PTP: How does standardization of documentation/reporting affect reimbursement? How does your software meet these needs?

Brooker: Standardization is a double-edged sword. On the positive side, standardization is great if it means a standard of precision and thoroughness. On the negative side, many software products out there are so standardized that they seem “canned,” with key phrases being repeated over and over and across patient cases. This raises an instant audit flag with insurance carriers.

PTOS endeavors to strike a balance here with the ability to enter free text into all aspects of the documentation process, while at the same time offering the option—but not the requirement—to select from a variety of common expressions to speed up documentation.

McMullan: In today’s health care environment, more and more demand is placed on the clinical documentation supporting the treatment provided and billed to the patient and insurance company. The standardization of clinical documentation and reporting is critical and helps to eliminate the typical arbitrary practice that exists today in the current paper-driven world of outpatient rehabilitation.

TherapySource software allows the PT to document the treatment performed and will consistently generate the same charges for identical treatments. The PT has complete control over the treatment documented and the charges associated with each treatment. We also provide the ability to set up customer-specific required and recommended documentation, to be addressed by the clinician, for each patient, and it is defined at the payor. Each individual payor typically requires a minimum, specific, clinical documentation to support the charges and the claim. We incorporate all of that into the business logic so that the PT does not have to manually keep up with the changing requirement.

Plymale: The regulatory environment imposed by the government and by private payors is becoming more complex. It is far too complex for a therapist to remember all of the pertinent rules and regulations while treating patients in a busy clinic. Standardization of documentation connects the threads between what services were provided, how those became charges, and what affect the services had upon progressing toward specific goals. Standardization of the look and feel of documentation is also important for marketing and communication to the referring physician. However, if you want it to help reimbursement, you must be able to tie the procedures performed to the visit notes and you must use a billing rule engine capable of turning those procedures into units and charges that comply with specific payor rules.  

Most software systems rely on the therapist and billing staff to code, calculate units, and apply the billing rules for each payor. Our software system enforces minimum standards for documentation, automatically calculates units based on procedure time, and automatically applies coding and billing rules unique to the particular payor. This ensures maximum allowable units for the time a therapist spends treating, a low denial rate, as well as a speedy resolution to any dispute. The system also protects you if your clinic faces an audit.

Quirk: An electronic medical record can increase reimbursement by directly controlling the content of the claim information, speeding up the claim-submission process, and eliminating bad visits. To begin with, an automated documentation system should work toward ensuring complete information gathering. Incomplete data collection or erroneous coding delays or prevents reimbursement. This, of course, pertains to demographic as well as clinical data. With an electronic medical record, the various clinic personnel responsible for their respective portion of data entry have real time, means, access, and cues to complete their part of the data-collection process.  

In TherAssist, if a patient is missing the diagnosis, insurance, or referral-source information, the therapist will be sent back to the demographic screen before they can start writing their note. TherAssist also provides administrators with the ability to make certain “click-note” statements mandatory. For example, you could make sure that all notes have functional deficits (disabilities) recorded within the context of the evaluation, as this is required by payors. With coding errors, TherAssist provides users with the ability to create payor-specific billing matrixes that limit therapists’ billing choices to only the valid choices for a patient’s insurance carrier. With a completely integrated program, changes to the bill made by billing personnel will be reflected on the patient’s next visit when the therapist goes to submit their charges.

Ryzner: Incomplete forms and illegible or missing notes will tend to delay reimbursement. The more information that can be provided in a clear and concise format to the payors, the less confusion will occur and the quicker the payment will be made. There are typically two types of information problem that we encounter: missing data and incorrectly entered data. While it is sometimes difficult to catch wrongly entered data, a good software system should be able to identify missing data. By using “prescrubbing” reports—reports that examine the completeness of your data prior to the invoicing process—many errors can be identified and corrected before the invoice even leaves your computer. This can save several days of waiting for your clearinghouse to report back problems resulting in the delayed resubmission of the corrected information. The bottom line is that PTs should be looking for software that produces clean output, which clearly flags potentially bad or missing information.

Stone: Standardization of documentation/reporting can have a positive impact on reimbursement as long as the therapist can create free text comments unique to a patient. Eighty percent of ReDoc Software is standardized drop lists and 20% consists of free text boxes that allow clinicians to better demonstrate functional and impairment processes.

Welty: Typically, a payor entity will compare claims to medical records for compliance with coverage, coding, and billing rules. A modern software solution should allow for all of these dimensions to be defined for each insurance carrier. Many payors require that copies of clinical documentation and/or prescriptions be sent along with the claim. Applications should automate these processes when generating claims.

The Raintree Therapy Manager application defines the coverage, coding, and billing rules in the insurance-carrier profile. Those rules will be automatically applied to all claims prior to billing processing, resulting in a “clean” claim. With billing claims and documentation coordination being handled by the software, claims will be processed in a timely manner. This will result in documentation compliance that will pass audits by payors and will mitigate loss of reimbursement income.

PTP: Which industry trends will inevitably lead PTs to adopt various software solutions for their practice?

Brooker: The biggest trend is the overall adoption of software.  Pretty much everyone uses billing software, but only a minority use scheduling or documentation software.  This will change rapidly as PTs realize the software’s added efficiency and, in the case of documentation, the policy-driven necessity.

The second big trend that PTs will face is the choice between a single vendor and an integrated assemblage of software from multiple vendors.  Using a single vendor, users have one point of support.  On the other hand, some PTs may want to look at their software decision in a modular way, by looking at many products and choosing the best they see in billing, documentation, and scheduling, even if they come from different vendors.  The selected solutions must, of course, integrate via interfaces.

McMullan: The key industry trends that will inevitably lead all PTs and physical therapy practices to adopt information system technology for all aspects of their business are: evidenced-based practice; pay-for-performance , and regional health information organization (RHIO).

The industry trend I personally believe that should be the catalyst for 100% adoption of information software solutions in the physical therapy practice market is the need for evidence-based practice. The ability to have real-time access to evidence-based research to appropriately define the course of treatment for each patient and to provide the treating therapist with the most beneficial interventions to incorporate into their treatment program in order to get the maximal functional outcome for the patient should be reason enough.

Unfortunately, I feel that the main industry catalyst for forcing adoption in the physical therapy practice market will be more directly business and reimbursement driven as outlined in the two other industry examples below.

In an effort to consistently justify the efficacy of physical therapy services and their positive impact to the functional outcome of the patient-population information technology solutions have the capability to easily capture the necessary data at the time of each patient encounter to facilitate outcome based results over the course of a patient’s episode of care. Several large insurance organizations including the Centers for Medicare and Medicaid Services already have several pay-for-performance pilots underway in the physician practice market with positive results. The only key factor is nearly all pilots have a software package in order to capture the data and transmit it via an HL7 standard to the parties in the program.

As these pay-for-performance programs become more refined and established as standards for reimbursement physical therapy practices will need to have a software package in place to efficiently capture required data and transmit it to allow for timely payment.

A RHIO is a group of organizations with a business stake in improving the quality, safety and efficiency of healthcare delivery. The purpose of a RHIO is to electronically exchange health information in a secure format so that the receiver can use the information.

The terms “RHIO” and “Health Information Exchange (HIE)” are often used interchangeably. RHIOs are the building blocks of the proposed National Health Information Network initiative proposed by David Brailer, MD, and his team at the Office of the National Coordinator for Health Information Technology . To build a national network of interoperable health records, the effort must first develop at the local and state levels. RHIOs are forming at a very rapid pace and currently number over a hundred.

As these to continue to grow and as we move as an industry closer to realizing a National Health Information Network it will be essential for any physical therapy practice to have the information technology capability to exchange pertinent patient data and outcomes with all health care providers in their RHIO or community health information exchange.

Morrill: Adoption of electronic submission standards for medical records will ultimately force clinicians to move toward software solutions. Unfortunately, unless clinicians are proactive in legislation and practice issues, these standards will be developed by nonclinical personnel who could negatively affect our daily practices.  

Another industry trend that seems to be influencing the move to software solutions for PTs is the movement to include more clinical outcomes during the treatment of our patients. Clinical outcomes may be our best method to prove to patients and the medical community the effectiveness of rehabilitation and with quality software, outcome tracking and statistical analysis becomes easier.

Petrie: Outcomes. Verifiable outcomes data is quickly becoming a key concern for PTs. Physicians want to see results before referring patients; payers are moving toward basing payments and network acceptance on outcomes; and outcomes analysis is also critical to manage your practice. That's why SpectraSoft has incorporated one-click submission to the CareConnections outcome database into its software. It's easy to submit case data and just as easy to retrieve meaningful statistics that show you how your clinic(s) and therapist(s) compare with other PTs across the country.

Workflow Efficiency. As increased competition and reduced compensation make PT management more demanding, your office has to work at peak efficiency. An integrated software system is critical to productivity. It allows colleagues to share data seamlessly without retyping information or searching for paper files. It also brings structure and accountability to an office so that nothing falls through the cracks. For example SpectraSoft's Workflow Manager allows you to assign critical tasks to anyone in the office and monitor progress and completion from your desktop. SpectraSoft's AppointmentsPRO allows you to place any no-show or canceled appointment on a recall list, improving patient compliance with a prescribed regimen.

Reimbursement. As payer requirements become more severe, an integrated software system like SpectraSoft's Total Workflow Solution can do more to ensure maximum reimbursement for your efforts. The system creates a "closed loop"—reminders and visual cues built into the system ensure that every scheduled patient is seen, every case is documented, every treatment is billed and every claim matches the documentation.

Plymale: Three trends will dominate the PT industry in the next few years:
• Tighter reimbursement policies
• Increased pressure from the payers to interact electronically and
• The shortage of therapists.

These trends will inevitably cause all rehabilitation clinics to need:
• One central, retrievable record for all of the organization’s information, including clinic schedules, clinical documentation, patient accounts, and financial and management reports.
• Powerful business intelligence analysis tools to quickly spot trends and provide direction for management.
• Clinic and financial outcomes analysis.  Healthcare organizations will increasingly be subject to “pay for performance” standards from payers.  Having performance information will become mandatory.

Because the need for therapists will outstrip the supply, clinics will need to make everyone who works around their therapists more efficient, giving the therapist the freedom to focus on treating patients instead of doing paperwork.

Quirk: There are many continuing and new trends that we expect will fuel the adoption of software solutions for the outpatient pt/rehab industry.  Declining reimbursement (or said another way, reimbursement that does not keep pace with the costs of operating a physical therapy facility) will put pressure on clinics to look for ways to be more efficient, that is, to reduce their cost and increase their revenue per patient visit—improved tracking and process automation will be the key.

In addition, a shortage of therapists will cause clinics to look for ways to engage part-time staff and offer alternative schedules to address work/life balance concerns. This will require software to be "portable" and remotely accessible.  Therapists will want to complete their documentation from home or other locations. At TherAssist, we recognized this trend several years ago and developed an internet-based product that can be accessed anywhere. Finally, as we mentioned previously, there will be an increasing trend towards integration with other computer systems. Vendors (and customers) with “closed” systems will be at a disadvantage.

Ryzner: In discussions with our clientele, there seems to be three trends emerging—all having to do with access to information.

First, many private practice PTs are now involved with multiple clinics not just one, presenting several information-related challenges. Any PT planning to operate more than one clinic at any time down the road should ensure that any software package they are examining is capable of dealing with multiple locations. Basically, what this means is that each patient should be able to be assigned to a specific physical location. All billing and scheduling should respect that location information and all reporting should offer both individual clinic statistics as well as for the operation as a whole.

It is important for the PT to discuss with the software vendor how all of the information can be tied together for multiple locations—will they all share one common database or will each clinic have its own self-contained information? This will all depend on how much back-and-forth of patients and therapists exists within multiple locations, but needs to be discussed before proceeding with any one software package.

The second trend involves the amount of information and automation now available from clearinghouses and insurance companies. Paper Explanation of Benefits will become a thing of the past and ultimately the PT will be able to receive an electronic file indicating what services have been paid for and which have not and to have that data automatically posted into their practice management systems. Ultimately, this will be a substantial time-saver and boon to collections. This feature should definitely be on the short-term road map for any software vendor specifically dealing with the rehabilitation industry.

The third trend involves the availability of information pertaining to evidenced-based practice. More and more PTs are wanting to harness the data within their practice management systems to understand what type of treatment works best for specific injuries or why one particular therapist in their clinic is having a greater success rate than another. This is the type of information that potential referral sources may want to examine prior to sending patients to a specific clinic. While this may not be of immediate concern to many PTs, it is key that whatever software solution is being deployed at least gathers these statistics for use down the road.

Stone: The Ability to submit claims electronically with complete, compliant, and legible supporting documentation. The need to capture and better demonstrate outcomes.

Welty: HIPAA Regulations. HIPAA regulations for protected health information are a compelling reason to consider an electronic medical record. It is much easier to ensure that only the correct information is accessible to a party using an electronic medical record. The documentation of user access and any resulting disclosures should be automated by software applications. Payor Entities Requiring Electronic Claims Submissions & Quicker Processing of Medicare Part B claims alone reported an increase of over 49 million electronic claims from calendar year 2004 to 2005. While Medicare currently affords exclusions for smaller providers, many insurance carriers are moving toward no exclusions since statistics are demonstrating that EDI transactions are more cost effective. Payments to providers are received quicker when claims are submitted electronically.

With this trend in place, most providers are moving to electronic claims submissions.  Providers who adopt these solutions realize that if they implement an integrated software system that supports streamlined data flow from patient registration, to service delivery documentation, to electronic claims submission they will realize workflow efficiencies and cost reductions.

Rising health care costs. Rising health care costs are prompting more payer entities to perform billing and compliance audits. Preparation and participation in these audits is greatly simplified by providing payors with easy access to electronic medical records. With today’s advanced software tools, providers can ensure that their patient documentation and billing processes are maintained in compliance with payor requirements. Proper documentation, coding and submission will result in higher and more rapid service reimbursement.

For more information, contact PTPEditor@ascendmedia.com.

Most Commonly Asked Questions

Is your documentation software both fast and flexible? 

Most documentation software products either focus on documentation speed but sacrifice flexibility (the ability to control the document templates and enter free text), or the software products focus on flexibility but give up speed so the software is not much faster than documenting by hand or voice. It is important to ask a prospective vendor to show how their software addresses both flexibility and speed, and then think about what best serves your needs. — Brooker

Is the software easy to use?

Today’s therapy provider requires a software application that is designed to mimic the way the therapist currently works. For example, many clinicians write their documentation following the SOAP note format. They also keep a tracking sheet of the individual therapeutic activities provided and a charge sheet for these services, and they often refer back to previous notes for progress tracking. Therefore, it is important that their software reflects familiar formats within an interface that is easy to navigate. They need an application that mirrors best practice objectives and meets all of their regulatory and reporting requirements. — Welty

Will the software grow with me?

PTs want to know if they will be able to add users and locations down the road. Many systems use databases that can only support a limited number of users before performance degrades; other systems cannot support multiple locations. When buying software, you have to envision what your practice will look like in the future and how the software will support that vision. — Petrie

Can your software tell me what’s driving my business?

As competition increases and profit margins get tighter, therapists are concerned about getting and staying ahead. A clinic gathers a large amount of information, and within this data set are key performance indicators, like “referrals per therapist” and “billable units per visit.” Software should make it easy for a therapist/owner to take action on key performance indicators. The biggest industry trend is the ability to report on goals and progression to goals. — Plymale

What is the level of support, training, and infrastructure around the product?

Choosing a software product for your practice is like choosing a business partner. Is it reliable? Will it adapt to new market needs? As part of this, prospective users often ask: Are product seminars or training available locally? How many people are in the customer-support department, and what are their backgrounds? How easy is it to find staff who is already familiar with the product? — Brooker 

How do I know that my team is staying on top of critical issues?

The organization and management of the clinic’s day-to-day tasks is a major issue for most therapists. A software system should help a clinic’s staff by enabling them to do their jobs as efficiently as possible. Clinic-management software can provide personalized task lists, giving direction where needed. When a clinic’s workflow is automated within a software system, a set of alerts can be set up to warn clinic staff when specific information is missing or to alert them to when a certain task should be performed. For example, if a patient’s insurance authorization is nearing expiration, the front desk can be notified to renew the insurance authorization before the patient’s next visit. — Plymale

Do you offer an end-to-end solution?

PTs have finally realized that the best-of-breed approach to purchasing a scheduling system, electronic clinical documentation, and a billing system from separate vendors may not be optimal. In order for a software vendor to adequately compete and meet market needs, it should offer a complete solution including registration/scheduling, clinical documentation, and billing and collections. Then, PTs have only one software vendor as an appropriate business partner, versus three. — McMullan

Owners and managers typically raise financial and technical questions such as:
• How much will a new system cost, and how much money will it save the clinic?  
• Will the clinic’s claims be paid faster and with fewer appeals and denials?
• Will the system require a lot of in-house technical expertise to maintain?
• Will the system “talk” to other systems via interfaces or data imports/exports?  

Therapists typically have different concerns such as:
• How much time will it take to learn a new system?
• Will the new workflow require more or less time to document?
• Will a new system allow therapists to maintain inde pendent clinical decision-making?
• Will a new system interrupt or interfere with the hands-on component of patient care? — Quirk

Technology Terminology
Application Service Provider (ASP). An ASP is a software provider that provides computer-based services to physical therapy customers over a network. Software offered using an ASP model is also sometimes called “on-demand” software. Through ASPs, the complexities and costs of software and issues with upgrading are decreased by placing the onus on the ASP to maintain up-to-date services,  24/7 technical support, physical and electronic security, and in-built support for business continuity and flexible working. — McMullan

Business Intelligence and Drill-down. Business intelligence is the ability to filter down to just the information that is critical to support business decisions and critical actions within an organization. Drill-down refers to the ability to click on any number in a business intelligence report and drill down to the transactions that make up that number. This capability is very useful for analyzing what is causing a key performance indicator to move up or down. — Plymale

Health Level Seven (HL7). HL7 is one of several American National Standards Institute-accredited Standards Developing Organizations operating in the health care arena. HL7’s domain is clinical and administrative data. HL7 is an international community of health care experts and information scientists who are collaborating to create standards for the exchange, management, and integration of electronic health care information. HL7 promotes the use of such standards within and among health care organizations to increase the effectiveness and efficiency of health care delivery for the benefit of all. HL7 capability should be a critical requirement for any PT considering a software solution. — McMullan

Integration. Integration is an important consideration when examining a new software application. Many software companies claim that their systems are integrated, but few solutions provide customers with seamless data flow in an all-in-one management application. An integrated software system should transfer information throughout all modules without the need for manual uploads and duplicate data entry. Patient-registration data should populate the appointment and clinical records that in turn automate the coding and charge entry processes. — Welty

Interoperability. This term has been gaining attention recently, and it refers to a system’s ability to integrate with other software applications and systems. A system that can easily integrate (that is, exchange data) with other systems will allow clinics to reduce duplicate data entry and communicate more efficiently with their trading partners (payors, clinic networks, hospitals, and nursing homes, etc). — Quirk

Network. Many buzzwords can be rolled up into this category; however, two that are more common are wired versus wireless networks, and Virtual Private Networks (VPNs). Wireless networks allow users to be mobile within the facility to be able to treat patients while staying connected. VPNs extend the network at the central office to areas outside the office, such as a home or second office, by using the Internet while still being secure. — Morrill

Paperless. A paperless clinic is one where the scheduling book, file folders, and billing slips are replaced by software that keeps track of all of the day’s details. Many software solutions tout the benefits of a paperless system but neglect to mention that the positive results come from the integration of data, people, and processes—not from the actual paperlessness. — Plymale

Scalability. As part of their software-selection process, therapists should ensure that the system can accommodate growth or changes in their practice and can scale to meet their future business plans. — Welty

Security. There is a lot of misunderstanding around what is required of anyone handling PHI, and a lot of misunderstanding of the consequences of a mistake. How does the software vendor help you ensure compliance with the Health Insurance Portability and Accountability Act (HIPAA) around security and privacy?  A good vendor will have a strategy that protects you in every aspect of HIPAA compliance from software,  to hardware,  and  to procedures, such as backing up. — Plymale

Servers. A server can be anything from a desktop computer to a dedicated computer used as a central repository for software, data for sharing, and ease of management. — Morrill

Web-based. Web-based software is accessed via a Web browser or a Web-based client. Web-based software enables you to access your system safely anywhere and at any time. — Plymale

Workflow. A clinic’s workflow describes the movement of tasks and data through a work process. Workflow describes the actual tasks, who performs them and in what order, how information is organized to support the tasks, and how the tasks are tracked. — Plymale