Documentation / Billing

Question 1

Purpose of documentation:

Answer 1

1. Record what was done
   
   • covering therapist & legal issues
2. Organization of thought process
3. Reimbursment
   
   • medical necesity & skilled care provided
4. Communication
5. Tracking pt progress
   
   • research data
   • re-evaluation

Question 2

What do you document?

Answer 2

1. PT sessions: everything
2. phone calls
3. E-mails
4. Cancellations
5. No-shows

Question 3

What is considered “documentation?”

Answer 3

1. Written reports
2. Standardized assessments
3. Graphs/tables
4. Photos**, videos**, drawings

*Written consent

Question 4

How do you line out errors in documentation?

Answer 4

with a single line, initial and date

Question 5

should you cross out any blank lines or spaces in documentation?

Answer 5

yes

Question 6

What is the SOAP format documentation?

Answer 6

• Subjective: pt report, direct quote, pt perception of his or her condition
• Objective: measurable data. T&M taken, Tx, Instructions given, equip provided, communication.
• Assessment: overall impression, summary of situation, modification of goals. Clarification of inconsistencies bet O and S, justification of continued services.
• Plan: what will you do in the next sessions

Question 7

In which part of the documentation do you write modification of goals if needed?

Answer 7

A:

Question 8

In which part of the documentation do you write a summary of the situation?

Answer 8

A:

Question 9

In which part of the documentation do you write the overall impression of the session?

Answer 9

A:

Question 10

In which part of the documentation do you write clarification of inconsistencies between Subjective and Objective ?

Answer 10

A:

Question 11

In which part of the documentation do you write a justification of continued services

Answer 11

A:

Question 12

In which part of the documentation do you write instructions and communication given to the pt?

Answer 12

O:

Question 13

In which part of the documentation do you write equipment provided to the pt?

Answer 13

O:

Question 14

In which part of the documentation do you write changes in the current plan of care?

Answer 14

P:

Question 15

In which part of the documentation do you write patient’s own perception of his or her condition

Answer 15

S:

Question 16

In which part of the documentation do you write what will you do in the next session?

Answer 16

P:

Question 17

Untimed codes:

Answer 17

ONE CODE:

• Evaluation
• Re-Evaluation
• Hot or cold packs
• Mechanical traction
• E-Stim

Question 18

How many codes to bill a 2h pt evaluation?

Answer 18

one code

Question 19

How do you bill for the application of a 20 min hot pack?

Answer 19

• one code

Question 20

Timed codes:

Answer 20

Require full attention

• TherEx
• Neuromuscular education
• Gait training
• Ultrasound
• Manual therapy
• Functional training

Question 21

Rule of 8’s

Answer 21

• 15 minutes chunks = 1 unit
• 30 min = 2 units
• etc

Question 22

What is the minimun amount of time that you can bill?

Answer 22

8 minutes

Question 23

What is the minimun amount of time that you can bill 3 units?

Answer 23

38 min

Question 24

what is the min amount of time that you can bill 1 unit?

Answer 24

8 minutes

Question 25

how do you bill 3 min on gait training, and 5 min of therex?

Answer 25

1 unit of TheEx

Question 26

How do you bill the following 35 minutes total session:

• 8 minutes therex
• 9 minutes neuromuscular re-education
• 10 minutes gait training
• 8 minutes manual therapy

Answer 26

• 1 unit NM Re-Ed
• 1 unit gait training

Question 27

How do you bill 47 minutes total session:

• 23 minutes Functional Training
• 24 minutes Gait training

Answer 27

• 2 units gait
• 1 unit functional training

Question 28

How do you bill the following 52 min session:

• 30 min E-Stim
• 8 min manual therapy
• 14 min therapeutic exercise

Answer 28

• 1 unit E-stim
• 1 unit manual therapy
• 1 unit therex