How Easy is it to Switch EMRs—Really?

If your current electronic medical record isn’t pulling its weight for your clinic, you may be wishing for a better one. However, switching EMRs isn’t nearly as easy as switching shops for your morning cup of coffee. You’ve invested time and money—in some cases, a lot of both—into your current system, so leaving could be more hassle than it’s worth. But it doesn’t have to be, because if you’re switching to the right EMR for your clinic, your new partner will do everything in its power to make your transition smooth, simple, and—dare we say—easy. Plus, once you’ve experienced the incredible benefits of a top-notch EMR, you’ll wonder why you didn’t make the leap sooner (even if it takes a little work to get there).

So, how easy is it to switch EMRs—really? Well, that depends on both your current EMR and your future one. Here are some things to think about:

The Contract

If you’re under contract with your existing EMR, it’s time to dust off the old paperwork and read the fine print. Before making any decisions, you should know what you’ve already committed to and what penalties you may face for terminating that contract early. When weighing the pros and cons of making a switch, consider this: whatever consequences you may face for leaving, you will most definitely make up in the benefits of finding a system that actually works for your clinic. There aren’t enough fees in the world that should keep you tethered to a software that’s making your life a living you-know-what.

Plus, the best EMRs don’t keep you under contract. They make their products so good that their customers want to keep using them. And if for some reason their system is not the best fit, they’d rather their customers have the freedom to find a partner who is.

The Data

Some EMRs on the market right now—we won’t name names—believe that in order to keep their customers loyal to them, they have to hold said customers’ data hostage. If your current EMR won’t give you back your data, you may have to devote some time to manually transferring your clinic’s information into a format you can upload into your new system. While that may seem somewhat daunting—and will be a bit time-consuming—the alternative is to stay beholden to a company that’s manipulating you. In this case, the data isn’t the only thing being held hostage.

Break free, and switch to a system that safely secures your data on your behalf with absolutely no absurd notions about who retains ownership rights: you do, obviously. That means you can take your data with you anytime you please.

The Learning Curve

When switching to a new EMR, there’s bound to be a learning curve as you and your staff get used to the new system. However, if you choose an easy-to-use and intuitive system, that curve will be anything but steep. You can make it even easier to get up and running on your new EMR if that new system offers in-depth, instructor-led training for your entire staff; an intuitive online training tool that you and your staff can consult whenever you need a refresher on a particular feature or function; and lifetime access to a super-knowledgeable, super-friendly Support team—all at no extra charge.

The Overwhelming Benefits of a Good EMR

Even if the road to your new EMR isn’t bump-free, you’ll be thrilled when you get there, because the best EMRs offer a ton of great benefits, including:

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As the saying goes, nothing worth doing is ever easy. And that certainly applies to changing EMRs. But, with a little planning and forethought, making the switch doesn’t have to be nearly as difficult as you might have thought—and the benefits far outweigh the cost. Switching sounds pretty good right about now, doesn’t it?


7 Ways to Increase Efficiency in Your Private Practice

You’ve surely heard the saying, “Time is money.” And as a physical therapist, you experience it first-hand when you bill for your timed services. But what about your non-billable hours? Are you using that time efficiently? In this Entrepreneur article, author Michael Moroney writes that “employees spend about 31 hours per month in meetings and spend less than 60% of [work] time actually working productively.” According to the infographic Maroney references in his article, the salary cost of unnecessary meetings for US businesses is $37 billion. Talk about inefficiency.

Even if your practice’s stats aren’t quite that shocking, there’s a good chance that you’re spending time on things that aren’t helping your patients, your staff members, or your bottom line. Luckily, you don’t need to overhaul your entire clinic to increase your efficiency—and you certainly don’t need to sacrifice patient care. Instead, try these seven small things to get the most out of every minute:

  1. Create and share processes. Whenever you identify a best practice—whether it be an efficient way to verify patient information or communicate instructions for a particular exercise—document it. Then, educate your staff and—when appropriate—your patients. Additionally, empower your staff members to become experts of their own domains by identifying, documenting, and sharing their own best practices—all in the name of efficiency.
  2. Keep things moving. While we definitely don’t recommend barking orders at your patients or your staff members drill sergeant-style, there may be opportunities to help everyone pick up the pace without rushing. Start paying attention to your patients’ experiences from the minute they walk into your clinic to the minute they leave. Are they spending a lot of time waiting on you or your front desk staff? If so, establish a process (see number one above) that helps speed things along at check-in. And consider prepping your therapy areas before patients arrive, so everything you need is easily accessible and ready to go. You also could enlist the help of an assistant or aide to start patients off with ultrasound, heat therapy, or warm-up exercises.
  3. See things through. As this article’s title points out, “Hand-offs are bad (but unavoidable).” Now, this doesn’t mean you shouldn’t delegate tasks when appropriate, but passing around to-dos without cause can lead to mistakes and a lot of wasted time. Unless you have good reason to involve multiple people in a particular task, designate a lead and let that person take the reigns and see it through.
  4. Hold morning standups. Start each day with a super brief team meeting—a standing meeting ensures it won’t drag on—to review the appointment schedule and discuss any questions or concerns. Some potential topics to cover might be patients who require extra time or assistance; cancellations or open appointment slots; or changes to staff schedules. By proactively addressing these items—and others that are pertinent to your clinic—you won’t have have to deal with them in the middle of a busy day when you have a waiting room full of patients.
  5. Build promptness into your culture. If you maintain a lax attitude about timeliness in your clinic, your staff members and patients will do the same—and that can lead to dawdling employees and lots of missed appointments. Instead, lead by example: show everyone you respect your time and theirs by doing your best to stick to the schedule.
  6. Work to your strengths. Everyone has a different working style, so experiment until you find one that enhances your productivity and efficiency—rather than diminishing it. Do you enjoy back-to-back appointments in the early morning; need a two-hour break midday to catch-up on notes; or perform your best work after the sun sets? Consider your personal preferences, and whenever possible, take advantage of the times when you’re in the zone.
  7. Make friends with technology. Using the right PT-specific EMR can drastically improve your clinic’s efficiency. (Choose one that offers integrated billing and outcomes tracking tools, and your clinic will be so efficient you may find yourself with extra time on your hands.) Speaking of extra, if you’ve got some extra money in your budget this year, you also may want to consider investing in an iPad or two so your staff can access patient charts and exercise flowsheets anytime, anywhere. You could even use the tablet to pull up one of these nifty iPad apps to help patients better understand their injuries.

What steps does your clinic take to improve efficiency? Tell us in the comment section below.


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.

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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.


Do Cash-Based Practices Need an EMR?

Many therapists are beginning to add cash-based services to their practice offerings—everything from gait analysis and golf fitness programs to aquatic therapy and deep tissue massage. After all, as Brooke Andrus writes in this post, “…in the current environment of declining reimbursements from third-party payers, adding cash-pay options to your practice’s current menu of services isn’t only smart—it might just be necessary to secure your survival.”

For some, offering a few cash-pay wellness services on the side might be enough, but for others, like physical therapist Ann Wendel, it’s cash-based all the way. While this business model certainly alleviates a lot of headaches when it comes to dealing with payer contract negotiations and increasingly stringent payment regulations, operating a cash-based practice isn’t all sunshine and rainbows—which is why even cash-based practices need an excellent EMR. Here are a few of the biggest reasons cash-based practitioners should equip themselves with top-notch EMR system:

Your patients still need insurance reimbursement, even if you don’t.

Sure, you get paid immediately, but many patients who are willing to pay out of pocket for physical therapy services do so because they’re able to submit claims to their health insurance providers and receive reimbursement directly. In this post, Wendel writes, “You may find it shocking, but my documentation and billing practices are not that different from [those of a PT in a traditional practice]. The end goal…is to get paid—it’s just that in my case, it’s the patient who is waiting for reimbursement.”

To ensure your patients are able to continue benefiting from your services, you have to help them get their money back—and that requires the same attention to quality documentation and billing processes you’d need to demonstrate if you were collecting reimbursements for yourself. But you’re not going to get that level of quality with pen and paper—or with a subpar EMR. That’s because only the best EMR solutions feature the alerts and safeguards necessary to ensure you create correct and comprehensive documentation that supports your invoices, gets them paid the first time around, and helps you generate those invoices and track patient payments—all within one streamlined system. And only the right EMR securely stores all that information—along with your patients’ medical records—so you can access it anywhere, anytime while remaining fully HIPAA-compliant. Plus, a physical therapy-specific EMR provides SOAP note formats that fit your workflow, so documentation is a breeze.

An EMR does more than improve documentation.

No matter how you choose to collect payment for your services (i.e., via cash pay or through third-party insurance providers) you still have a practice to run. And there are some practice management benefits that only the right EMR can provide. These include:

Scheduling

An integrated scheduling feature allows you to view and edit schedules for patients, therapists, and treatment rooms. And, because your calendar is connected to your documentation, your patient records and patient appointments are linked—thus enabling you to gain valuable insight from tracking no-shows, cancellations, and lost patients.

Automatic Patient Reminders

Sending your patients automatic appointment reminders via phone, text, or email can help you maximize your office hours and reduce no-shows. Plus, you can track your results directly within the EMR.

Referral Reports

Curious as to which referral sources are generating the most business for you—and which ones might need a bit of extra attention? Use referral reports to identify the marketing efforts that are worth your while.

Information Sharing

Whether it’s with your own staff or other members of a patient’s healthcare team, information sharing is critical to ensuring excellent care at every level. Use your EMR to easily communicate with staff via secure instant messaging and with external providers via secure email and faxing. Plus, with the right EMR, all of your external communication will be legible and branded with your clinic logo (talk about a leg up on the professionalism front).

Outcomes Tracking

An integrated outcomes tracking solution allows users to collect objective data, thus empowering them to prove their value and enhance patient care. With a library of standardized, industry-accepted tests, you can set concrete performance goals and track your team’s progress toward them. That’s great for your patients—and for your bottom line.

Security

HIPAA breaches are incredibly costly and can destroy patient trust, which is critical in a provider-patient relationship. With the right EMR, the burden of keeping PHI safe doesn’t rest solely on your shoulders, because the application is fully HIPAA compliant and stores all your data in a world-class, extremely well-guarded data center. Now, that’s a whole lot better than keeping it in a filing cabinet in your clinic—fireproof lock or not.

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In case you’re wondering, Wendel uses WebPT, because she likes the portability of a web-based application, the fact that she doesn’t need to store paper charts in her basement for seven years, and the professional quality of the notes she’s able to securely send to physicians and other healthcare professionals on her patients’ care teams.

Want to learn more about the best EMR for cash-based practices? Schedule your complimentary demo of WebPT today.


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:

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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.


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.

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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.


4 Reasons You Should Use an EMR for Practice Management

When you think about your EMR, documentation might be the first thing that comes to mind. And while defensible documentation is crucial—and should be the main component of your EMR—there are other perks your software vendor can offer you. One of the most efficient, cost-effective options available through your EMR is a practice management suite. Think you already have your processes on lock? Even if you do, you can further streamline your business when you take advantage of all of the benefits your software offers.

As this InformationWeek article explains, “Ideally, EHR and practice management systems work together so that patient registrations become patient health records, and the diagnosis recorded into the EHR turns into a properly coded insurance claim.” Sounds pretty slick, right? If you aren’t convinced yet, here are five mission-critical practice management functions made oh-so-simple with an EMR:

1. Capture Patient Demographics

When a patient enters your clinic, you’ve likely gathered all of his or her demographics before the appointment. You’ve got names, numbers, insurance information, and addresses. But, where do you store it all? Are you leaving PHI in paper files on your front desk or in a filing cabinet—thus putting your practice at risk for a HIPAA violation?

The best way to collect—and store—patient demographics is by entering this information into your secure EMR. Your EMR should provide a patient intake form option. That way, you can be sure you’ve collected all the relevant information, confirmed that it’s up to date, and stored all of it in a secure, cloud-based system. And if you ever need to access any patient info, it’s just a few clicks away. No more digging through stacks of paper—or shuffling through filing cabinets—to locate your patient data.

2. Schedule Appointments

Just like those stacks of files, your appointment book shouldn’t be left to the whims the paper gods—and at risk for HIPAA violations, natural disasters, or misplacement. With the right EMR, you can easily schedule patients, color-code their appointments, manage multiple schedules, and even send automatic appointment reminders. You’ll save time and money when you let your EMR help you decrease no-shows through a seamless scheduling system.

3. Maintain Payer List

With an EMR, you can easily assign the appropriate payers to each of your patients, and it’s simple to keep a comprehensive list that’s available for updating at any moment. Plus, your EMR should offer documentation safeguards based on your payer list. For example, your Medicare patients should trigger certain documentation alerts. With the right EMR, you can control all of this within your payer settings.

4. Generate Reports

Your EMR contains a wealth of information, and when paired with your documentation, you can generate and analyze a number of metrics through easy-to-run reports. With a good EMR in place, you can track no-shows, provider productivity, completed documentation, and even PQRS progress. Running these reports regularly will give you true insight into your business.

5. Submit Clean Claims

The first step to submitting clean claims is creating clean documentation. Your EMR should already have that down pat. But, does your EMR automatically generate CPT codes that flow into your billing software or to your billing service? If not, it absolutely should. Dr. Heidi Jannenga explains in this article that using “a medical billing software or service that is integrated with your EMR means that demographic and billing data will be seamlessly transmitted from your documentation system to your billing company.” The more you can automate processes through your EMR, the more time—and effort—you can save doing routine tasks. And that, ultimately, allows you to spend more time doing what you love: helping patients.

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If you’re looking to improve your processes, look no further than your EMR’s practice management system. As this HealthIT.gov article simply states, “79% of providers report that with an EHR, their practice functions more efficiently.” Are you taking advantage of everything your EMR has to offer?


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.

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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.


Why You Need an EMR for PQRS

Every November, Medicare releases its Final Rule. And nestled among the many regulatory updates—like warm buns in a basket—are the PQRS requirements for the coming year. The 2016 Final Rule reveals that not much is changing for rehab therapy providers on January 1. But, even so, satisfying PQRS requirements is rarely a piece of cake—er, bite of bun? Anyway, as I was saying: The rules can seem convoluted, and adhering to them requires precise documentation. Here’s how an EMR can help you remain compliant in the following areas:

Tracking Progress

In 2016, eight measures apply to physical therapy, ten to occupational therapy, and a whopping one measure applies to speech-language pathology. And the reporting requirements are pretty strict, as Brooke Andrus explains in this article: “Each eligible professional (EP) must report on nine measures across three NQS domains for at least 50% of Medicare Part B FFS patients.” That means PTs and SLPs are automatically subject to the MAV process, which allows Medicare to review their data to ensure they’ve reported on the maximum number of available measures for their specialties. With all of these complexities in mind, how do you track your progress? And how do you know that you are reporting on all of the measures available to you?

Things can get really complicated when there’s that much data to account for, but the right EMR system makes the process simple by providing you with user-friendly reports that accurately display your progress. That way, you can adjust your processes as the year goes on. Sure beats trying to manually track all of that data.

Satisfying Measures Requirements

One of the potential time-sucks of reporting PQRS data properly is the need to document your measures. It can be difficult to remember which measures to report—and at which intervals. A great EMR will prompt you to report any necessary PQRS data at the right time (e.g., some measures are only reported at initial evaluation, while others require reporting at every visit). That way, you take the guesswork out of satisfactorily reporting, and you can always count on your documentation to be compliant.

Something to be aware of: as always, your bottom line depends on your compliance. When it comes to PQRS, you’re looking at a hefty 2% negative payment adjustment in 2018 if you don’t satisfactorily report on the measures that apply to your specialty in 2016. But, if you use an EMR, you don’t have to leave anything to chance. You’ll know exactly how many patients you’ve seen, which data you’ve reported, and how far you’ve progressed toward meeting the minimum requirements for reporting.

Submitting Data

Okay, so now you know that an EMR can help you easily track your PQRS data, satisfy the reporting requirements for all your measures, and avoid the penalty. But, I’ve yet to cover one very important part of this whole shebang: actually submitting your PQRS data to Medicare. Here’s the cold, hard truth: not every EMR is equipped to handle your data. So, make sure you look for an EMR with a certified CMS PQRS registry, meaning the system automatically compiles and submits your data to CMS on your behalf. No hassle necessary.

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Attempting to report on PQRS without an EMR is a lot like preparing a hearty meal without hot buns: sad and pointless. All kidding aside, keeping track of all of the regulatory changes on your own is enough to make your head spin. But the right EMR can help you avoid penalties, stay compliant, and cleanly submit data to CMS like a hot knife through butta’.


4 Tips for Improving Patient Wait Times

Physical therapy treatment plans are designed to help people get back on their feet, yet your patients may find themselves doing a whole lot of the opposite when they’re at your clinic. Even the best physical therapy practices can experience long wait times now and then, but that can lead to patient dissatisfaction—and a lot of negative online reviews. Although your practice might not be the PT equivalent of the DMV, your patients will invariably spend at least a few minutes in your waiting room, so here are four tips to improve your wait times:

1. Collect patient feedback.

The first step toward improving your wait times is to understand exactly why your patients have to wait. Your gut may tell you to simply hire extra front office staff, but that might not be your most effective option for shortening patient wait time (and it’s certainly not the most cost-effective choice, either). So, talk to your patients, whether that’s through open and honest conversations or anonymous patient surveys. Once you know where your practice falls short, you can make improvements in those areas.

2. Rethink the space.

The above-mentioned patient surveys are a great way to discover what your patients dislike most about their wait (other than the wait itself, of course). That front office water feature you installed to help patients relax? Yeah, they may secretly want to throw it through a window to make the bubbling just stop already (and now that you mention it, where’s the bathroom?). So, consider how temperature, sound, lighting, color, and even the comfort of your chairs impact the environment in your waiting room. Think about it this way: if you’re in for a long flight, you’d be a lot more comfortable in first class than you would be in coach, right? Your patients feel the same way about sitting in stiff, armless chairs with no padding; trade up for something a little cushier.

3. Acknowledge the wait.

Have you ever noticed that the drive to somewhere always seems longer than the drive back? Similarly, if your patients don’t know how long they have to wait—or why—then their wait will seem much longer than it really is. To avoid that, you’ll need to acknowledge the wait time in two ways. First, set expectations by informing patients of your average wait time when they schedule their appointments. Second, if the wait time is longer on the day of a patient’s appointment, you should apologize, explain what caused the delay, and keep the patient updated during the wait. Your time is valuable, but be sure your patients know their time is valuable, too.

4. Use an EMR.

Is your practice having trouble scheduling and managing patient appointments? Patients showing up late and throwing off your whole day’s schedule? That’s where an EMR can help. WebPT, for example, allows you to easily view and edit schedules for your patients, therapists, and treatment rooms. Plus, you can automatically send appointment reminders so patients show up on time.  

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Of course, the best tip for improving the patient wait time is to keep it as short as possible. In fact, it’s possible to eliminate the waiting—and the waiting room itself—almost completely, like this practice did. But for the days when emergencies, flat tires, and bad traffic make staying on schedule an impossible task, strive to keep your patients comfortable and informed. The road to recovery for your patients can be grueling, but their wait time at your clinic shouldn’t be.