documentation is an integral component of providing patient
care. Concise and accurate patient documentation not only helps to deliver
quality patient care, it also can help ensure timely and complete
reimbursement. Conversely, incomplete or inaccurate patient
documentation can be considered as poor patient care, and can delay
reimbursement or even ultimately result in complete denial of a claim or a
demand from the payer to return payment.
In addition, as the O&P industry continues to move away from being
considered a craft or trade to being a professional health care discipline with
master’s level requirements and higher levels of
accreditation, satisfactory patient documentation becomes
important in aiding outcomes research and achieving evidence-based practice.
How can O&P practitioners ensure their patient documentation supports this
level of accreditation and credentials for the profession?
|© 2010 iStockphoto.com/Luis
The most crucial aspect of patient documentation that O&P
practitioners need to embrace is that documentation is patient care,Brian
Gustin, CP, president of Forensic Prosthetics and Orthotics, explained. Even
though practitioners may not be laying hands on a patient or they may not have
a patient directly in front of them, having the ability to accurately document
their case and their progress and the ability to write and convey an idea is,
first and foremost, patient care.
There are two critical components of patient documentation. The first is
documenting what happens during a clinical visit with patients, and the second
is documenting why a particular procedure or service is being performed or why
a particular device is being used.
“As a profession, we do a pretty good job of documenting the
‘what’ we do. For instance, ‘Fit patient with 12-ply sock,’
but we are not as strong in documenting the ‘why’ we are doing what
we are doing,” Mitchell Dobson, CPO, FAAOP, director of compliance for
Hanger Prosthetics & Orthotics, said. “By explaining the why component
within our clinical documentation, we can communicate better to those who are
not educated in orthotics and prosthetics, specifically payers and other
entities outside of the O&P industry who do not understand that an increase
in sock ply is going to lift the patient up out of the prosthesis a little bit.
They do not understand the cause and effect.”
Jonathan Naft, CPO, president of Geauga Rehabilitation Engineering and
O&P Business News Practitioner Advisory Council member, also
believes that O&P practitioners are good at documenting what they did
clinically but not why they did it.
“We are very good at documenting what we did. For instance, we
document that we fit a high-tech foot including complex components, but what we
need to do better is document why we used that particular foot and why that
particular foot is best for that particular patient,” Naft explained.
In addition, as both the level and cost of the technology being used in
O&P devices continues to increase over time, it is becoming even more
important for practitioners to adequately explain exactly why the technology is
necessary and why their patients need a specific device or component from a
Gustin explained that keeping the focus of the why explanation on the
specific medical condition, as well as offering evidence to support that claim,
is vitally important for reimbursement. He offers the following example: If a
practitioner requests reimbursement for a microprocessor knee claiming that it
will reduce stumbles and falls, the practitioner needs to support that claim
with evidence that the patient received treatment for a stumble or fall.
“Documentation needs to be truthful, believable and legitimate
relative to the patient’s condition and not geared toward getting
reimbursement for the practitioner,” Gustin said.
By communicating why patients need something within clinical
documentation, practitioners often can answer questions payers may have before
they can even be formulated.
Practitioners also should strive to be consistent, pertinent, factual
and timely in their patient documentation. Gustin recommends that practitioners
understand who they are writing to and address their points accordingly. He
suggests practitioners should learn to think of themselves as an attorney and
approach documentation as if they are writing an O&P medical, rather than
“Practitioners are advocating for a position, and the position is a
need that their patient has, and they have to be able to convey that in terms
the reader can understand,” Gustin told O&P Business
News. “Many times a practitioner is asked to provide a letter of
medical necessity to gain an approval for their proposed service. All too often
this is passed off to an administrative person or the practitioner writes a
poorly constructed letter, which often times is condescending in nature. Think
of the letter of medical necessity being the same as a lawyer who writes a
legal brief to the court advocating a position he or she wishes the court to
Ted Markgren, CO, chief surveyor for the American Board for
Certification in Orthotics, Prosthetics and Pedorthics’ (ABC) facility
accreditation programs, noted practitioners often tend to write casually and in
a manner similar to the way they talk in a social setting. Instead, he
recommends practitioners write with a medical mindset and use the time-honored
- Subjective: What did the patient say?
- Objective: What did I observe?
- Assessment: What is my assessment?
- Plan: What is my plan for treatment?
In addition, the content of clinical notes should be professional and
use approved and accepted terminology rather than jargon, which reviewers do
not understand. Phrases such as “a little bit,” “a tweak here
and a tweak there” and “big time” are out of place in a
patient’s clinical record, Markgren said.
Practitioners also should work on improving their writing skills. Being
able to write effectively, accurately and concisely should be viewed as just
another aspect of providing good patient care.
“All too often, practitioners will go into lengthy detail about how
a device or component works, which is immaterial to the reviewer,” Gustin
explained. “What the reviewer wants to see is how this service benefits
the patient from a medical standpoint, and if this is a covered benefit under
the patient’s plan, period.”
Documentation is necessary for reimbursement and provides justification
for the device by clarifying and supporting the medical necessity. Naft cited
three reasons practitioners document for reimbursement:
- It is required by policy for reimbursement;
- It allows communication among the different areas within a practice;
- It provides additional protection from liability.
In fact, many of the documentation requirements for the clinical record
are mandated by Medicare quality standards as well as by all other payers. If a
practitioner’s clinical notes do not accurately and completely reflect not
only what was done but also why it was done, payers can demand that monies made
as payment be returned. In such a situation, clinical notes can become a
defense tool against billing records.
“It is not just good enough that you have a prescription anymore.
Your prescription has to include your evaluation to confirm that the script is
not only appropriate but meets the patient’s functional requirement,”
Markgren said. “There is a standard that we have in the ABC accreditation
program, and it is also a Medicare quality standard, that the practice will
conduct a diagnosis-specific patient evaluation.”
Clinical documentation must include the goals and functional outcomes
that patients are expected to achieve with the orthosis or prosthesis. The
record needs to indicate that the device will allow patients to achieve some
benefit or functional improvement that will enhance their life by increasing
their stability or safety, reducing their risk of falls, enhancing their gait
or improving their activities of daily living.
“What we are seeing and what we are hearing in the field from
everybody is that when requests for additional information are coming in, they
are looking at those clinical records to see that every add-on component, every
feature is documented in a way that shows the clinical purpose for that
particular design or device,” Markgren said. “Why did you do a $1,200
item when a $100 item could do? Why did you do this when you could have done
that? Why did you do it all?”
Typically, clinical documentation is the first point of review by
payers. It is easy for payers to request, and it is easy for providers to
supply. As such, it is often the first impression that a payer has of a
practice, and as Dobson noted, “You do not get a second chance to make a
Good quality documentation that includes both what and why can set the
stage for reimbursement and give practitioners the best opportunity to gain
reasonable and fair reimbursement in a more timely fashion. Conversely, if
documentation is insufficient, reimbursement can be delayed by having to engage
the appeals process or reimbursement can even be denied entirely.
A practice’s procedures and processes also can have an impact on
the quality of patient documentation as well as on reimbursement.
“Practitioners should establish definable and repeatable process
measures to ensure consistent documentation for each and every patient by each
and every practitioner,” Gustin said. “Additionally, they should
establish an internal auditing process to ensure compliance with their own
standards. Failure to do so could result in future recoupment of reimbursements
at a minimum or more onerous fraud and abuse allegations at a maximum.”