Documentation in Healthcare

Question 1

Documentation

Answer 1

Speech-language pathologists prepare, sign, and maintain, within an established time
frame, documentation that reflects the nature of the professional service.
Results of assessment and treatment are reported to the patient/client and
family/caregivers, as appropriate. Reports are distributed to the referral source and
other professionals when appropriate and with written consent.
The privacy and security of documentation are maintained in compliance with the regulations
of the Health Insurance Portability and Accountability Act (HIPAA), Family Educational
Rights and Privacy Act (FERPA), and other state and federal laws.
Except for screenings, documentation addresses the type and severity of the communication or
related disorder or difference, associated conditions (e.g., medical or educational diagnoses)
and impact on activity and participation (e.g., educational, vocational, social).
Documentation includes summaries of previous services in accordance with all relevant legal
and agency guidelines.

Question 2

Documentation Medicare

Answer 2

Evaluation
* Plan of care
– diagnoses
– long-term treatment goals
– type (e.g., group, individual), amount, duration, and frequency of therapy services;
* Treatment notes
* Progress reports
* Discharge note
* For 2017, the therapy cap is $1,980 for speech-language pathology and
physical therapy services combined.

Question 3

Documentation Medicaid

Answer 3

Joint federal- and state-funded program to assist states in
providing medical care to low-income and medically needy
individuals
* Although documentation requirements may follow Medicare
guidelines, each state can impose its own requirements.

Question 4

Documentation private insurance

Answer 4

No universal documentation template. SLPs are responsible for
identifying the requirements of each payer.
* Documentation typically reports why the patient was seen, what
was done, what was found, and what was recommended in a
way that justifies the assigned diagnosis and procedure codes
* Health plans reviewing claims will ask for documentation to
justify the services delivered.

Question 5

HIPAA

Answer 5

The Health Insurance Portability and Accountability Act of
1996 (PL 104-191)
* Law designed to improve the efficiency and effectiveness of
health care system.