4 Common Rehab Therapy Documentation Mistakes

Documentation is a thorn in the side of many a rehab therapist. It can be convoluted, confusing, and insanely time-consuming—and it definitely doesn’t help that the rules change every year. (Thanks a lot, CMS.) But, even though writing SOAP documentation can feel like an unforgiving and tedious task, it still deserves your full and undivided attention—because distractions can trigger mistakes, which can trigger denials, which can trigger attention from CMS, which can trigger an audit. Talk about a domino effect! Luckily, you can stop the first domino from falling—if you’re familiar with some of rehab therapy’s most common documentation mistakes. 

1. Missing Certifications and Recertifications

Regardless of your state’s direct access laws, payers can (and often do) require plan of care certifications from physicians before they are willing to cough up a dime of payment. So, even if you have unlimited direct access power (like the PTs in Alaska), you may still have to get a physician’s dated signature before you can bring in that sweet, sweet money. And having a signed and dated certification doesn’t necessarily put you in the clear for the entirety of the patient’s treatment. Some payers (like Medicare) require recertification 90 days after the initial visit or whenever there’s a major change to the POC. 

The Fix 

To avoid this common documentation problem, establish a protocol that requires your therapists or office staff to verify that POC certifications roll in when required. Or, if you don’t want to deal with the hassle of remembering to collect signatures, you can always team up with a reliable EMR that provides automatic, customizable POC certification reminders (like WebPT). 

2. Unproven (and Questionable) Medical Necessity 

Despite how it may feel, CMS and other payers don’t require extensive documentation just for kicks—solely to burden hard-working therapists. They uphold these strict requirements because they want to know, without a doubt, that every individual service you provide your patients is an undeniable and unequivocal medical necessity. Unfortunately, it does take a little more note-writing legwork to prove medical necessity and thus, create truly defensible documentation—which is why this can be an issue for a lot of therapists. 

The Fix 

There’s no quick fix for crafting defensible documentation that supports medical necessity—you simply must provide enough information to CMS proving that your services or supplies “are proper and needed for the diagnosis or treatment of” your patient’s medical condition, “are provided for the diagnosis, direct care, and treatment of” your patient’s medical condition, “meet the standards of good medical practice in the local area, and aren't mainly for the convenience” of you, as the provider.

As we mention in our defensible documentation toolkit, the ideal documentation will communicate:

• the patient’s condition and functional goals, 
• the chosen intervention (and why it was selected), and 
• the patient’s progress. 

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3. Missing or Incomplete Progress Reports

Now, this is a documentation mistake that’s specific to Medicare—but it’s common enough that I thought it deserved a place on the list. Progress reports must be completed once every ten visits and, according to Dianne Jewell, PT, DPT, PhD, FAPTA, and John Wallace, PT, MS, they should also “address the patient’s progress toward his or her goals as noted in the established plan of care. Simply documenting treatment provided on the tenth visit does not meet this requirement—even if you conduct follow-up standardized testing and record results.”

But, even when you remember to complete a progress note every tenth visit, it can be tough to remember to include all of the information necessary to satisfy CMS’s requirements. 

The Fix

Unfortunately, dodging this documentation pitfall isn’t as easy as getting your team on board with a new progress note protocol. Even the most organized therapist will have a tough time manually tracking numbered visits for every single Medicare patient. That’s why your best move is teaming up with a documentation solution that does all of the remembering for you. Find an EMR that provides automatic progress note reminders so therapists are guaranteed to create progress notes exactly when they need to.

As for correctly and fully completing the progress notes themselves, be sure they contain:

• a signature, 
• professional identification, 
• a date, 
• an evaluation of the patient’s progress, 
• a professional judgment about the patient’s future care, and
• modified or discontinued goals and/or treatment plans—if appropriate. 

4. Insufficient Support for 8-Minute Rule Calculations

If you thought your career as a rehab therapist would allow you to leave behind your math skills, then you were sorely mistaken. Almost every payer calculates units based on the CMS 8-minute rule—or some version of that rule, at least. That means just about every outpatient therapist needs to keep their algebraic skills sharp at the risk of adding (and therefore billing) units incorrectly.  

For those of you who aren’t familiar, the 8-minute rule governs the manner in which therapists calculate the number of billed units for Medicare and some other payers. Essentially, therapists add up the minutes spent providing single or multiple timed services, divide the total by 15, and then look at the remainder. If the remainder is eight or more, then they may bill another unit. The tricky part is that there are different versions of the 8-minute rule (like the AMA Rule of Eights)—but no matter which rule you use, you must support your billing vis-à-vis your documentation.

This is where therapists often slip up. Your daily notes must contain enough specific information to support how you billed your visit—but not everyone knows what that specific information is, exactly. 

The Fix

If you want to successfully back up your application of the 8-minute rule, John Wallace states that your daily notes must contain: 

• the total number of “timed code treatment minutes” for each service, and 
• the total number of provided treatment minutes (includes timed and untimed). 

Additionally, if you want to bill for management and assessment time—something that every therapist can and should do—then you should, per Wallace’s suggestion, “document the assessment and management time activities as if they are part of the interventions you document each visit.” This can include: 

• personal observations and clinical reasoning, 
• instructions, counsel, or advice that you provide a patient or his or her caregiver, and
• patient questions and thoughts about progress.

Remember, this isn’t an exhaustive list of documentation suggestions—you can include any information you believe will help you justify your billing to payers. 

Creating solid, defensible, squeaky-clean SOAP documentation is a task and a half—but it’s a skill that is absolutely critical for every rehab therapist. And it’s one that we’re willing to help you with. If you have any documentation noodlers that you’re currently stewing over, feel free to drop them below! We’ll do our absolute best to answer them.