Clinical documentation is one of our most important tasks, yet many practitioners view documenting services as a "chore"-or something they have to do to "get paid." It may be helpful to think of documentation as the story of what we do to help individuals communicate or accomplish other crucial functions (such as swallowing) and to carry out the requirements of ethical clinical practice.
The ASHA Code of Ethics, Principle I, Rule K states: "individuals shall adequately maintain and appropriately secure records of professional services rendered, research and scholarly activities conducted, and products dispensed and shall allow access to these records only when authorized or when required by law" (ASHA, 2003). The Joint Commission on Accreditation of Healthcare Facilities (JCAHO) provides detailed guidance regarding expectations for "Management of Information" (IM) in the Comprehensive Accreditation Manual for Hospitals (CAMH) (see www.jcaho.org).
According to the JCAHO's overview of the CAMH IM section, the goal of the information management function is to "support decision making to improve patient outcomes, improve health care documentation, improve patient safety, and improve performance in patient care, treatment and services; governance; management; and support processes….a hospital's provision of care is a complex endeavor that is highly dependent on information" (p. IM-1). JCAHO emphasizes that accurate, complete, and secure information is essential to the provision of safe and effective patient care. Hospitals and other health care organizations purchase access to online and paper versions of the CAMH; therefore, readers are encouraged to review this resource on organization intranet sites or in accreditation services department offices, as available.
Professionals now also consult Internet resources. A recent Google inquiry about the definition of documentation yields: "information recorded permanently," "substantiation of actions or decisions," "providing evidence," and "descriptive text."
These phrases, together with our more formal documents, provide a foundation to a discussion of essential information for clinical documentation. As SLPs, our definition of documentation is comprehensive, and includes the components of the service itself (e.g., the use of information for clinical decision-making), charge capture, diagnosis coding, and procedure coding as well as the actual recording of clinical service activities.
It is helpful to think of the clinical record primarily as a communication tool shared among the team (however large or small) serving the patient/client. The team also includes the patient/client and family members and/or caregivers and practitioners as full participants, with access to health information. The clinical record is an overall indicator of clinical and service quality, and serves as a basis for planning care and for service continuity.
According to Paul & Hasselkus (2004), the purposes of documentation are to:
- Justify initiation and continuation of treatment
- Support diagnosis and treatment (including medical necessity and need for skilled services)
- Describe client progress
- Describe client response to interventions
- Justify discharge from care
- Support reimbursement
- Communicate with other practitioners
- Facilitate quality improvement
- Justify clinical decisions
- Document communication among involved parties (practitioners, client, caregivers, or legally responsible parties)
- Protect legal interests of client, service provider, and facility
- Serve as evidence in a court of law
- Provide data for continuing education
- Provide data for research (i.e., efficacy)
Documentation Requirements and Formats
When practitioners discuss documentation requirements for reimbursement, they usually refer to the guidelines published by the Centers for Medicare and Medicaid Services (CMS), although commercial payers and managed care organizations also have certain rules. Requirements related to the nature and type of services provided and the contents of the clinical records of Medicare beneficiaries are discussed in detail in Chapter 15, sections 220 and 230 of the Medicare Benefit Policy Manual (an Internet-only manual found at www.cms.hhs.gov under "Regulations and Guidance").
Medicare fiscal intermediaries (FI) also may have their own requirements stated in Local Coverage Determinations (found under "Medical Policy" at the FI Web site). According to the Medicare Benefit Policy Manual, "therapy services shall be payable when the medical record and the information on the claim form consistently and accurately report covered therapy services…Medicare requires that the services billed be supported by documentation that justifies payment. Documentation must comply with all legal/regulatory requirements applicable to Medicare claims."
The documentation required by CMS for Medicare payment includes:
- Evaluation and certified plan of care
- Certification by the treating physician or non-physician practitioner (NPP), who may be a nurse practitioner or physician assistant, for example, that the treatment services are medically necessary and meet coverage rules (required 30 treatment days after initial treatment)
- Progress reports (when treatment exceeds 10 treatment days or 30 calendar treatment days/one month, whichever is less)
- Treatment encounter notes (may also serve as progress reports when required information is included in the notes)
- Records justifying services over the cap for therapy cap exceptions
Treatment Encounter Notes
The current revision of Chapter 15 of the Medicare Benefit Manual includes, for the first time, the important distinction between progress notes and treatment encounter notes, which document every treatment day, and every treatment service. The purpose of the encounter note is to create a record of all encounters and skilled interventions by qualified professionals to justify the use of the billing codes on the claim (patient bill to Medicare). The progress note documents medical necessity or appropriateness of ongoing services.
The following elements must be included when documenting each treatment encounter:
- Date of treatment
- Treatment minutes and total treatment time for timed codes. (The amount of time for each specific intervention provided to the patient is not required because it is indicated in the billing of the codes.) However, billing and total timed code treatment minutes must be consistent.
- Identification of each specific intervention/type of treatment provided and billed for both timed and untimed codes
CMS also details the assumptions underlying the required documentation. Payable services, for example, are those offered by qualified professionals who treat eligible beneficiaries. It must be demonstrated that the patient needs services that can be provided only by a professional with the expertise, knowledge, clinical judgment, and decision-making ability of the qualified clinician (e.g., the SLP) and that other staff or caretakers could not provide similar services independently. The clinician's services may also be required for patient safety reasons.
Moreover, the patient must be under the care of a physician/NPP. That clinician must demonstrate evidence of involvement in the patient's care. The physician/NPP must have an expectation that:
- The patient's condition has the potential to improve or is improving in response to treatment.
- Maximum improvement is yet to be attained.
- The anticipated improvement is attainable in a reasonable and generally predictable period of time.
CMS requirements for each step in the documentation process are too detailed for the scope of this article. Therefore, a sample "Outpatient Speech-Language Pathology Services Audit Template" that can be used to review and monitor Medicare requirements is posted on The ASHA Leader Online with this article (see note at end of article).
Although Medicare documentation requirements often serve as a model, professional associations, health care provider organizations, and commercial payers have established their own policies and templates to guide practitioners. ASHA lists the following components of clinical record-keeping (Paul & Hasselkus, 2004):
- Identifying information
- Client history
- Assessment of current client status
- Treatment plan
- Documentation of treatment
- Discharge summary
- Record of consultation (with other professionals; with client/caregivers)
Electronic Health Records
There is no single format used by all professionals or organizations; whatever format is used for clinical record-keeping should conform to federal, state, and local laws and adhere to specific facility standards. Clinical records should be consistent in format and style and use appropriate terminology, approved abbreviations, and correct diagnosis and procedure codes.
The advent of electronic health records (EHR) has both streamlined and complicated clinical documentation. Electronic records can use free text, structured text ("macros" or "boilerplate"), and interactive text that includes clinical decision-support functions. Electronic records may be supplemented by bar coding (for tracking supplies used, medications administered, etc.) and use of identity recognition programs to authenticate users.
Swigert points out that electronic documentation can pose specific challenges: "Clinicians who have the opportunity to participate in the development of templates for a computerized documentation system should plan carefully to assure that each template is thorough enough to capture integral information and that a template is available for each type of disorder presented by patients treated. The templates must allow for personalization so that the document is accurate and complete" (Swigert, 103). Readers are encouraged to thoroughly review Swigert's article for comprehensive information and detailed samples of documentation formats, coding, and billing requirements.
Codes in health care are numeric (or alphanumeric) representations or identifiers of a diagnosis of illness, injury, condition, or disorder (the patient's reason for seeking care) or a health care procedure or service performed by the provider or professional.
Coding is integral to billing compliance. The essence of billing compliance is found in the following four points.
- All diagnostic and treatment services are necessary, appropriate, and meet established standards of care.
- All care is documented accurately and completely.
- ICD-9-CM codes accurately represent documented problems/disorders/conditions/diseases.
- CPT codes accurately represent documented care.
Clinicians should code to the highest level of specificity possible. Code sequencing is also important for payment purposes. For example, for rehabilitation services, code first the reason the patient/client is receiving SLP treatment; then code the underlying medical diagnosis. Also code all documented conditions that coexist at the time of the encounter.
Swigert states it most succinctly: "Coding and billing are intertwined with clinical documentation. Correct diagnosis and procedure codes must be selected to describe the presenting disorder or condition and the services provided in order to bill and receive payment" (Swigert, 108). Original-source Web sites should be used to obtain complete information. ASHA's Web site is also an excellent source of detailed information about codes applicable to speech-language pathology and audiology services and information about documentation, billing, and reimbursement issues (see Web resources, page 29).
The International Classification of Diseases (ICD) is the international resource used to classify mortality and morbidity. Although most of the world uses the ICD-10, the United States uses the International Classification ofDiseases, Ninth Revision, Clinical Modification, (ICD-9-CM). The ICD-9-CM includes:
- A tabular list containing a numerical list of the disease code numbers in tabular form
- An alphabetical index to the disease entries
- A classification system for surgical, diagnostic, and therapeutic procedures (alphabetic index and tabular list)
Readers are advised to seek specific training in using the ICD-9-CM because there are pitfalls involved in trying to code without instruction. For example, errors likely will result for those who do not first seek correct code assignment in the Alphabetic Index followed by review of the tabular list. CMS offers a 60-minute on-line instruction module titled "Using the ICD-9-CM" at: www.cms.hhs.gov/MLNEdWebGuide/. Practitioners who work for hospitals or other facilities should seek help from coding specialists employed by the health information department.
Clinical documentation is among the most basic of our professional responsibilities-and is both an obligation and a privilege. An era of accountability is advancing upon the health care community. We must demonstrate our added value to our organizations, but more importantly, to our patients' lives. Attention to the foundations of our practice will help us continue to thrive.