appeal, go to: D. Tips for Improving Documentation Efficiency      

Document at the point of care—while you are with the patient/client. Develop specific forms related to common diagnoses or specific daily note forms that include ‘cues’ for the necessary documentation elements. Investigate electronic patient record options. Document concise information and avoid long paragraphs. Document only the information that is necessary for historical data, support of skilled care, and communication. Use as many objective tests and measures as necessary to demonstrate the impairments, activity limitations, and participation restrictions of the patient.

Frequently Asked Questions A. Administrative Can our PT aide or administrative personnel ever document in a patient’s record? Yes, administrative or support personnel can document administrative information such as schedule changes or authorization updates in a patient’s record or chart. In addition, support personnel may be able to assist a therapist in recording information in a patient’s record as directed. For example, if a therapist is measuring range of motion or girth, another person may be recording that information as appropriate in the chart. It is recommended that each facility include in its documentation policy what information can be documented and by whom and what kind of authentication is required.

How long do I need to maintain patient/client records? There is no one answer to that question. There are a variety of rules, regulations, or standards that might apply (i.e., HIPAA or state statute, whichever is the longest). The American Health Information Management Association (AHIMA) publication “Practice


Brief: Retention of Health Information (Updated)” can assist in determining the requirements for your particular service. It can be found at ame=bok1_012545 This publication includes AHIMA’s retention standards in addition to tables citing agency, federal, and state laws or regulations covering retention standards. In addition, there are may be regulations regarding retention of records in the Medicare Conditions of Participation. In Pediatric settings, PT’s who provide services to children in federally funded school settings to which the Individuals with Disabilities Education Act (IDEA) applies, should follow the provisions of the Family Educational Rights and Privacy Act (FERPA) governing educational records. Physical therapy documentation in this setting would be considered a part of the child’s educational record. You can access information about FERPA at the following web site: How long do I need to maintain billing records? The 2009 Medicare Physician Fee Schedule Final Rule (CMS-1403-FC) modified the requirement that “a provider or supplier is required to maintain ordering and referring documentation, including the NPI, received from a physician or eligible NPP” in order to “match the information on the Medicare claims form”. Since there may be delays in claims submission and payment, CMS revised the requirement to maintain ordering and referring documentation for 7 years from the date of service, rather than 7 years from the date of payment. However, it is important to check all rules, regulations, or standards that might apply (i.e. state statute) and adhere to the most strict. Do I need to keep two charts on a patient/client if he/she is using two different insurances? No. The medical record for the patient/client should be in one chart. All patient/client management should be documented in one place and should be inclusive of all diagnoses regardless of insurance. Can I take patient charts home to complete? According to HIPPA and other federal and state regulations, health information is protected and must remain confidential. One problem with taking charts home is how they are transported to and from the office and who might have access to the medical records at any given time. If you transport records anywhere, you must ensure that they are kept in a locked bag and remain accessible only to you at all times. You should always comply with the policies and procedures of your clinic or facility related to the management of patient records.


For PT’s in school-based settings, the Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) is a Federal law that protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education. For more information, go to:

Can I use my home computer to document patient records? According to HIPPA, FERPA and other federal and state regulations, health information is protected and must remain confidential. If you utilize a personal computer for documentation of patient services, you must comply with all federal and state regulations regarding confidentiality; include password access, encryption, etc. B. Documentation of Communication and Collaboration

How should I document verbal orders in a patient’s/client’s medical chart? You may receive verbal orders in an inpatient or outpatient setting. Depending on the practice setting, you should check with the policies and procedures of the clinic or facility, state practice act, and payer requirements to determine if there are any procedures for documenting verbal orders. In addition, if the facility or practice is accredited by an agency such as CARF, CHAPS, or Joint Commission there may be particular standards that are required for compliance. Medicare also includes procedures for documenting verbal orders in its requirements in the hospital conditions of participation. Do I need to document every phone call or contact with a patient’s/client’s physician or other health care provider? Communication with the patient/client, family/caregiver, and/or other professionals, health care or otherwise, should always be documented.

C. Forms and Format Can I use flow sheets for documenting and tracking changes in a patient’s/client’s exercise program? APTA’s Guidelines: Physical Therapy Documentation of Patient/Client Management, (BOD G03-05-16-4) states that “other notations or flow charts are considered a component of the documented record but do not meet the requirements of documentation in and of themselves.” If a flow sheet is used, additional documentation needs to be included, such as the patient’s/client’s response to the intervention or any adverse reactions. Evidence of skilled decision making and other factors related to the intervention are always a requirement and should be included in the daily documentation.


D. Content I would like to improve my documentation, including more of a focus on functional outcomes. What resources can help me? APTA’s Guidelines: Physical Therapy Documentation provides the information that APTA recommends being included in the style/format you select. The information may be organized in a way that works for your setting. You can find these guidelines and other pertinent information on documentation at PT Practice/Documentation. The Guide to Physical Therapist Practice is a good source for determining the appropriate terminology. You may also refer to the Guide for both “anticipated goals” and “expected outcomes” when addressing function in your notes. Generally, anticipated goals and expected outcomes are related to impairments and functional limitation. Global outcomes are related to disability, secondary prevention, and optimization of patient/client satisfaction. The language in the Guide should be helpful in ensuring that your notes adequately address function. For additional information on the topic, review PT Magazine articles such as the following: 

“To Compare Apples With Apples: Guide-based Documentation,” June 1998.

“Patient Management Form: The Next Generation,” the updated version of patient/client management templates (inpatient and outpatient version), September 1999. “The Reliable Resource: Physical Therapy Documentation.” September 1999. You also may want to refer to the March 1996 PT Magazine article “Improving Functional Reporting,” which includes a short bibliography of other sources.

 

In order to decrease the time it takes to document, my facility wants us to use a ‘document by exception’ process. What is this? Generally, documentation by exception means that the facility has determined a clinical protocol or pathway of interventions, goals or outcomes that are expected in the course of a patient’s episode of care, sometimes with timeframes. The protocol or pathway is then copied and placed in the patient’s chart. The only documentation then is any status or event which is not indicated on the protocol or pathway. APTA does not recommend this type of documentation for physical therapists for many reasons. It does not allow for an individualized plan of care nor will it meet most payer or regulatory requirements for documentation. You may consider having a pre-formatted evaluation or treatment note, but interventions, goals and prognosis, along with the timeframes for each should be individualized to the patient / client needs. Does APTA have an approved abbreviations list for physical therapy?


APTA does not have an approved abbreviations list. There are many partial published listings of abbreviations and acronyms, such as those found in any of the widely used medical dictionaries (e.g., Dorland’s, Webster’s, Stedman’s). There are perhaps as many variations in the forms of many abbreviations as there are listings (e.g., one source abbreviates “twice a day” as “b.i.d.” while another source abbreviates it “BID.” One of the most comprehensive and authoritative listings is a book titled Medical Abbreviations: 28,000 Conveniences at the Expense of Communications and Safety, by Neil M Davis (published by Neil M Davis Associates, Huntingdon Valley, PA). This edition was published in 2006. This book should be found at any medical library or PT school library. A cautionary note: The more abbreviations you use, the lower the chance that all readers will be able to understand what you are trying to communicate. Use abbreviations sparingly. Should incident reports be kept in the patient’s/client’s chart, or a separate file? Do the circumstances of an incident make a difference relative to how it is reported and filed? As a general rule, incident reports should not be included as part of a patient's/client's medical record. In the skilled nursing facility and inpatient rehabilitation facility, physical therapists should educate themselves on the facility policy related to when an incident report should be filled out and the process for insuring it gets to the appropriate people. It is recommended that physical therapy practices have a standard incident report and appropriate policies and procedures in place so that all staff have clear guidance on matters such as: when an incident report is required, who can fill it out, who signs the forms, who reviews the forms, and what actions are taken as a result of a report (e.g., how the action of filling out an incident report is documented and where). It is prudent to develop an incident reporting form and related policies and procedures in consultation with legal counsel to ensure that you have addressed the needs of your setting appropriately. If you don't already have an attorney, APTA’s legal resources Web page – 75&TEMPLATE=/CM/ContentDisplay.cfm is a good place to start your search. This page has been designed to help members find attorneys who are familiar with their state laws and can provide them with personalized assistance. For more on incident reporting, see Other Issues below.

Other Considerations A. Confidentiality It is very important that the documentation of a patient’s/client’s care is kept confidential. All patient/client documentation must be kept in a secure area with access limited to appropriate staff. Documentation in hard copy or electronic formats must not be 51

accessible/readable by unauthorized individuals. If there is a name on the chart, it should be kept face-down so the name is not displayed, and the chart should never be left unattended. Therapists should be careful not to discuss patient/client cases in open/public areas such as elevators or lunch rooms. The Health Insurance Portability and Accountability Act (HIPAA) addresses the security and privacy of protected health information (PHI) in all mediums. It includes provisions for establishing and maintaining proper access, use and disclosure of PHI and electronic protected health information (EPHI), which includes patient/client care documentation and related data such as billing records. Some of the main objectives of HIPAA are to decrease fraud and abuse and protect patient’s/client’s rights including the privacy of health-related data. It is important that you have procedures in place related to HIPAA and that you know the regulations for governing you as a covered entity for releasing any patient/client information. There are other specific agreements such as the HIPAA Business Associate agreement that you may encounter. The definition of a business associate is a person or organization that performs a function or activity on behalf of a “covered entity” such as an interpreter service that is providing interpretation services for your patient/client. If you need additional information regarding HIPAA go to: dPageDisplay.cfm&TPLID=183&ContentID=18513 or In Pediatric settings, PT’s who provide services to children in federally funded school settings to which the Individuals with Disabilities Education Act (IDEA) applies, should follow the provisions of the Family Educational Rights and Privacy Act (FERPA) governing educational records. FERPA is a Federal law that protects the privacy of student educational records. Physical therapy documentation in this setting would be considered a part of the child’s educational record. You can access information about FERPA at the following web site: B. Incident Reporting As noted above, incident reports should not be included as part of a patient's/client's medical record. For additional information on the topic, check out these resources:  

The September 1996 PT Magazine article titled “Incident Reports: Protecting the Record.” The Joint Commission Web site at and the Commission on Accreditation of Rehabilitation Facilities Web site at If you are Joint Commission or CARF accredited, you will definitely want to be sure you are in compliance with any standards or requirements they may have regarding incident reporting. If you are not accredited by either of these groups, you may still find their standards and guidelines useful as you craft/review your policies and procedures in this area.


If you have workers' compensation insurance (WCI) for your staff, then you might find it useful to contact your WCI carrier to see if they have any particular forms or information that they look for on incident reports.

Finally, following are some general Dos and Don'ts related to incident reporting, excerpted from Risk Management in Physical Therapy: A Quick Reference, an APTA publication. This publication is available for purchase through our Service Center at 800/999-2782, ext. 3395 or via our online store at (Order No. P-169-05, member price $9.49). What you should do…     

 

DO follow the incident reporting policy that is in place in your workplace and alert the risk manager and/or immediate supervisor to what has happened as soon as possible. DO notify the referring physician or other health care provider immediately whenever an injury occurs, existing signs or symptoms worsen, or new signs or symptoms develop. DO ensure that the patient/client receives appropriate care after an incident. Most facilities provide this care at no cost. DO listen to your patient’s/client’s concerns, be supportive, and be calm. DO record only factual information regarding the incident when you fill out an incident report. Once you complete an incident report, it should be given directly to the supervisor or risk manager, and you should wait for further direction before doing anything else. DO isolate, tag, and secure any equipment involved in an incident so that it will not be used again until it has been certified as completely safe. DO be available for follow-up as needed after the incident. If it seems likely that the incident is going to lead to a claim, you will want to consult with your risk manager/supervisor and notify your professional liability carrier, who can provide guidance.

What you should not do…    

DO NOT discuss the relative guilt or innocence of anyone involved in an incident or problems with any piece of equipment used. DO NOT make inferences related to cause in your incident report. When completing an incident report or an unusual occurrence report, it is critical that you only report factual information regarding the incident. DO NOT enter your incident report into the patient’s/client’s chart. DO NOT attempt or document attempts to do further investigation into the cause of the incident. This is the responsibility of your organization’s risk manager and/or designated attorney. Any notes or documents may be discoverable (to what extent will vary by state). This is the reason a risk manager or attorney should be responsible for the investigation.


C. Electronic Patient Records No discussion of current trends influencing documentation standards would be complete without mention of electronic patient records. All trends point to electronic communications, including patient medical records, becoming more prevalent in health care. Electronic documentation can have many benefits for physical therapists, but careful consideration should be given to what type of system would work best for your practice. In November 2005, APTA created a document, Risks, Benefits, and Responsibilities Related to the Use of Electronic Communication Within Patient Care, to help practitioners be ethical, legal, and informed users of electronic communications within patient/client care. Because the use of electronic communications and other technology within patient/client care is growing and technical and regulatory standards are continually evolving, this document is intentionally non-prescriptive. Rather, it provides an orienting framework to general risks and benefits associated with the use of electronic communications, as well as the risks, benefits, responsibilities, and considerations specific to four pertinent topics—security and encryption, scope of practice, ethics and legal issues, and reimbursement. This document and other electronic communications/telehealth information can be found at: TaggedPageDisplay.cfm&TPLID=199&ContentID=21898 In the summer of 2006, APTA launched APTA CONNECT, a point-of-care, computerized patient/client record system that combines the clinical expertise of the American Physical Therapy Association and its members with the technological capabilities of Cedaron Medical, Inc. This system incorporates patient/client documentation with various clinic management programs. APTA CONNECT was designed with the assistance of more than 50 physical therapists who are well known and highly respected in their areas of expertise. It is also the platform for the first national outcomes database for physical therapy services. Information on APTA CONNECT can be accessed at the following link: CM/ContentDisplay.cfm.

D. Documentation Tools    

Sample Documentation Review Checklist Documentation Tips Sheet Documentation Self Assessment Tool Documentation Examples Using the Same Case Study

Definitions and References 54

A. Authentication The process used to verify that an entry is complete, accurate, and final. Indications of authentication can include original written signatures and, for secured electronic record systems only, computer "signatures." Authentication/Designation may be state and facility and other regulations. B. Medicare Regulations There are many regulations relating to the physical therapy evaluation and treatment of patients/clients who have Medicare coverage. The regulations can change often, and it is important that you stay informed of any changes that occur. You may access current information at the following link: gedPageDisplay.cfm&TPLID=32&ContentID=18290 Clinician Refers to only a physician, nonphysician practitioner or a therapist (but not an assistant or aide) providing a service within their scope of practice and consistent with state and local law. Clinicians make clinical judgments and are responsible for all services they are permitted to supervise. Certification For Medicare payment purposes, certification of the plan of care requires the Physician/Non Physician Provider (NPP) approval of the plan. This is required within 30 treatment days after the initial therapy visit. An initial certification may be written for a period of up to 90 days. Recertification Recertification of the Plan of Care requires the Physician/Non Physician Provider approval of the plan. Effective January 1, 2008, CMS extended the recertification period to up to 90 days. This means that the initial plan of care must be recertified when the initial plan of care is extended or at least once every 90 days – whichever comes first. bersOnly.cfm&ContentID=44000 Progress Reports For Medicare Part B (outpatient services) payment purposes, progress reports should be completed at least once every 10 treatment days or once during the interval (30 calendar days or one month), whichever is less. Progress reports may be provided more often than required when the physical therapist judges them appropriate. In most Medicare Part A


settings (i.e. skilled nursing facilities), progress reports or weekly notes should be completed weekly. Re-evaluation Provides additional objective information not included in other documentation. Reevaluation is periodically indicated during an episode of care. It may be separately payable when the professional assessment of the patient indicates:  a significant improvement or decline  an unanticipated change in the patient’s condition  an unanticipated change in the patient’s functional status Although some state regulations and state practice acts require re-evaluation at specific times, for Medicare payment, reevaluations must also meet Medicare coverage guidelines in order to be paid. Documentation In Chapter 15 of the Medicare Benefits Manual CMS includes documentation requirements for all outpatient therapy services billed to Medicare. CMS clarifies that contractors shall not require more specific documentation than that required in the manuals unless other Medicare policies (regulation or statute) require it. These guidelines identify minimal expectations for outpatient therapy documentation under Medicare. State or local laws may require more extensive documentation. The documentation requirements can be accessed at the following link: It is strongly recommended that physical therapists and physical therapist assistants read Sections 220 and 230. Correct Coding / Modifiers On January 1, 1996, CMS implemented a policy known as the Correct Coding Initiative (CCI). This policy is used to promote correct coding and to ensure that it makes appropriate payments for services. The purpose of the CCI is to develop correct coding methodologies to curtail improper "unbundling" of services for Medicare Part B claims. The CCI applied to physicians and physical therapists in private practice as of January 1, 1996. As of 2000, a modified version of the CCI edits (OPPS edits) applied to therapy services provided in outpatient hospital settings. Effective January 1, 2006, those same OPPS CCI edits now apply to all other providers of outpatient rehabilitation therapy services including skilled nursing facilities (Part B), CORFs, rehabilitation agencies (ORFs, OPTs), and home health agencies (Part B). The CCI edits are updated quarterly, and it is strongly recommended that every practice review the updated CCI edit file. For information on correct coding initiatives, please access the following link: bersOnly.cfm&ContentID=31605

CERT Report Definitions 56

The following areas are the most frequently noted errors when providers are submitting medical documentation to CERT contractors.

1. Insufficient documentation. The provider did not include pertinent patient/client facts (e.g., the patient’s/client’s overall condition, diagnosis, and extent of services performed) in the medical record documentation submitted. This could include missing physician signatures, orders, or documentation supporting the medical condition or the therapy plan of care. 2. Medically unnecessary service. This includes situations in which the CERT claim review staff identifies enough documentation in the medical record to make an informed decision that the services billed to Medicare were not medically necessary or did not require the skills of a therapist. 4. Paid claims error rate. This is based on dollars paid after the Medicare contractor made its payment decision on the claim. This rate includes fully denied claims for carriers/DMERCs/FIs/QIOs. The paid claims error rate is the percentage of total dollars that all Medicare FFS contractors erroneously paid or denied and is a good indicator of how claim errors in the Medicare FFS Program affect the trust fund. CMS calculated the gross rate by adding underpayments to overpayments and dividing that sum by total dollars paid. This error rate is quantified in dollars. 5. All Other Claims. This means all outpatient, fee-for-service Medicare Part B claims. 6. No Documentation. In cases in which the CERT contractor received no documentation from the provider once 90 days had passed since the initial request, the CERT contractor considered the case to be a no-documentation claim and counted it as an error.

7. Other errors. These include instances in which provider claims did not meet benefit category requirements or other billing requirements.

Billing and Coding Resources The following link will assist you with billing and coding questions: PageDisplay.cfm&TPLID=59&ContentID=16527  CPT – Common Procedural Terminology. This is a set of codes, descriptions, and guidelines that describe procedures and services performed by physicians and other health care providers. Each procedure or service is identified using a five-digit code. CPT codes are developed by the American Medical


Association (AMA) and are updated annually. For more information, click on the following link:  ICD-9 CM -The International Classification of Diseases, Ninth Revision is based on the World Health Organization’s International Classification of Diseases. ICD9-CM codes are updated annually and become effective on October 1 each year. When billing for services provided by a physical therapist, it will be necessary to specify the diagnosis that is being treated. For more information, click on the following link: entDisplay.cfm&CONTENTID=22529.

APTA Position on Documentation Documentation Authority For Physical Therapy Services (HOD 06-00-20-05) It is the position of the American Physical Therapy Association that: Physical therapy examination, evaluation, diagnosis, prognosis, and intervention shall be documented, dated, and authenticated by the physical therapist who performs the service. Intervention provided by the physical therapist or selected interventions provided by the physical therapist assistant is documented, dated, and authenticated by the physical therapist or, when permissible by law, the physical therapist assistant. Other notations or flow charts are considered a component of the documented record but do not meet the requirements of documentation in or of themselves. Students in physical therapist or physical therapist assistant programs may document when the record is additionally authenticated by the physical therapist or, when permissible by law, documentation by physical therapist assistant students may be authenticated by a physical therapist assistant. Discharge Discharge occurs when the anticipated goals and expected outcomes have been achieved and is based on the physical therapist’s analysis of the of the patient’s/client’s achievement of the anticipated goals and expected outcomes. Discharge does not occur with a transfer to another site of care. Discontinuation Discontinuation occurs when 1) the patient/client, caregiver, or guardian declines to continue care; 2) the patient/client is unable to progress toward the expected outcomes because of medical or psychosocial complications or due to financial constraints; or 3) the physical therapist determines that the patient/client will no longer benefit from physical


therapy services. When services are terminated prior to goal achievement, patient/client status and the reason for termination are documented. Goals can be considered in terms of impairments in body structures and functions, activity limitations, participation restrictions, and prevention.

Prevention There are three types of prevention in which physical therapists are involved:  Primary: Preventing a target condition in a susceptible or potentially susceptible population through such specific measures as general health promotion efforts.  Secondary: Decreasing duration of illness, severity of disease, and number of sequelae through early diagnosis and prompt intervention.  Tertiary: Limiting the degree of disability and promoting rehabilitation and restoration of function in patients with chronic and irreversible diseases.

Appendices APPENDIX A: Documentation Resources Documentation Requirements Resources APTA Professional Standards Appropriate documentation for patient/client care is included in the following APTA Documents: Code of Ethics M/ContentDisplay.cfm&CONTENTID=25854 Guide for Professional Conduct TMLDisplay.cfm&ContentID=24781 Criteria for Standards of Practice for Physical Therapy 748&TEMPLATE=/CM/ContentDisplay.cfm State law regulations In addition, some state practice acts regulating physical therapy services contain specific documentation requirements within their regulations. It is important that you review your state’s licensure regulations with respect to documentation requirements. The following


link will direct you to information about your state practice act: Medicare Other Additional regulations by payers and practice settings are discussed in specific sections of this document. To stay current with payer-related documentation requirements, it is a good idea to become a member of their email listserv. Invitations to teleconferences, town hall meetings, and/or notification of draft payer policies are regularly emailed to subscribers. Instructions for subscribing to this service are usually found under the “Education” or “Resources” tab of the payer website. Medicare also has provider outreach activities. There are regularly scheduled Open Door Forums (ODFs) for each practice setting. These ODFs are a dedicated time for Medicare representatives to inform providers of new/revised policies and give providers a time to ask Medicare representatives direct questions or inform them of issues/challenges they are facing. You can join this email listserve by going to and subscribing to the setting(s) of your choice. APPENDIX B: Guide to Physical Therapist Practice Template Documentation of history may include the following: General demographics Social history Employment/work (job/school/play) Growth and development Living environment General health status (self-report, family report, caregiver report) Social/health habits (past and current) Family history Medical/surgical history Current condition(s)/chief complaint(s) Functional status and activity level Medications Other clinical tests


Documentation of systems review may include gathering data for the following systems: Cardiovascular/pulmonary  Blood pressure  Edema  Heart rate  Oxygen saturation  Respiratory rate Integumentary  Pliability (texture)  Presence of scar formation  Skin color  Skin integrity Musculoskeletal  Gross range of motion  Gross strength  Gross symmetry  Height  Weight Neuromuscular  Gross coordinated movement (e.g., balance, locomotion, transfers, and transitions)  Motor function (motor control, motor learning) Documentation of systems review may also address communication ability, affect, cognition, language, and learning style:  Ability to make needs known  Consciousness  Expected emotional/behavioral responses  Learning preferences (e.g., education needs, learning barriers)  Orientation (person, place, time)

Documentation of tests and measures may include findings for the following categories: Aerobic capacity/endurance Anthropometric characteristics Arousal, attention, and cognition Assistive and adaptive devices Circulation (arterial, venous, lymphatic) 61

Cranial and peripheral nerve integrity Environmental, home, and work (job/school/play) barriers Ergonomics and body mechanics Gait, locomotion, and balance Integumentary integrity Joint integrity and mobility Motor function Muscle performance Neuromotor development and sensory integration Orthotic, protective, and supportive devices Pain Posture Prosthetic requirements Range of motion (including muscle length) Reflex integrity Self-care and home management (including activities of daily living and instrumental activities of daily living) Sensory integrity Ventilation and respiration Work (job/school/play), community, and leisure integration or reintegration (including instrumental activities of daily living)

Documentation of each visit/encounter shall include the following elements:       

Patient/client self-report (as appropriate). Identification of specific interventions provided, including frequency, intensity, and duration as appropriate Changes in patient/client impairment, functional limitation, and disability status as they relate to the plan of care. Response to interventions, including adverse reactions, if any. Factors that modify frequency or intensity of intervention and progression goals, including patient/client adherence to patient/client-related instructions. Communication/consultation with providers/patient/client/family/ significant other. Documentation to plan for ongoing provision of services for the next visit(s)


Documentation of reexamination shall include the following elements: o o o

Documentation of selected components of examination to update patient's/client's impairment, function, and/or disability status. Interpretation of findings and, when indicated, revision of goals. When indicated, revision of plan of care, as directly correlated with goals as documented.

Documentation of discharge or discontinuation shall include the following elements: o Current physical/functional status. o Degree of goals achieved and reasons for goals not being achieved. o Discharge/discontinuation plan related to the patient/client's continuing care. Examples include: Home program. Referrals for additional services. Recommendations for follow-up physical therapy care. Family and caregiver training. Equipment provided. APPENDIX C: Guide to Physical Therapist Practice Terminology Health Condition: Disease, disorder: An abnormality characterized by a particular cluster of signs and symptoms and recognized by either the patient/ client or practitioner as “abnormal.” It is primarily identified at the cellular level. Body Functions and Structures: Body functions are the physiological functions of body systems which includes psychological functions. The term ‘body’ refers to the human being as a whole. Body structures are the anatomical parts of the body. Impairment is defined as a ‘loss or abnormality in body structure or physiological function”(WHO, pg 213). Impairments in body function and structure are components of health that may influence human functioning. Disability and functioning exist along a continuum of health, as interactive constructs encompassing the health condition and contextual Functioning: Functioning is an umbrella term for body functions, body structures, activities and participation. It reflects the positive interactions between an individual with a health condition and the individual’s environmental and personal factors. Activity: Activity is the execution of a task or an action by an individual and represents the individual perspective of functioning. Activity limitations are difficulties that an individual may have in the execution of a task or action. Activity limitations occur as a result of the inability to perform the actions, tasks, and activities that constitute the “usual activities” for a given individual, such as reaching for a box on an overhead shelf. An activity limitation may span a range of minor to severe with respect to quality or quantity in execution of the activity in a way that is expected of a person without the health condition. Participation: Participation is an individual’s involvement in a life situation and represents the societal perspective of functioning. Participation restrictions are difficulties that an 63

individual may experience in his/her involvement in life situations. The presence of a participation restriction is determined by comparing the individual’s participation to that which is expected of an individual without a disability in the individual’s culture or society. Disability: Disability is an umbrella term encompassing impairment, activity limitation and participation restriction. Disability describes the negative aspects of the interaction between an individual's health characteristic and that person's contextual factors. Prevention: Activities that are directed toward (1) achieving and restoring optimal functional capacity, (2) minimizing impairments, functional limitations, and disabilities, (3) maintaining health (thereby preventing further deterioration or future illness), (4) creating appropriate environmental adaptations to enhance independent function. Primary prevention: Prevention of disease in a susceptible or potentially susceptible population through specific measures such as general health promotion efforts. Secondary prevention: Efforts to decrease the duration of illness, severity of diseases, and sequelae through early diagnosis and prompt intervention. Tertiary prevention: Efforts to limit the degree of disability and promote rehabilitation and restoration of function in patients/clients with chronic and irreversible diseases. Also see Episode of physical therapy prevention. APPENDIX D: CERT Error Trends &which=long&reportID=7&tab=4

APPENDIX E: How to Communicate Skilled Interventions and Medical Necessity How to Communicate Skilled Intervention: Consider: 1) What was done in the visit which required the skills of a physical therapist or physical therapist assistant? You might want to consider why you had to provide the intervention and another provider or caregiver could not? What knowledge, training and skills were used to provide the intervention? Non- skilled: Patient attempted to get out of chair independently. Noted difficulty getting to edge of chair. Multiple attempts required to come to standing position Skilled: Provided transfer training from sit to stand. Patient requires tactile and verbal cues to facilitate trunk flexion. Non- skilled: Gait training – patient ambulated with standard walker


Skilled: Moderate assistance provided with gait training to compensate for left sided neglect and assist with weight shifting for proper progression of bilateral lower extremities. Pt able to demonstrate ambulation 30’ x 1 with standard walker Non- skilled: Bike x 15’ followed by treadmill x 10’ at 3.0 followed by therapeutic exercises per flow sheet. Skilled: Prior to activity HR- 83 BP- 128/89 and SaO2 – 98% on room air. Patient monitored during the following activities: bike x 15’ followed by treadmill x 10’ at 3.0 mph. Patient’s vital signs after activity as follows: HR- 123 BP- 146/89 and SaO2 – 89% on room air. Patient also visibly fatigued and short of breath. After 5’ rest, vital signs returned to baseline. Other statements which convey skill: Patient/client educated in the use of progressive exercises to facilitate trunk stabilization for improved balance during gait. Training provided in don / doffing lower extremity prosthesis with verbal and manual cues for technique and safety. Ambulation training with standard walker to facilitate proper foot placement. Patient/client requires frequent monitoring of vital signs due to poor endurance and cardiac risk factors. Patient requires VS monitoring to determine impact of activity on cardiovascular status / CV response to exercise. Patient/client demonstrates consistently good balance on level surface therefore progressed patient/client to performing standing balance activities on unstable surface to decrease fall risk and increase community ambulation safety. How to Communicate Medical Necessity Document complications and safety issues as a result of the patient/clients current status such as: Fall risk – Patient ambulates 30’ x 1 requiring moderate assistance for mobility and for safe progression of standard walker. Pt remains at significant risk for falling at this time. Reduced mobility/ Risk for further complications – Patient is unable to perform bed mobility without further intervention and training. At present, he does not have enough strength or motor control to roll or weight shift to either side thus remains at risk for complications of skin breakdown and respiratory complications. Inability to complete tasks (i.e. activities of daily living) – At this time, patient limited in strength, endurance and balance. As a result she is currently unable to perform activities of


daily living that she was previously able to do independently, including dressing, bathing and cooking. Note: Physical therapists and physical therapist assistants working in skilled nursing facility or home health settings should strive to complement the documentation of other health care providers, such as nursing and the other therapy disciplines. Therefore every effort must be made to facilitate communicate so the documentation can be consistent throughout the medical chart. How to Communicate Progression of Care and Ongoing Assessment in Daily Notes Consider if the note contains information about: What is the status before interventions? What is the status after interventions? What is your assessment patient’s response to interventions? What is the plan to continue (or change)? Transfer Training example: Patient seen for transfer training from bed to chair. Initial status was maximal assist. Patient trained with tactile and verbal cues to promote trunk flexion and facilitate appropriate lower extremity muscle contraction. Patient able to demonstrate both improved pelvic tilt and more effective hip extensor firing. Will continue to facilitate proper and safe technique as patient continues to require moderate assistance. Prognosis for independent transfers remains good. Gait training example (without or minimal progress): Visit #1: Gait training with patient in parallel bars. Patient unable to shift weight to affected side with verbal cueing. Applied manual cues however patient required maximal assistance to shift weight and was unable to maintain weight shift for progression of unaffected lower extremity. Patient complains of vertigo and BP found to be 96/ 65. Blood pressure and complaints return to normal after sitting x 5 minutes. Visit #2 - Vital signs normal at start of visit. Gait training with patient in parallel bars. Patient unable to shift weight to affected side with verbal and manual cues. Requires maximal assistance to shift weight in standing. Modified exercise program to include activities to promote weight shifting in other postures. Visit #3: Vital signs normal at start of visit. Training with patient to weight shift in sitting. Pt able to shift weight to unaffected side after training in sitting. Requires moderate assistance for trunk control when attempts to weight shift to affected side. Pre-gait training in parallel bars demonstrates increased ability in standing tolerance from 1 minute to 3.6 minutes. Will continue to progress pre-gait activities at this time.




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