Documenting Therapy Services

Physical therapy modalities are often an integral part of treatment in a chiropractic office. With concurrent and retrospective reviews on the increase, it is more important than ever to make sure your treatment plan and daily SOAP notes contain the information needed to verify the services billed and to establish and substantiate the medical necessity of care. In short, proper treatment plans and SOAP notes can be a lifeline in your practice.

With each exam/re-exam, a new treatment plan should be established/revised.  The treatment plan should describe the frequency and duration of care, the goals of the care and the plan of care.  Both long and short-term goals should be outlined in your plan.

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Frequency and Duration

As the patient progresses in care, insurance companies are looking for decreasing frequency.  Frequency can be expressed as “2 times a week for 4 weeks” or “Once daily, 3 times a week tapered to once a week over 6 weeks”.  At the end of each treatment plan period, a re-examination should be performed, progress assessed and a new plan created.

Goals of Care

Each treatment plan requires the formation of short-term goals.  These goals should be quantifiable, verifiable and related to activities of daily living.  Many of the most common goals are measured using the Outcomes Assessment forms.  These forms are a valuable asset in determining and substantiating the need for continued care.  The Outcomes Assessment questionnaires provide a tool that identifies limitations the patient is currently experiencing and provides the physician with easy access to a quantifiable goal setting.

Plan of Care

The detail level necessary in the plan of care should allow the recipient to clearly understand the services provided.  Each therapy’s detail should be based on the type of modality/procedure used and may include anatomical region(s) treated, duration, specific exercises to be performed, repetition(s) and/or techniques used.  Each therapy should address one or more specific goals as stated in the plan of care.  Phrases like “increase joint range of motion”, “reduce or eliminate soft tissue swelling”, “stretching of shortened connective tissue”, “strengthening”, “improve endurance”, “restore muscle imbalance” help the reviewer to understand the purpose of the therapy prescribed.  Failure to provide the correct details for the CPT® code billed can result in a denial of care in concurrent or retrospective reviews.

Re-examinations

At the end of each treatment plan period, a re-examination should be performed and outcomes assessment questionnaires used to quantify progress.  A 30% change in score is considered clinically significant.  Outcomes assessment is used to establish the need for care and the need for continued care. A recent post-payment review stated: “without baseline assessments and other important outcomes assessment scores, measurable functional improvement cannot be shown”.  This means your care can and will be denied.  

Daily Notes

When documenting each visit, be sure to identify specific segments adjusted (C2, L3,) as well as the specific details of each therapy/modality provided.  Documenting session start and stop time as well as the duration of each therapy is the standard for most carriers.

Selecting the appropriate CPT® codes and providing the level of documentation required for each service performed helps to ensure that your claims pass many concurrent and retrospective reviews. Additionally, his not only helps you get paid for the services you perform but assists you when trying to keep the money you’ve earned when claims are audited.