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Support PT Evaluation with Strong Documentation

By Shannon Sullivan, CPC, CMBS
Well supported evaluation and management (E/M) documentation is essential to the coding of physical therapy (PT). It must be thorough, specific, highly detailed and the exact findings should be noted to assign accurate codes.
The initial evaluation for physical therapy must include:

  • Diagnosis;
  • Onset date;
  • Date of surgery or surgeries;
  • Past medical and surgical history;
  • Current complaints;
  • Review of systems;
  • Tests/measures;
  • Goals of physical therapy intervention; and
  • The treatment plan.

Build Up Therapy Necessity with Details

Make sure the physical therapist includes any other health services the patient receives at the same time as their therapy. If the patient needs durable medical equipment (DME) at the time of evaluation, document it. Throughout the patient’s course of therapy, the physical therapist should document communication with other providers and communication with family members. Make sure the therapist recorded the presenting problem’s history and the current complaints of the patient. Look for specific information as to why the patient is seeking therapy, and inquire into the goals of the patient. Be certain the physical therapist documents onset dates and dates of surgery.

Get the Full Range of Functioning

If a patient had an open reduction internal fixation on Dec. 1 and is now seeking therapy to increase their strength and decrease pain, the charts should be specific as to the premorbid level of functioning.
The physical therapist should have asked questions such as:

  • Was the patient able to perform daily activities without difficulty before Dec. 1?
  • Was the patient pain free before Dec. 1?
  • Did the physical therapist describe the patient’s prior and current functioning status in detail?
  • Did the physical therapist evaluate and document the patient’s strength, range of motion, and clinical observations during the evaluation? Objective testing is a must when assessing levels of independence: goniometric range of motion measurement, manual muscle testing, and other measures should be noted for your selection of codes. Remind the physical therapist to document findings in detail and continuously update documentation as the patient’s functional status improves or worsens.

Encourage your physical therapists to always obtain baseline measurements at admission and then reassess on an ongoing basis. At the beginning of each session, the therapist should take a thorough and subjective assessment of:

  • pain levels at rest and with use;
  • compliance with recommendations; and
  • any possible changes in functional status.

It is also a good idea for the physical therapist to briefly re-assess biomechanical components, such as edema, range of motion, and strength. Depending on the diagnosis and condition of the patient, a thorough re-evaluation should be done every three to six weeks. At discharge, outcomes should be clearly noted.
Here’s an example:
Subjective (S): “I am using my hand normally again. I can eat, tie my shoes, do everything just like before.” Denies pain at rest or with use.
Objective (O): Active range of motion and strength well within normal limits throughout right upper extremity. Wounds are well healed by primary intention, no sign of infection or fibrosis. Tactile hypersensitivity is fully resolved. Patient and spouse re-educated to scar maturation techniques. Demonstrates full competency and was without questions.
Assessment plan (A/P): Patient met all goals; however, needs to continue scar maturation techniques daily for another six months. Patient expressed full satisfaction, understanding, and agreement and is without questions. He will telephone this office if further needs or questions arise. This discharge summary will be forwarded to the referring physician.
This outlines an ideal case. Some key areas to note in the subjective section are: the therapist stated the patient’s comfort level and documented the ability to use the affected area. In the objective section, the spouse was included and noted to show thorough patient/family education, which ensures good recommendation carryover outside of the clinic. It cannot be assumed the patient demonstrated competency—assure your physical therapist made note of it and showed the patient was asked if he had questions. In the assessment/plan section, the physical therapist’s impression, recommendations, and directives should be given, concluding with how the visit ended.

Push for Relevant Medicare Documentation

Educate your physical therapists. Teach them that when documenting anything, pay close attention to Medicare guidelines. For example, the treatment time spent to increase a patient’s endurance is not reimbursable; however, the time spent to increase sustained functional activity tolerance is. Sustained functional activity tolerance is relevant to function, whereas endurance might only be relevant to how long a patient can perform a progressive resistive exercise without tiring.

Don’t Skimp on Education Follow-up

Immediately following the evaluation, the patient should receive home exercise program education, if warranted. The education should be verbal, visual, and written. Make sure the physical therapists kept a copy of the written portion in the chart and documented the patient expressed full understanding, demonstrated full competency, and was without questions. Treatment can be provided on the same day. Yes, Medicare will pay for education and treatment on the same day of the initial evaluation.
Remember: For patient education, bill a relevant code to the education itself. For example, if a patient is educated to self range of motion and strength exercises that are performed with the physical therapist, bill therapeutic exercise.

Present a Working Form

Putting it all together on one neat evaluation form is essential. List all components needed and work with your physical therapists to build your form from there. Keep it simple, thorough, and concise. Use check boxes and pre-typed statements wherever possible to save yourself time. This will allow you to spend more time with patients. For example, at the end of the evaluation, you might have a pre-typed statement stating “patient was educated to home exercise program with verbal, visual, and written (see attached copy) instruction. The patient demonstrated full competence and was without questions.” If this does not occur, simply cross it out with one line and initial it. For further convenience, have common goals pre-typed onto the form such as:
Short term goals (to be achieved by ________)
1. Patient to demonstrate full competency with home exercise program three consecutive sessions.
2. Patient to report pain at rest decreased by 50 percent
3. Patient to report pain with ROM decreased by 50 percent
In everything we do, whether it is in the clinic or in the billing office, staying current with regulation changes, paying consistent attention to detail, providing education to physical therapists, and having honesty and integrity will ensure success.

Evaluation and Management – CEMC

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