Understanding the Importance of Thorough Documentation

Documentation in the health care professions, including orthotics and prosthetics, is often time consuming, arduous and detail-oriented. Yet the who, what, when, why and how in the charting process is necessary to understand if an health care provider wants to treat the patient effectively, avoid denials and get paid. The specifics of documentation are numerous. This article highlights fundamental aspects of charting that every O&P practitioner should know.

1. What do I need?

To get reimbursed for services, many practitioners are surprised at the detail involved in documentation. For instance, a prescription is needed for basically everything, said Brian Gustin, CP, general manager, Wisconsin Prosthetics & Orthotics, Benchmark Medical in Green Bay, Wisc.

“Some practitioners think that if they are being paid with cash, they do not need a prescription,” Gustin said. “This is not true. There is the presumption of being treated by a professional and as such, those services fall under the ABC Cannons of Ethical Conduct that stipulate a practitioner works at the direction of a physician. In addition, this is simply good practice from a liability standpoint.”

Moreover, some clinicians are still unaware of the HIPAA privacy notice and providing that documentation to patients is necessary. Even the signature on a file card is foreign to many, Gustin said. They do not realize that they cannot simply put the patient’s name on the claim without that patient actually authorizing them to do so.

“When practitioners are told what they need in terms of documentation, they basically say, ‘You have got to be kidding, I need to do all that stuff?’” Gustin said.

Medicare regulations indicate that the business must post the “Supplier Standards” in a conspicuous place as well.

2. What is not needed?

Hand writing with penThere are also some things a clinician does not need. For example, when Gustin speaks to audiences and consults with O&P businesses on the topic of charting, he gets many questions about certificates of medical necessity (CMN). No such thing exists in the field of O&P, he said.

“You may need a letter of medical necessity, but a CMN is a specific document that is required by Medicare of certain DME providers and O&P is not one of them,” Gustin said.

Additionally, a letter of medical necessity does not automatically ensure coverage or payment.

3. What is a valid prescription?

Many times, Gustin will get calls from practitioners who have been audited and are told they have to pay money back to the payer because they did not have a valid prescription. Sometimes, all they will have is a chart note of a verbal order from a physician or a nursing home may have gotten verbal orders from the physician. That is not good enough to bill with, Gustin said. Even though a therapist in a nursing home may have a verbal order form that says, in essence, ‘Doctor Smith said yes, we can go ahead and do an AFO for a particular patient,’ it is not a valid prescription.

“It gives the provider the physician’s permission to start treating that patient, but a more detailed prescription to bill it is required,” Gustin said.

The verbal order is appropriate for the initial evaluation, treatments and dispensing of an item, but not appropriate for billing. The practitioner needs a detailed prescription that is an original. A fax or electronic one will suffice. However, if it is a Medicare patient, Medicare reserves the right to require that the provider produce the original prescription. Additionally, the order needs to be detailed, Gustin said. It must spell out clearly what the clinician is doing for the patient. It is not enough to write ‘left AFO.’

If the practitioner made an AFO with ankle joints, for example, Medicare could come back to that clinician and demand payment for the ankle joints in that AFO, Gustin said.

“Bill for what you provide and provide what you bill,” he added.

4. What is medical necessity?

Medical necessity to the physician or patient can be completely different than medical necessity to the paying entity, Gustin said. Practitioners need to know what the definition of medical necessity is to whomever is paying them. They need to know what the definitions are before they start the project.

Hand writing with pen“Medical necessity are the reasons why you needed to do what you want to do.” Gustin said.

It is important for practitioners to avoid words that would trigger a denial based on patient convenience or comfort; in other words, do not tell the insurance company the patient needs a device because it will make it easier for the patient to walk.

“This explanation will get you an automatic denial,” Gustin said.

The insurance entity is not concerned about how easy or difficult something is for a patient. Their concern is whether the practitioner is providing something that is a medical benefit to the patient.

“Whether it is easy or not is immaterial to them,” Gustin said.

5. Who writes the letter of medical necessity?

The letter of medical necessity may need to come from the physician, but the practitioner may want to write it. Only the practitioner knows about the device they will make and how that relates to the patient’s physical condition, Gustin said.

“The physician does not know,” he said. “The practitioner has to relate the device he or she is making back to the medical condition the patient is being treated for.”

6. What do I chart?

Essentially, just about everything needs to be charted. According to Gustin, the clinician needs to think in a logical pattern.

“For me, a SOAP note is most effective,” he said.

SOAP is an acronym for:

  • Subjective; what the patient said
  • Objective; what the clinician observed
  • Assessment: what the clinician did for the patient
  • Plan: what the clinician will do next for the patient.

7. What does the insurance company want?

It is crucial to understand the insurance company’s language. According to Gustin, practitioners need a copy of the summary plan document (SPD) for each patient. Among a variety of information, it states the definition of an initial prosthesis; what the insurance company considers to be reasonable and necessary; what they consider to be medically necessary; the definition of ambulatory; the least costly, most functional alternative clauses; whether they pay for repairs versus replacement and if they pay for those, and if it is based on physiologic change or based on pathologic change.

“Those are all things practitioners need to find out before they embark on a project,” Gustin said.

An analogy of an athletic team can apply to this situation.

“The Packers are here in Green Bay,” Gustin said. “They would not go out on Sunday afternoon and play a game on a blank green field. That field is gridded out and they know where the out of bounds are, how far they have to go for a touchdown, first down, etc. The SPD is the grid of the playing field the game O&P is playing.”

Read the SPD and read it with an eye toward ambiguity, Gustin advised.

“An insurance policy is nothing more than a legal and binding contract, and in contract law any ambiguity is construed against the party that wrote it. If you can find something that is not clearly defined you need to seize that opportunity to argue the point.”

8. Why do I have to read the insurance policy?

If the clinician wants to get paid, the bottom line is that he or she needs to read the policy. Often, people in O&P do not understand the rules of the game insurance companies play by, Gustin said.

“O&P people think everyone should play by their rules,” he said. “The insurance companies play by the golden rule: It is those that make the gold who make the rules. We think because we have a prescription from a doctor and because we are ‘the professional’ that the insurance company should just pay for these things. That is not the case. The needs, wants and desires of the insurance companies are often diametrically opposed to the needs, wants and desires of the physician and the patient.”

Gustin has worked on the insurance side of the fence as a consultant to insurance companies reviewing orthotic and prosthetic claims. He has called colleagues as a case manager to ask questions about the claim they have submitted.

“As a general rule, we do a good job of telling people what we are doing,” he said. “Yet we do a terrible job of telling people why we need to do what we want to do.”

For example, Gustin was successful in obtaining an authorization from an insurance company to provide a microprocessor knee for a patient because she had chronic migraine headaches. How does a migraine headache relate to someone with an amputation? He was able to relate this back to an asymmetrical gait pattern, which caused muscle imbalances, which then manifested itself in migraine headaches.

“That is not something that is ordinarily ferreted out in an evaluation with a patient,” he said. “O&P practitioners are too focused on the body part or segment that they are treating and not on the whole body of the patient they are treating.”

9. When should I document?

Research shows that the best time to chart is while the patient encounter is ongoing; in other words, in front of the patient. Sometimes, that is uncomfortable for people to do. It is, however, the most accurate.

“It also lets the patient know that you are not making anything up,” Gustin said. “If they were ever to contest something down the road, they know you made that note in front of them.”

10. Is there anything I should not document?

Do not make judgmental findings. Do not guess.

“I call it my Sergeant Friday protocol: Just the facts, ma’am,” Gustin said. “Do not say something you would be embarrassed to say in a court of law or in front of your mother. Make sure the documentation is objective, not subjective.”

11. How do I manage all this stuff?

An O&P practitioner needs to think like your computer thinks — put things in folders and files, said Gustin. Organize. Do chart noting contemporaneously. You almost have to put blinders on during a busy day so you do not get distracted from the purely clinical side of what your doing as a practitioner.

That is why I suggest the second best time to do your documentation is before you exit the exam room,” Gustin said. “Once you leave the exam room you leave yourself open for others in your office to grab you and to ask you questions. Have a routine of how you go about your day.”

The summarization of documentation is to first know the rules of the game you are playing, Gustin said. Understand you have to satisfy a clinical aspect and a financial aspect. You have to be able to alter how you write to satisfy both without fabricating things.

You can make and document purely clinical decisions, but you have to then relate those clinical decisions to satisfy the payer and their needs, wants and desires. Be accurate at the same time. Stay organized with your business activities and thoughts and be contemporaneous with your notes.— by Rachel Kelley

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