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Documentation
953 Plays2 years ago
Josh highlights what are some important aspects of documentation as it relates to hand therapy,
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Transcript
Introduction to Hand Therapy Academy
00:00:06
Speaker
I'm Josh McDonald. And I'm Miranda Materi and we are Hand Therapy Academy.
Importance of Proper Documentation in Legal Cases
00:00:10
Speaker
So we have Josh on and he is going to be talking about documentation, what really needs to be in there to get paid and to stand up in my legal case, which Josh has some experience with and he's going to be sharing that with us today.
00:00:26
Speaker
So I had the opportunity, I'm still in the middle of the opportunity to be a witness in a case where they are questioning if this patient's care, her plan of care was sufficient. And the big thing that's coming back to bite the treating therapist from four years ago was her documentation and she
00:00:43
Speaker
like we all do. I know I would be scared to death if someone took some random patient from four years ago and wanted me to testify on my note taking from a Friday afternoon when
Key Components of Effective Documentation
00:00:52
Speaker
I was trying to go home. So it really kind of brought home to me some things that I want to make sure I'm including my documentation and I want to kind of share with whether it's our employees or new grads or students, all that, just to make sure your notes are a little bit more legit and can hold up not just in court, but also when you're trying to justify to a provider why this patient still needs services, just to make sure they're a little bit more legitimate and solid.
00:01:14
Speaker
Yeah, and was it, I guess for this case, was it
00:01:19
Speaker
Like was the legal action taken like sometime later or was it, do you think the therapist up front knew that this was potentially a legal case? I feel like sometimes you can really identify these based on was it a car accident, the type of injury, what was it? Yeah, the situation was a car accident and the therapist, the treating therapist, I don't think she had any idea this was going to turn into a legal case and it didn't become a legal case until two years after the patient was discharged.
00:01:46
Speaker
Like it didn't come back on that therapist's doorstep for two years. We are now two years again removed from that. So total of four years, it's actually getting to arbitration. So your notes, if it's going to go to court, it's not going to go to court within any timeframe that you're going to remember any of this stuff. So your notes have to be thorough enough that you can go into court and say, this is exactly what my note says. This is what I did. And this was the patient's response and knowing that,
00:02:11
Speaker
that if I picked up my note from four years ago, could I testify as to what I did, all the factors of what was going on and the patient's response to it? Right, okay, that's good to know.
00:02:23
Speaker
Yeah, so one of the big take-homes was when I'm documenting in my objective portion the activities that we did, whether it was therapeutic exercise, physical activity, self-care, neuromuscular reed, whatever it was, there's four components I want to make sure are included in each activity that I did. So if I do, let's say, for example, we have the button book, and I pull out this book that's got all these decreasing sizes of buttons, I'm going to say what we did, that's the obvious one. We did the button book.
00:02:49
Speaker
why we did it for functional self-care independence or lateral pincer grasp or what was the why? Why did I decide to do that task? So what we did, why we did it, how long we did it for. So for example, if that button book took them 20 minutes to get through, they were a trooper and they worked really hard, I'm gonna document it took 20 minutes. I might be able to measure later, it only took them 15.
00:03:14
Speaker
But that helps support the billing units that I'm identifying as how many units per 15 minutes. So if it took them 20 minutes, that figures into that. So I need to justify what I did, why I did it, how long I did it for, and what makes it a skilled service. What sets the task apart from what I did versus if a tech walked across the room, put the button book down and said, here you go, you know the button book and walked away. They could do that at home with the button up shirt. What did I do that made this a skilled service?
00:03:44
Speaker
Maybe it was monitoring them for mechanics. Maybe it was giving them cues to decrease compensatory strategies using the other side. Maybe it was scaling it down and saying, let's go to the bigger button books. Sometimes that can be done from across the room. I can say, hey, you're using your middle finger. It's just indexing thumb today.
00:04:02
Speaker
That's still a skilled service that is, as an OT, something I would identify. So what we did, why we did it, how long we did it for, and what makes it a skilled service to set apart each of those activities. It doesn't have to be three sentences. That can all happen in one sentence. Okay. So what would be an example? Can you just say something? Absolutely. So we'll do like the button book again. Patient completed button book in 15 minutes with min queues for mechanics.
00:04:30
Speaker
what we did, why we did it, how long we did it for, and the min queues. So let me do that again. I got confused on that one. What we did, we'll do patient did button book for 15 minutes to work on self-care independence with min queues for functional mechanics.
00:04:47
Speaker
Okay. We could do patient completed putty size tools for 15 minutes for functional grasping mechanics with min cues for taking rest breaks as needed. Okay. So in this one, if you said with verbal cues to correct
00:05:06
Speaker
um, risk position that would work right for how it's skilled. Yes. The more detailed, the better for sure. But on a Friday afternoon, we're all trying to sneak things out there a little bit, the more detailed, the better. And if this person is, if it's the 17th time they've done that, maybe I need to pick something different, but they need less cues. But if you didn't do something to make it a skilled service, then insurance doesn't want to pay for it. So make sure that you're adding something of value to the situation. Otherwise a tech could have done it.
00:05:36
Speaker
So it's not only what you did, it's what the patient did, it's what you did as a therapist too. Yes, yes. Because if I'm just handing patients stuff and walking away and there's nothing I did that makes it a skilled service, then A, why is insurance going to pay for it? And B, did that patient get the best outcome or is that me being kind of lazy and not doing my job thoroughly that a lawyer down the road is going to come back out? Right. Okay, great. Good tips.
Billing Units and Insurance Differences
00:05:59
Speaker
Another thing that we need to be mindful of is how we bill our units. And there's something called a roll-up rule with Medicare. Most of us know the eight-minute rule. If we hit eight minutes on each 15-minute interval, we get to bill the next unit. So, zero to seven minutes. If I spent five minutes on something, that doesn't count for billable unit. If I spent eight minutes, I get to round up to a 15-minute one-unit charge.
00:06:24
Speaker
If I use another eight minutes and get up to 23, I can build a second unit.
00:06:30
Speaker
But there's some difference with what we can build for all of our other providers versus Medicare. With all of my other providers, it's unit specific. So in a therapeutic exercise, 97110, if I did eight minutes of an activity, I can build one unit. If I did eight minutes of manual, I can build a unit. Eight minutes of something else, I can build a unit. Medicare says, we're not starting with units, we're starting with minutes. Eight plus eight plus eight is 24. That's only two units worth of time.
00:06:58
Speaker
So if I bill three units, because I did three things, that's over billing. I only spent two units worth of 24 minutes. It works the other way too, where if I spend 20 minutes on therapeutic exercise and 20 minutes on therapeutic activity, that's only one unit of each because I didn't reach 24 to justify a second unit. So under all my other insurances, that's only two units, 20 and 20. Under Medicare, if I start with 40 minutes,
00:07:27
Speaker
that qualifies for three units. So then I can divide that up by how many units in each thing. So if I have 40 total minutes, I can bill three units under Medicare. So every other insurance you start with the units, how many minutes in each one Medicare start with how many minutes and divide that and see how many units I get to bill because 40 or 20 or how many minutes. Yeah. I think that's a really good tip because I think in schools and
00:07:52
Speaker
Even when we have these new grads coming out, they're always saying, well, we just need to follow Medicare guidelines. But this is actually when you have a non-Medicare case, it's actually very different, right? And what we do. And I know a lot of documentation platforms have this already built in it, but I think that's really an excellent tip to share.
Common Pitfalls in Documentation
00:08:11
Speaker
And I think a good last tip for this is our documentation systems, the EM&Rs that we use, all the electronic database stuff are not set up for therapy. They're set up for physicians, they're set up for maybe even PTs and that OTs, certainly maybe not even hand therapists. So do not trust the documentation system. You need to look at what the final report looks like on a random patient, print off their eval, and see what a lawyer's gonna be looking at. How much stuff did you not write that they auto-filled in there?
00:08:40
Speaker
How much stuff from the previous eval is auto-populated? You need to make sure you're unchecking boxes when appropriate, checking new boxes, updating goals. Do not let auto-populate bite you in the butt later on. That's exactly what happened in this legal case I'm on. Things just kept auto-populating. This therapist made one comment about patients not aware of their home program.
00:09:00
Speaker
and that auto-populated for every single note after that. So it looks like the patient never knew their home program and she never educated just because you didn't unclick a box. So you need to understand what your final product eval soap note progress report, all those look like so you know how to adjust because it may be an auto-populate, but it's your note that you signed off on.
Ensuring Thorough and Accurate Documentation
00:09:20
Speaker
Right. And I think one other thing that you can implement in your clinic is doing peer reviews of each other's documentation, right? So sometimes when we share patients, we do this naturally, right? Like I get a patient from someone, I'm reading their note and I'm like, I don't understand this. And then asking those questions like, Hey, can you provide clarification of what this means in your note? And then that gives the therapist a hint like, Oh, that note, you know, need more needed more detail in it.
00:09:43
Speaker
And then if you have anybody in your management or maybe one of your more senior therapists review the younger, newer therapists, I think that can be really helpful as a new grad learning how to document appropriately. Yeah, yeah. I do think too, maybe having a new grad or a one or two year out checking on the experienced therapists who think they're doing a fantastic job but have fallen into a groove and take some things for granted a little bit.
00:10:07
Speaker
Yes, that's definitely the case. Okay. Yeah. Thank you for sharing all that. That was very, I think helpful.
Upcoming Court Documentation Course
00:10:14
Speaker
All right. Okay. And that we do have a court documentation course that is coming out. It won't be until August of 2023, August, September 2023. So be on the lookout for that. And if you guys have any questions, reach out to us at info at hand therapy academy or check out our Instagram page at hand therapy academy.