Documentation is almost nobody’s favorite topic. And that’s a problem. When documentation practices don’t get the close, sustained attention they deserve, documentation issues only grow more complex, time consuming, and expensive. Poor and uneven documentation habits interfere with clinicians’ productivity, interfere with timely and full payment for your skilled service, increase denials, and contribute to chronic uncertainty about both your practice’s compliance and its expected revenues.

The bottom line? Documentation will demand your time and attention. You have control over when you give that time and effort: up front, when you can implement a system for executing and monitoring documentation that ultimately saves time, money and stress. Or at the back end, when documentation issues give rise to a whole host of other problems, including putting your practice at high risk for audits.

Rather than thinking about documentation as a tedious topic you can’t wait to move on from, flip the script: approach documentation as a prime opportunity for growing your business, by capturing revenue and time that’s currently being lost to poor habits. These are five essential components of a revenue-capturing approach to documentation.

Establish standard practices

Does every therapist in your clinic approach documentation in the same way? Do they provide clinical information in detail and summary form, and do they know when it’s best to document with structured data and when to use free text? Are they striving to complete documentation at points of service? Does your entire team share a commitment to simple, jargon-free language that’s accessible to a broad readership? Are you confident that your clinic is billing for all billable time at the most accurate, highest-reimbursing codes? Every step in the process can be standardized, for the benefit of more defensible documentation, better patient outcomes, and higher revenues. Implementing a standard set of practices for documentation—and getting the genuine buy-in you need from your staff to make these practices live up to their promise—can take some time. But the investment is more than worth it.

Train everyone on entire process

There’s no greater drag on productivity, efficiency, and the capturing of revenue than confusion among your staff. That can be confusion about expectations and goals, and confusion about the workflow itself. Providing training for your entire team on documentation practices—and the EMR and billing systems that support those practices–can cut down on errors, reveal redundancies and streamline the process. Ideally, each member of your team, from clinicians to aides to billing and front desk staff, understands their individual contributions to smooth, efficient documentation—and how their roles connect to the bigger picture. A staff that understands the documentation process and sees it as a collaborative endeavor will be more alert to issues, more empowered to ask questions, more motivated to suggest improvements.

Use single system for EMR and billing

This one is a no-brainer. When EMR and billing are housed separately, two completely different systems must continually align in order to produce clean claims. That’s a burdensome—and unnecessary—challenge. A unified EMR and billing system cuts your team’s workload in half. Not having to make two separate entries ensures more complete and accurate documentation in less time. That lets your practice capture additional revenue, and frees your therapists to spend more meaningful, billable time with their patients.

Stay on top of data

You can adopt and devise all kinds of systems for streamlining documentation, but you can’t truly know how well your systems are working until you consistently track their performance. Core metrics that every practice owner should be relying on with can reveal essential information about how well your documentation practices are working from the treatment room to the billing department, including first pass payments, denial rates, net collections, and measurements of units and revenues per visit, both aggregated and broken out by individual therapist.

Learn the new approaches for tracking outcomes

As we know, the transition away from fee-for-service and to value-based care is well underway. That means a whole different set of metrics are emerging. In fee for service, we track units and revenue, per visit. In value-based care, we track cost per case. Particularly with outcomes tracking, the shift to value-based care introduces a whole new set of metrics that are essential for you and your team to know and understand, and to reflect in your documentation practices. Don’t be afraid of these changes. It’s time to embrace them. There’s tremendous opportunity for physical therapists in value-based care. Stay ahead of the curve by getting your entire team up to speed on using outcomes tracking, to improve delivery of care and its documentation, encourage more engagement with patients, and better quantify the value of your services to payers and future/prospective patients.

Tracking metrics and improving documentation help you to better demonstrate your value and expertise to current and prospective patients. Want to learn more about how to reach the patients you’re most interested in treating? Download your FREE copy of my latest guide, 5 Simple Ways to Increase Patient Visits (without spending a dime).Dr. Jamey Schrier is a physical therapist and founder of Practice Freedom U, which teaches practice owners how to grow and scale their business so they can prosper in and out of the clinic.


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