This text-based course is a transcript of the live event, “Do’s and Don’ts of Documentation” presented by Shelly Mesure, M.S., OTR/L.
>> Shelly Mesure: One of the things that I have specialized in is writing six-hour live seminars. This course is actually a snippet from one of those seminars, and it really came about because of the training issues that are in healthcare right now. No matter what setting you are working in from pediatrics to geriatrics and everyone in between, we are really getting scrutinized very closely based on our documentation. There is a lot of money at stake for making innocent mistakes, coding errors, or just having sloppy documentation. You could provide the best therapy you have ever given to your patient, they got better and they made a full recovery, but that claim still ends up getting denied. Under review, it all boiled down to the documentation. That is really what our goal is today. It is to look at some of the current issues that are trending right now in healthcare, and then look at how we can strengthen our documentation, specifically for speech therapy needs.
Quick Tips
Let’s get started. Here are a couple of quick tips. Some of these tips apply if you use paper versions of your documentation; other of these tips will apply to the computerized versions. Unfortunately, nobody is on the same standard just yet, so everyone may be doing things a little differently. Write legibly. Do not use white-out for corrections. Even if you have a computerized system where you do all of your clinical documentation and you print out those notes to file them onto the patient's chart, you need to make sure that if you have noticed a correction that needs to be made, you do one of two things: Make the change in your computer system, print out another copy, and give an original signature with that; or do a single line through it, write “error,” and provide your initials next to it. Ultimately, that is the legal document -- not what is in your computer system, but what is actually filed on the medical record. For some of you, if you are fully integrated with your electronic medical records and your system automatically pulls them from all areas, then this may not be such an issue. For the rest of us, even with the computer systems, we want to make sure we do not make that mistake. When we are documenting, no matter what we are using -- paper or computerized versions -- you really do not ever want to leave any blank spaces. Blank spaces look like the documentation was incomplete or it basically makes it look sloppy. Even if you just indicate N/A or draw an X or cross out that area that you not assessing at the time, that is fine. Obviously we should make sure that we sign and date all of the documentation.
Regulatory Changes
Why are we so focused on documentation? This is because of all the trends that are happening with the regulatory changes. There are a couple of key areas right now that are affecting our industry, but I want to just make sure everyone has a good understanding of what is expected from these systems. That ultimately dictates what we have to document.
Mandatory Medical Review
Key fact number one was the implementation of the mandatory manual medical reviews that started last fall. They were all enacted on October 1, 2012, and they were renewed for the calendar year of 2013. This basically says that any patients who have claims that exceed $3,700 for the calendar year will automatically come under manual medical review. These are for your Medicare Part B patients; that includes outpatient therapy services through outpatient clinics, hospital-based outpatient therapy, nursing homes that are providing part B services to the long-term-care residents, and in some cases, it may also apply to home health that is being billed under Medicare Part B. There are other versions of home health, specifically through home health agencies that bill directly to Medicare Part A. In those cases, they are not subject to the manual medical review. They follow completely separate rules and regulations, and have a different payment structure.
