Compliance: Scribbles Aren’t Going to Cut it Anymore

With compliance regulations and documentation requirements on a steep upward trajectory—both in complexity and sheer frequency—it’s becoming next to impossible for us to do our jobs as physical therapists without the help of supporting technology—specifically, electronic medical record (EMR) systems. Today, one incorrect claim or one illegible or incomplete note can cause a ripple effect that results in delayed or even denied reimbursements as well as audits, penalties, and revoked incentives. And without the help of an EMR, it’s just too easy to make a mistake or miss a step and end up in some seriously hot water.

Recently, one of my writers went to see her doctor for a routine checkup. As she was sitting on the table, making small talk with her physician about the weather, she noticed the doctor look at her chart, look at her on the table, and then back at the chart again, startled. After a few more awkward seconds, the doctor looked up once more and asked my writer what she did for a living, to which she replied, “I’m a writer.” The doctor looked at the chart again and burst into laughter, showing my writer the form. Whoever transferred her occupation from her intake form to her chart had scribbled “writer” in such jumbled cursive that it looked very much like the word “witch.”

This, of course, is a silly example of illegibility, one with no compliance or clinical consequences. But there were consequences in terms of patient perception. It led my writer to question her doctor’s practices and take a second, more scrutinizing look at the towering stacks of disheveled paper everywhere and the rooms upon rooms of filing cabinets—especially considering that she had already experienced more than one billing mix-up with this provider. And what might have happened if that messy scribble was a diagnosis or a prescription or a note about an allergy instead of merely her occupation? It’s easy to see how this type of situation could snowball into more than just a slightly awkward interaction; it could lead to some serious repercussions for the patient and some serious repercussions for the practitioner under many of the new compliance regulations.

For stuff this important—safety, credibility, and compliance—relying on handwritten documentation isn’t the way to go; there is just too much room for error. That’s where an EMR comes in. Not only will going digital ensure that all your documentation is neat, orderly, legible, uniform, and accessible, but with an EMR you’ll also have built-in alerts and flags that’ll help you keep track of what information needs to go where, for which patients, and when. After all, we’re no longer just talking about submitting basic claims. Today, most PTs have to comply with an array of Medicare regulations: physician quality reporting system (PQRS), functional limitation reporting (FLR), the 8-Minute Rule, and the therapy cap. Plus, beginning October 1, 2014, all HIPAA-covered practitioners have to transition to an entirely new coding system: ICD-10.

As we move further into this new pay-for-performance, regulation-heavy healthcare environment, it’s crucial that our documentation clearly and defensibly support the medical necessity of our treatments as well as our patients’ accomplishments in therapy.

Scribbles aren’t going to cut it anymore. But a good EMR will.

About the Author

Heidi Jannenga is the co-founder of WebPT, the leading electronic medical records (EMR) solution for physical, occupational, and speech therapists. As Chief Operating Officer, Heidi leads the product strategy and oversees the WebPT brand vision. She brings with her more than 15 years of experience as a physical therapist and clinic director as well as a passion for healthcare innovation, entrepreneurship, and leadership.

Since launching WebPT with her husband Brad Jannenga in 2008, Heidi has helped guide the company through a period of explosive growth, culminating in WebPT being named to the 2013 Inc. 500, an elite list of the nation’s fastest growing companies. In addition to speaking as a subject matter expert at numerous rehab therapy events and conferences, Heidi participates as a speaker and panelist at local and national technology, entrepreneurship, and women-in-leadership events.

Heidi was a collegiate basketball player at the University of California, Davis, and remains a life-long fan of the Aggies. When she’s not playing, snuggling, and enjoying time with her daughter Ava or helping her husband Brad train for his next triathlon, you can find Heidi at the gym, doing yoga, hiking, reading, baking, or watching Shark Tank or the Food Network.

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Rachael Lowe
Rachael Lowe
November 15, 2013 at 3:17 pm

This is a good point well written! We often hear the benefits of EMR’s as a contribution to time efficiency and cost effectiveness. It is true that computerised documentation can also provide you with sound legal support should you need it, as long as your records are well written!

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