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Is Your EMR Hurting or Helping Your ICD-10 Efforts?

We’re several days into the transition to ICD-10, and it seems like most folks made it through to the other side just fine. Many of you might even be thinking the new code set isn’t such a big deal. But is this the calm before the storm? After all, we’ve yet to see whether providers coded correctly, and thus, whether their ICD-10 claims actually will get paid. So, between watching the leaves change color and picking a prime pumpkin from the patch, you’ve got to maintain your ICD-10 efforts. While I’m sure you studied and practiced your tail off in anticipation of October 1, you may have overlooked one key part of a successful switch: your EMR. Here are two reasons why your EMR might be leaving you out in the cold (without your North Face jacket):

Automatic Conversions

Be wary of any EMR that claims it can automatically convert all of your codes or pick an ICD-10 code for you. While it may be tempting to “cheat” your way through selecting ICD-10 codes, taking shortcuts likely will come back to haunt you. As the American Health Information Management Association (AHIMA) explains in this post, thanks to “significant differences in language and structure between ICD-9 and ICD-10,” automatic conversions aren’t all they’re cracked up to be. The article explains that while “ICD-10 conversion can be highly automated [they] cannot be fully automated, and they cannot be finalized without review and evaluation by a person familiar with each system being converted.” In fact, AHIMA warns that “autoconverted ICD-10 systems may not work as intended, and skipping a human review can expose an organization to legal and financial risk once the converted systems go live.” If your EMR has automatically converted all your ICD-9 codes, do your due diligence. If you don’t make sure the conversions are accurate and as specific as possible, no one else will.   

Cheat Sheets

Some EMR vendors have created cheat sheets, and those resources might seem like a great idea, because they convert your most frequently used ICD-9 codes to their ICD-10 code counterparts. But according to this resource, that’s exactly the problem. Why? Because “pain codes…are the most commonly used ICD-9 codes for PTs. In ICD-10, though, you shouldn’t use a pain code as a patient’s primary diagnosis if you can help it. ICD-10 requires a far greater degree of specificity; thus, payers want you to code for the underlying injury or condition first and foremost. Only then should you list the pain codes associated with the main diagnosis.”

Plus, even though seventh characters are required for injury codes, cheat sheets don’t account for the seventh character because this character—and the information it represents—doesn’t exist within ICD-9 (hence, part of why we needed to make the leap to ICD-10). Plus, you must use clinical judgement to determine which seventh character best describes the patient’s condition or treatment phase. Don’t waste your time on an EMR that spends its time creating cheat sheets that put your practice at risk.

Working with an EMR that relies on code selection shortcuts is like wearing Uggs with shorts: just plain ridiculous. So, how do you know your EMR can protect your clinic’s productivity and cash flow post-transition? Look for an EMR that offers these three crucial features:

1.) An intuitive ICD-10 code selection tool

Your clinical judgement is critical to selecting the correct ICD-10 codes. An intelligent ICD-10 tool can assist you with making the best choice possible while simultaneously ensuring that you, as the therapist, make the final judgement call.

2.) Built-in alerts and safeguards

Does your EMR let you know when you’ve selected an invalid or non-billable ICD-10 code? If not, you’re leaving your clinic open to a heap of trouble.

3.) Free training, support, and resources

If your EMR doesn’t offer free training, support, and resources, then figuring out how to use the system’s ICD-10 functionality—and understanding ICD-10 itself—is entirely up to you.


Don’t settle for a basic EMR (that doesn’t even like pecan pie-scented candles). When it comes to ICD-10, ensure your EMR isn’t out apple-pickin’ and pumpkin-carvin’ instead of supporting you in your transition efforts. If your vendor is taking shortcuts—or is plain ol’ unprepared—you could be left feeling like someone left the pumpkin spice out of your latte.

EMR Can Help with the ICD-10 Switch; Here’s How

Love it, or hate it? Tired of reading about it, or just beginning to delve into all of the details? Regardless of which of these phrases most closely describes your relationship with ICD-10, there several things you can do to make this transition a smooth one. One of the most effective? Using an EMR. If you’re already using a system, great; now’s the perfect time to evaluate whether it offers everything you need to be successful with ICD-10 adoption. “Because of ICD-10’s complex code structures, implementing associated changes in electronic health records, billing systems, reporting packages and other decision-making and analytical systems will require either major upgrades of multiple systems or outright replacement of older systems,” says this HealthIT article. So, as we move toward and beyond October 1, the necessity of making these changes is inevitable. Here are some ways that an EMR will help you with the ICD-10 switch:


Do you love thumbing through hundreds of pages of codes? I know that I don’t enjoy spending extra time on tasks I could complete more efficiently—and accurately—using the proper tools. When you use an EMR, you’ll save yourself the papercuts and the time it takes to find the most accurate diagnosis code in a 10-pound book. However, while coding by the book might be inefficient, a code book can act as a useful guide, and it may offer additional information about the ICD-10 codes specific to your your area of practice. That said, usefulness doesn’t always equate to efficiency. To boost your productivity, look for an EMR that offers an easy-to-use ICD-10 tool and plenty of free customer service to help you navigate the new functionality.


Working more efficiently doesn’t count for much if you sacrifice accuracy for speed. And when it comes to ICD-10, the proof is in the accuracy pudding, which means you need to whip up some accurate codes—quickly and without much time to “chill” for the best results. So, instant accuracy pudding it is: you can use your EMR’s functionality to help you quickly narrow down all of your coding options. Once you’ve made your selection, you’ll want to make sure you have clean documentation to back up the medical necessity of treatment.

So, if your EMR does not support clean and accurate documentation in addition to offering an intelligent ICD-10 tool, it might be time to make a change. As this Government Health IT article points out, “With the introduction of ICD-10, EHRs must also be capable of producing documentation with a high degree of specificity and ideally offer the appropriate codes.” Even when you have the help of an EMR for coding and documentation, you’ll still need to use your clinical judgement. But, with the help of an intelligent code picker, you’ll have an easier time sifting through all 68,000 codes to find the precise ones you need.


The transition to ICD-10 has the potential to provide better data for evaluating and improving the quality of patient care; interoperability aims to achieve those same goals. And—you guessed it—an EMR can help connect these two pieces of the patient care puzzle. As this HIMSS article explains: “In the larger context, ICD-10 is not a competing initiative but an enabler for the EHR adoption to help build the data infrastructure needed for a nationwide healthcare system where clinicians, hospitals, laboratories and pharmacies can share patient information electronically, in a secure way.”


Like it or hate it, to face ICD-10 with efficiency, accuracy, and interoperability, you’ve got to adopt—or evaluate and change—your EMR.

Is Your EMR Ready for ICD-10?

It’s only a matter of time before the leaves start changing and the pumpkin spice lattes start flowing—and that means the October 1 transition to ICD-10 is just around the corner. But rather than kicking their preparations into high gear, many providers are kicking back and relaxing—because their EMRs already have everything handled, right? Right? Anyone? Bueller?

Unfortunately, not all EMRs are created equally—and not all are equally prepared for the impending ICD-10 transition. So, how do you make sure your system is in fighting shape for ICD-10? For starters, nail down the answers to the following questions:

1. Does your EMR prompt you to document specific details of the patient’s injury or condition?

One of the biggest reasons the medical community is transitioning away from ICD-9 is that the old code set doesn’t allow providers to accurately—and specifically—represent patient diagnoses through the use of diagnosis codes. And to encourage—er, force—healthcare professionals to move away from the now-common practice of submitting generalized or unspecified diagnosis codes, payers will require a high level of coding specificity as a condition of payment. As this HIMSS page explains, “With the expansion of diagnosis codes comes a greater level of detail; therefore a greater level of detail will be required in the encounter documentation in order to assign an appropriate diagnosis code.”

Of course, detailed diagnosis coding goes hand-in-hand with detailed documentation—especially if the clinician (e.g., the physical therapist) isn’t the one submitting claims. How is a biller or coder supposed to select and/or verify a diagnosis code if the supporting documentation isn’t detailed enough to inform that choice? Unless your practice’s coder moonlights as a psychic, he or she won’t be able to pull that one off—at least not 100% of the time. So, if you want to receive 100% of your payments—and I’m no psychic, but I’m betting that you do—you better cross all your t’s and dot all your i’s within your documentation, and make sure your EMR allows you to do so, too.

2. Does your EMR’s code selector prompt you to choose more specific codes when greater specificity exists?

Maybe you’ve already called up your EMR vendor and asked whether the system has—or will have—an ICD-10 code selection tool. (If you haven’t, stop what you’re doing and pick up the phone. I’ll wait right here.)

Okay, let’s assume your vendor has assured you that the system absolutely, positively will have functionality that allows you to select and document ICD-10 codes. That’s fantastic—but your investigative work shouldn’t stop there. Sure, your EMR might have all the applicable codes loaded into its system—and you might even be able to search for the right code by diagnosis or anatomic site. But just because you can find codes doesn’t necessarily mean you’ll find the right ones, especially when specificity comes into play.

For example, let’s say you’re searching for a code to express the diagnosis of patellar tendinitis. The code M76.50 (Patellar tendinitis, unspecified knee) might appear at the top of your search results, but it doesn’t account for one very important diagnostic detail: laterality. However, if your EMR prompts you to code for laterality when that specificity exists, then you’ll land on either M76.51 (Patellar tendinitis, right knee) or M76.52 (Patellar tendinitis, left knee). And by using a more specific code, you’ll greatly decrease your chances of receiving a claim denial.

3. Did your EMR base its ICD-10 code library on GEMs?

Despite this acronym’s sparkly association, there’s nothing precious about GEMs—a.k.a. general equivalence mappings. As this blog post explains, “…GEMs were never intended to serve as single-code translation dictionaries. Because of the way they’re structured—in clusters of two to four related codes—GEMs may map one ICD-9 code to several ICD-10 codes and vice-versa.” While GEMs can be useful for converting large batches of data, they’re not reliable mechanisms of one-to-one code translation. So, if your EMR simply used GEMs to map each of its existing ICD-9 codes to an ICD-10 substitute, then you could be in for a rude awakening come October.

4. Does your EMR claim to have an automatic crosswalk from ICD-9?

Like an ill-prepared college student desperately searching for a cheat sheet the night before the big test, healthcare professionals who have put off their ICD-10 prep work until the eleventh hour are desperately searching for a magic bullet that’ll make all their ICD-10 worries fade into oblivion. Some EMR vendors have capitalized on that desperation by claiming to offer solutions that automate the ICD-10 code selection process or produce accurate ICD-10 matches for all of the ICD-9 codes you know and love. The problem is, no such tool exists—at least not one that actually works. Why? Because, as this blog post points out, “…when it comes to translating ICD-9 codes into the language of ICD-10, there’s no technology sophisticated enough to do the thinking for you.” Furthermore, “the new code set wouldn’t function the way it’s supposed to without the human decision-making factor.”

5. Will your EMR allow you to practice coding with ICD-10 prior to October 1?

As the old saying goes, practice makes perfect. Attempting to code in ICD-10 with zero practice would be like showing up to run a marathon with zero training mileage under your belt. And with payment at stake, this definitely isn’t the time to wing it. The same goes for your coding tools: If your first time using your EMR’s ICD-10 functionality is October 1, 2015, then you could be fighting an uphill battle fraught with frustration, claims backup, and workflow disruption. So, make sure your EMR will release its ICD-10 coding tool before the go-live date. That way, you and your staff can train in a relaxed, no-pressure environment. Plus, you’ll be able to run internal testing programs and participate in external testing opportunities.


Technology will play a huge role in the transition to ICD-10, and if you arm yourself with the right tools, you can greatly ease the shock of the shift. But while Ferris Bueller seemingly can navigate any sticky situation relying on wit and charm alone, no amount of charisma can make up for an EMR with a sub-par ICD-10 solution. So, before you put your feet up and enjoy the last of the summer sunshine before the fall chill sets in, make sure your EMR is truly ready for October 1.

4 Reasons Why You’ll Need an EMR for ICD-10

With the switch to ICD-10 looming on the horizon, many healthcare providers are searching for a catch-all solution to ensure a smooth, snag-free transition. As this article points out, while there’s really no “magic bullet” for ICD-10, adopting an electronic medical record (EMR) will definitely help ease some of the pain associated with implementing this new diagnosis code set. In fact, the thought of tackling ICD-10 without an EMR is close to inconceivable. Here’s why:

1. It will be your life preserver in a sea of new codes. If you’re overwhelmed by the sheer number of codes included in ICD-10, you’re not alone. To give you an idea of the scope, there are more than 68,000 ICD-10 diagnosis codes and 72,000 procedural codes. For comparison, ICD-9 has 13,000 diagnosis codes and 4,000 procedural ones. Add to that a complete overhaul of the actual code structure—ICD-10 codes contain up to seven characters, whereas ICD-9 codes only contain up to five—and you’ve got a recipe for a serious panic attack. But if you have the right EMR, you can breathe easy—or at least easier. Good EMRs feature built-in intelligence to help you select diagnosis codes based on the information you’ve recorded in your documentation. That way, you don’t have to thumb through hundreds and hundreds of pages of diagnosis codes to find the one you’re looking for.

2. It will ensure you code as specifically as possible. In addition to helping you find the right code for each diagnosis, an EMR also will prompt you to code to the greatest possible level of specificity. For example, as explained in this blog post, some diagnosis codes require a related external cause code to indicate the origin of a patient’s injury or condition. These codes do not exist within ICD-9, so remembering to add them might prove difficult at first—unless you have an EMR that remembers for you. And with everything else you’ve got on your plate, that peace of mind could be huge—especially considering that payers will come to expect this information to be readily available on patient claims.

3. It’s a big piece of the interoperability puzzle. In their quest to increase the efficiency and quality of patient care in all specialties, healthcare leaders all over the world have pushed for a medical landscape with fast, seamless information exchange—a.k.a. interoperability—across all healthcare platforms. The global move toward ICD-10 represents a huge part of this initiative as it allows for uniform coding of complex information, thus making the resulting data easier to share. But true interoperability cannot exist without effective communication and adequate technology—and that’s where EMR comes into the picture. In this day and age, it would be nearly impossible to achieve constant interconnectivity and communication across all healthcare providers without across-the-board implementation of secure, portable, cloud-based EMR systems.

4. It will allow you to focus on what truly matters—your patients. The magnitude of the transition to ICD-10 could easily pull your attention away from your ultimate goal of providing exceptional care to each and every patient. But with an EMR, you’ll have a partner to tackle some of the tedious code selection stuff so you’ll have the bandwidth to handle bigger-ticket tasks—like helping your patients achieve amazing outcomes through therapy.

So, before you pull your hair out over this whole ICD-10 switch, be sure your practice has all of the tools necessary to make the transition as painless as possible—chief among them: an EMR.

Why a Lack of Outcomes Tracking is an EMR Dealbreaker

If you’ve been searching for a while, you probably know that a cloud-based, therapy-specific EMR solution is the way to go. You also might appreciate the importance of added benefits like built-in compliance safeguards and ICD-10 coding capabilities, billing and RCM services, and comprehensive scheduling and business reporting functionality. But, there’s one more factor you should be considering—the rehab therapy software X-factor, so to speak: outcomes tracking.

Why is outcomes tracking such a big deal? Well, at the patient level, measuring progress has always been integral to providing the best possible care. Otherwise, it’s tough to know whether the treatment you’re providing is actually working. But, with the advent of technology, PTs and OTs now have the opportunity to leverage the information they record on a larger scale—one that’ll help move the entire profession forward and ensure rehab therapists survive and, more importantly, thrive in the face of a rapidly changing healthcare payment landscape.

Now, the word “data” often carries a negative connotation, especially in the rehab therapy world. That’s because historically, payers have been the owners of that data—which means they’ve used it to justify reduced payments for physical therapy services. But now that therapists have the power to compile their own data, they have a chance to tip the scale in their favor—if they track that data in the right way, that is.

Healthcare reform initiatives are pushing all providers—rehab therapists included—to deliver higher quality care at a lower cost, all while achieving higher levels of patient satisfaction. It’s the so-called triple aim, and it’s the driving force behind the industry-wide shift to value-based payment methodologies. Soon, the outcomes your patients achieve will have a direct impact on the amount of payment you receive. And you can help make that impact a positive one by:

  • Tracking your own outcomes data—rather than leaving yourself beholden to the data payers bring to the negotiation table.
  • Using an outcomes tracking platform that will help you compile and analyze that information in a way that’s digestible and meaningful.
  • Supporting your case for higher payment rates with results that are applicable across the entire healthcare spectrum (i.e., by using outcome measurement tools that are specialty-agnostic).

Now, the term “data” might conjure up not-so-rosy visions of complex formulas and spreadsheets. In reality, though, you’re probably already halfway to the data collection finish line—and you might not even know it. Because if you use outcome measurement tools to assess patient progress, then you are, in fact, collecting data. So, why not put that information to use beyond your clinic walls?

Here’s another tidbit you might not know: there are EMR solutions out there that allow you to complete—and track the results of—outcome measurement tools directly within your documentation. These platforms even generate easy-to-read reports that tell you how your clinic is performing at the individual therapist level, at the regional level, and even at the national level. This allows you to assess and fine-tune your own clinical processes and approaches to ensure you’re always providing the best possible care. More than that, though, it allows you to prove your value to payers, referring providers, and healthcare consumers using cold, hard facts.


So, if you’re in the market for a new EMR—or if you’re simply evaluating your current one—integrated outcomes tracking capability certainly should be one of the boxes on your checklist. That way, you can be sure your EMR isn’t just your practice’s Mr./Ms. Right Now—but its forever soulmate.

What’s the Best Software for Physical Therapists?

There are plenty of software systems for physical therapists on the market today, but you wouldn’t want to waste your time on anything but the best—especially if the best is super affordable with no long-term contracts and a ton of fantastic features, right?

Here’s what you should be looking for in the very best software for physical therapists:

One with an Intelligent ICD-10 Tool

Your EMR doesn’t need to make your breakfast à la Rosie from The Jetsons, but it does need to help you stay ICD-10 compliant. Make sure yours does the following, at the very least:

  • Prompts you to document the specific details of every patient’s injury or issue
  • Suggests a more specific code when one with a greater level of specificity exists
  • Alerts you when you’ve selected an invalid code or one that’s not billable
  • Maintains a complete library of ICD-9 and ICD-10 codes (some payers, like auto and workers compensation companies, can still use ICD-9)
  • Provides free ICD-10 training, support, and resources
  • Bases its ICD-10 code library on more than just general equivalence mappings (GEMs)

Beware of any EMR that claims to have an automatic one-to-one crosswalking tool that translates ICD-9 codes into ICD-10. According to this ICDLogic whitepaper, ICD-9 and ICD-10 “differ so widely that all attempts at translation offer only a series of compromises and subjective choices. This is necessarily so because there is no ‘mirror image’ of one code set in the other.” In other words, beware: they aren’t a magical solution and can end up costing you a lot of problems (read: claim denials) in the long run. Instead, go with a software that helps you streamline your ICD-10 coding by using detailed, defensible electronic documentation as the foundation for code selection.

One that’s a Certified PQRS Registry

Physical therapists have the option to report PQRS via paper, but why would you? Medicare has made clear that it intends to move toward electronic reporting for all future regulations. (That’s why, over the last few years, CMS has been strategically removing claims-based reporting eligibility for certain PQRS measures, encouraging providers to go the registry-based route.)

But even if claims-based reporting was here to stay—which it isn’t—there are plenty of other reasons why the best software for physical therapists also is a certified PQRS registry.

Here are some of the benefits of registry-based reporting:

  • All you need to do is choose your measures and document. The right software manages the rest (read: collects your reporting data and submits it directly to CMS).
  • You won’t ever have to complete a paper PQRS form for an applicable note again. With a certified PQRS registry, the measures on which you choose to report are built right into your documentation.
  • You get automatic checks and balances, because the registry will alert you if you’re not properly reporting.
  • The available measures are always up to date based on the most recent final rule.

One with Built-In Outcomes Tracking

We’re in a pay-for-performance healthcare environment, so it’s crucial for therapists to have the tools necessary to demonstrate their value. That’s why the best software for physical therapists has built-in outcomes tracking, complete with a library of evidence-based, risk-adjusted tests—as well as integrated patient surveys and comprehensive reports—that are already familiar to, and respected within, the healthcare community at large. With access to these tools, you’ll be able to objectively demonstrate your clinical performance to insurance providers, patients, and referrers.

Here are some of the outcome measurement tools your software should include:

  • Quick DASH
  • Lower Extremity Functional Scale (LEFS)
  • Oswestry
  • Neck Disability Index
  • Dizziness Handicap Inventory

One that’s Web-Based

You’re busy treating your patients and running a practice, which means your software systems need to be available whenever you are, wherever you are. That’s why the best software for physical therapists is web-based, so you can access—and document—your patient records, schedules, and reports from any device with an Internet connection.

Plus, your data is secure, because each therapist, PTA, front-office staff member, and administrator has a unique ID and password. This way, clinic owners can control everyone’s access to patients’ protected health information. And all of that data is housed in gold-star data security centers like IO in Phoenix, which boasts a defensible perimeter, digital video surveillance, biometric screening, and round-the-clock armed guards—so there’s almost no threat of a physical or digital breach impacting your data.

Finally, the best web-based software is always up to date with the latest technology and compliance regulations, because it can make upgrades and amendments fast—like, as fast as Medicare changes its reporting regulations. Speaking of updates, the best software for physical therapists provides updates:

  1. automatically,
  2. at no charge to you, and
  3. with as little downtime as possible.

To learn how much downtime is the right amount, check out this article.

One that’s Designed for PTs

You’re a physical therapist—not a physician, not an opthamologist, and not an oral surgeon. And that’s an important distinction, because your software solution should be tailored to you and your workflow—not theirs. The best software for physical therapists comes complete with a host of other features that make it easy for users to succeed in business, including:


If you’re thinking there’s simply no way that one software solution offers all of this, think again: WebPT has it all and more. Schedule your complimentary demo today to see for yourself.

How an EMR Can Help with Physical Therapy Billing

Do you frequently find yourself facing claim denials and payment delays in your physical therapy clinic? Well, you’re not alone. With so many rules and regulatory changes, billing for physical therapy isn’t easy—but it doesn’t have to be a total challenge, either. When you use an integrated EMR and billing system, you can bid “adieu” to these three common billing blunders:

Ciao, Coding Errors

Okay, so you probably won’t get rid of all coding errors—your billers are still human, after all—but a great EMR can dramatically reduce those human errors, thereby greatly improving your claim accuracy. According to this cost-benefit analysis published in the American Journal of Medicine, an EMR is better able to capture charges and can “decrease [billing] errors by 78%.”

Plus, cloud-based EMRs are regularly updated to keep you compliant with all the latest regulatory changes (anyone remember ICD-10?). While that doesn’t mean you don’t have to be familiar with those changes, it does relieve pressure from you and your staff. Plus, it ensures your claims won’t get denied simply for failing to meet a new requirement.

Bye, Bye, Double Data-Entry

An EMR that’s integrated with your billing system isn’t just accurate; it’s efficient, too. reports that using an EMR reduces the time and resources needed for manual charge entry. Right now, you and your staff likely spend way too much valuable time manually entering data into your billing system. That’s a waste of your limited resources. Instead, choose an EMR that allows all your billing data to flow directly from your EMR to your billing software, so you can scrub and submit your claims with greater ease.

Auf Wiedersehen, Slow Cash Flow

The time between saying “aloha” to your claims and, uh, also “aloha” to your payments should be minimal. This analysis of electronic health record systems found that using one of these systems can improve cash flow by:  

  • eliminating billing errors or inaccurate coding
  • reducing outstanding days in accounts receivable and lost or disallowable charges
  • sending automatic reminders to providers and patients about routine health visits

But without an EMR to speed up the process and reduce the above-mentioned errors, you’re stuck floating along at the rate of snail mail. Don’t settle for slow payments. Get an EMR that can offer you complete documentation profiles, built-in prompts to help keep you compliant, and tools and tips to ensure accurate and complete coding.


An EMR designed for physical therapists can help terminate your billing troubles (but don’t discount the importance of having the right billers on your team). When you find the right EMR for your practice, get ready to say “hasta la vista” to your billing headaches and “hello” to improved billing processes.

Dishing on Big Data: Information Exchange and the Future of Health Care

When it comes to life in the modern world, data reigns supreme. Whether you care to admit it—or even think about it—the fact is, you cannot escape the influence of data. And in some cases, that’s a good thing. No, I’m not talking about the discount offer for your favorite restaurant that suddenly appears on your Facebook news feed just minutes after you’ve perused the menu online—though that’s definitely a data benefit, too. In this article, though, I want to focus on the benefits of big data with respect to health care—in terms of cost, quality, and efficiency.

If you’re a healthcare provider, there’s a good chance you’re already helping lay the foundation for a very bright—and data-driven—healthcare future. That’s because the government and other healthcare stakeholders already have implemented a variety of programs and systems—like PQRS and ICD-10—aimed at promoting quality data collection. But this is just the tip of the iceberg. As the US continues to make strides toward achieving the healthcare “triple aim”—that is, the nationwide push toward better access, lower cost, and improved accountability in health care—providers can expect data to step into an even bigger role in the delivery of, and payment for, their services.

Of course, you can’t have a conversation about data without mentioning technology. To return to the food theme, if data is the basket full of raw ingredients, then technology is the oven that turns those ingredients into something useful (and delicious). And that’s where EMR comes into the picture—er, kitchen. Because in today’s healthcare landscape, EMR isn’t just a tool for documentation; it’s a means of participating in—and benefitting from—the collective effort to amass meaningful information that has the potential to:

  • foster evidence-based practice;
  • improve patient outcomes; and
  • uncover trends—both globally and regionally—that influence the efficacy of care.

But, for those things to happen, providers cannot use their EMR systems in isolation. More importantly, EMRs cannot be designed solely for isolated use. To stay relevant in a value-driven healthcare system, EMRs must allow for interoperability—that is, the ability for different systems and organizations to exchange information, and thus, work together for an overarching purpose. In a healthcare context, this means successful, seamless data transmission across all healthcare platforms. This allows a patient’s entire care team to have access to up-to-date information about the patient and his or her treatment progress—making care delivery much more efficient and effective. It has the potential to take care quality to a whole new level—not to mention reinforce physical therapy’s place on the overall care continuum.

So, if interoperability isn’t on your EMR vendor’s roadmap—or even its radar—then it might be time to explore other options. That said, the US, as a country, still has a few significant hurdles to overcome in the road to total interoperability. As this article explains, the architecture that currently exists is laden with “trouble spots” that lead to “errors, omissions, and variability that are impeding data exchange.” Even more concerning, though, are the barriers created by current laws—or lack thereof—that prevent this type of information exchange from happening at all. While most of those laws are designed with privacy and security in mind, they—like technology—must evolve to align with changing care delivery models and payment structures.


In a perfect world, all healthcare stakeholders would have access to all of the information relevant to their various functions—from plan of care development to payment for services rendered. Getting to that “heathcare utopia” will take time; after all, Rome—like interoperability—wasn’t built in a day. Still, it’s important that physical therapists—and all other types of providers—prepare themselves for a world in which data is the main ingredient in the recipe for creating a stronger, healthier society.

Defensible Documentation Best Practices

Defensible documentation—what a buzz word (er, phrase). But it’s not just hot air; there’s a good reason why it’s so trendy. According to the APTA, creating “documentation throughout the episode of care is a professional responsibility and a legal requirement.” As a “tool to ensure safety and the provision of high-quality care,” defensible documentation serves to:

  • Communicate information about a patient’s care, status, and treatment outcome among providers.
  • Tell others about the unique—and valuable—services you provide as a therapist.
  • Demonstrate compliance with local, state, federal, and payer regulations.
  • Help third-party payers determine appropriate payments.
  • Act as a historical account of patient encounters for legal purposes.
  • Provide a resource for policy or research purposes (e.g., outcomes).

So, for your physical therapy documentation to be defensible, it must be able to justify and support your diagnosis and plan of care—and thus, your payments. But, how do you know if your documentation is thorough enough to stand up to scrutiny? Start by taking a few moments to ask yourself these questions (as adapted from this WebPT blog post):

  • Would your documentation provide enough information to recall a particular encounter—and protect you against any questions or possible legal claims—months or even years after the fact?
  • Does your documentation support and justify your diagnosis, treatment, number of visits, and charges?
  • Is your documentation clear and legible to a non-clinician?
  • Does your documentation accurately describe the patient’s course of treatment?

If you can’t answer “yes” to any of these questions—or if you frequently spend time on the phone or writing letters trying to appeal or explain your documentation to a reviewer—then you’re not only losing payments; you’re also losing your rightful place in the continuum of care.

Basically, creating defensible documentation comes down to proving the medical necessity of your treatment. As Deborah Alexander from the PT Compliance Group discussed during her presentation at Ascend 2015, “Your documented services must be at a certain level of complexity and sophistication, or show that the patient’s condition requires services that can only be delivered by a therapist.” That means you must demonstrate that you provided skilled care. To that end, the APTA offers these recommendations to improve your documentation:

  • Provide a brief assessment of the patient’s/client’s response to the intervention(s) at every visit or event.
  • Document your clinical decision-making process (like explaining why you changed the patient’s/client’s exercise program, added or discontinued a modality, or progressed a functional activity).
  • Make sure your documentation is not repetitive (i.e., don’t write the same thing every time).
  • Make sure your documentation leaves no room for doubt that only a skilled physical therapist could have provided the treatment.

Additionally, here are a few more tips for creating defensible documentation from the University of Scranton’s DTP program:

  • Avoid using abbreviations or vague phrases like “patient tolerated treatment well” or “as above.”
  • Date and sign all entries.
  • Complete progress reports, as necessary.
  • Document during the visit, whenever possible.
  • Clearly identify note types.
  • Include all related communication and missed/cancelled visits.
  • Incorporate valid and reliable —and standardized—tests and measures.
  • Produce legible documentation—or risk having your claim delayed or outright denied

One last tip: use a physical therapy EMR.

Not only can electronic medical record-keeping make sure payers don’t have to decipher your notes, but it also can keep you compliant with all defensible documentation regulations. Alerts, measures, and reminders are built into your documentation, note types are easy to identify, and you can conveniently document during (or immediately after) a visit—you know, when you can easily remember what happened and can paint an accurate picture of the patient’s condition and treatment.


Think of it this way (and bear with me): you know how castles have moats? Well, as a physical therapist, your practice is your castle, and defensible documentation is your moat. And like a moat, your documentation is more defensible when it’s full—of crucial information, that is. So, follow these tips to ensure your documentation—and your practice—is safe and sound.

Want more tips and examples of defensible documentation?
Download this chart for defensible documentation tips.

How a Physical Therapy EMR Can Work for Occupational Therapists

If you’ve spent any time at all searching for an EMR, you know it’s not one-size-fits-all technology—but it’s not one-size-fits-one technology, either. Despite the name, a physical therapy EMR—like WebPT—isn’t for physical therapists only. Here’s how to make a PT EMR work for your OT practice:

What to look for in an EMR

The reason a PT EMR can work so well for OTs is because both specialties need many of the same EMR features, including:

  • Comprehensive documentation
  • Regular—and free—compliance updates and built-in alerts regarding regulatory changes like PQRS, FLR, and ICD-10
  • Scheduling
  • Practice management
  • Billing
  • Free and easy-to-access customer education and support
  • Cloud-based platform (especially convenient for mobile and in-home OTs)

If an EMR has all these features, you’re off to a great start—but just because an EMR offers them doesn’t mean they all will work for your OT practice as-is. The best way to ensure an EMR has refined the crucial parts of its functionality with occupational therapists in mind is simply to ask.

What to ask your vendor

Because selecting—and switching to—an EMR requires time, effort, and resources, there are lots of questions you’ll want to ask yourself when evaluating an EMR. But asking the right questions of your vendor becomes much more important when your profession isn’t part of that vendor’s primary market. As you talk to potential PT EMR suitors, make sure you ask these questions:

  • How did your company approach tailoring its software to meet the needs of OTs?
    • Did you consult with practicing OTs?
    • How did you conduct industry research?
  • Does your software offer a separate OT user profile?
    • If not, how do you ensure my clinic’s accounts are OT-specific?
  • How does your software brand my documents so it’s clear my practice is an OT clinic?
    • Do you have an occupational therapy label?
    • Can I add my clinic name and logo to my documents?
  • Does your software feature OT billing codes? What about Medicare therapy cap-tracking?
  • What OT-related tests and tools are built into your software?
    • Activities of Daily Living (ADL) profile?
    • Disabilities of Arm, Shoulder, and Hand (DASH) test?
    • Upper extremity functional test?
    • Shoulder pain and disability index?
    • Hand and joint tests?
    • Detailed wrist/hand profile?
    • Ability to document and bill for custom orthoses, casts, and splints?


While it might not have been designed for occupational therapists originally, a PT EMR can indeed work effectively for OTs—and it doesn’t have to require a crazy number of workarounds, either. In fact, the right PT EMR won’t require you to do anything beyond selecting your specialty within the application. It might not be easy for you to weed out all the ones that don’t offer OT functionality, but if you keep these features and questions in mind, you’re sure to find a PT EMR vendor that also suits occupational therapists—and makes it easier for you achieve greatness in therapy practice.