As I mentioned in my last post on point-of-care documentation, documentation during treatment is widely recommended. But when it comes to billing, the RAI User's Manual says that only skilled therapy time is billable and "[t]he therapist’s time spent on documentation or on initial evaluation is not included."
Based on my interpretation of the rules, I would never do any documentation during sessions when I was starting out. I'd wait until later in the day (hopefully) or week (yikes!) to flip through my notes and start documenting the session.
This meant I'd end up with a growing pile of notes (not always legible, unfortunately). And as the top of the stack got higher and higher, so did my blood pressure!
So I'd sit down outside of work hours to complete my documentation. And if I couldn't read my notes, I had to think back and try to remember the visit, which wasn't always easy.
As I gained more experience, I came to understand that good documentation is part of treatment. I couldn't help my patients progress if I wasn't keeping detailed notes. And, since I was taking notes anyway, why not take them in a format I could use for documentation?
According to Shelly Stangl, MS, OTR/L, President of AMeraSino, Inc., a company that provides regulatory compliance consulting for Medicare and Medicaid support facilities, point-of-care documentation is "often encouraged to maximize efficiency and accuracy of documenting services."
Every pediatric therapist wants to be more efficient, and accuracy is paramount if you want payers to accept your claims. Point-of-care documentation seems like a no-brainer!
But Is It Billable?
Stangl says that "the key to making [point-of-care documentation] billable time is that the clinician must be providing a skilled service simultaneously."
Jeremy Furniss, OTD, MS, OTR/L, BCG, AOTA Director of Quality, provided further guidance on when time spent on documentation is billable. Though AOTA doesn't have an official position on point-of-care documentation, Furniss says that whether or not you can ethically bill for time spent documenting depends on what's going on with the service and what you're billing.
"Typically, you should bill for providing skilled services, and you can document if it's practical."
Of course, it isn't always practical. Some kiddos need more supervision or a more hands-on approach. But when you can document while still providing skilled services, documenting in real-time provides several benefits.
(For more on when you can--and when you can't--bill for point-of-care documentation, see my last post, "When Can Pediatric Therapists Bill for Documentation Time?")
Here are some of the main benefits of point-of-care documentation:
1. It's More Accurate
When you were in school, did you wait until after class was over to take notes? Of course not! By the time class was over you'd be lucky to remember half of what your professor said.
The same goes for therapists. By documenting during treatment, you ensure that your notes are accurate and complete.
If you wait until later in the day (or, worse, days later) you'll have a much harder time remembering the session.
2. You Won't Get Overwhelmed
Speaking of waiting until days later to do your documentation, who wants a huge backlog of notes to do?
Before I started documenting during sessions, I once had so much documentation pile up that I had to take a day off to sift through my notes and complete all my documentation.
Don't let a growing backlog of notes stress you out. Get your documentation done as you go.
3. It Saves Time
If you take unorganized notes doing therapy, you're going to have put them into the SOAP note format later. That's just more time spent documenting. Why not get as much of it as you can done at once?
With more and more clinics implementing productivity requirements that equate billable hours to productivity, it's important to optimize your routine and be as efficient as possible.
4. It Protects You and Your Practice
Remember: If it’s not documented – it didn’t happen!
If Medicaid comes knocking at your door, you'll want to have every note written and ready to go. By documenting during treatment, you reduce the chance that you'll forget to document a visit.
Don't let poor documentation habits lead to losing your license or having to refund money to Medicaid.
It's Part of the Process
Documentation is part of the therapeutic process. Now that you have a better idea of the billing considerations involved, give yourself permission to document during your sessions and start experiencing the benefits today!
Know the Rules
Point-of-care documentation is a great way to improve efficiency, but it's not always appropriate. Read this post to learn more about when it's OK to bill for time spent providing a skilled service and documenting simulatneously. (Hint: the keyword is "simultaneously".)
If you're not sure, contact your Medicare Administrative Contractor (MAC) to confirm. (Find your MAC here.)
What about you? Do you document during or after treatment (or both)? Why?