by
Maureen E. Thompson
Documentation demands placed on audiologists and speech-language pathologists have increased dramatically. Clinicians must document their services not only for their facility, but also for health plans, referring physicians, and legal reasons. This column is intended to serve as a guide for audiologists and SLPs in maintaining appropriate documentation.
Why is documentation important
A.
Clear and comprehensive documentation is necessary to justify the need for treatment, to document the effectiveness of treatment, and to have a legal record of events. Regardless of employment setting, audiologists and SLPs must concern themselves with documentation. Incorrect or incomplete documentation can result in health plans denying reimbursement for the services you provide!
Does Medicare have documentation requirements?
A.
Yes.
For independently practicing audiologists:
-
Medicare covers independent audiology services for diagnostic tests only.
-
Each carrier may dictate whether the physician’s written referral is required before making coverage decisions.
For SLPs:
-
An initial assessment is approved when it is reasonable and necessary. A physician "certification" of the need for services must appear before the first monthly claim for payment.
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A "recertification" of the need for services must be documented at least every 30 days, which includes a plan of care (60 days for home health agencies and CORFs). These notes must document that the patient’s condition has improved significantly during treatment; however, additional treatment is needed and it is anticipated that further improvement will occur in a reasonable and generally predictable time period.
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Verbal orders for changes in the plan of care must be documented in the record by a nurse or SLP, with written confirmation by the physician or SLP soon after.
According to the Medicare Review Guidelines for Coverage of Speech-Language Pathology Services, documentation includes a short narrative progress report and objective information in a clear, concise manner. ("
Reimbursement and Coding
" on ASHA's Web site) The reviewer also must have access to an overall treatment plan with final goals and enough objective information with each claim to determine progress toward meeting the goals. For more information, refer to Nancy Swigert’s article, "
Managing Medicare: Documenting What You Do Is as Important as Doing It
" (
The ASHA Leader
, Feb. 5).
A physician referral for audiologic diagnostic tests or a speech-language evaluation must be noted in the clinical record.
What documentation do private health plans require?
A.
Each private health plan can establish unique documentation requirements. Most plans prefer information that describes functional progress, such as ASHA’s Functional Communication Measures. Michael Rolnick, director of the speech pathology department at William Beaumont Hospital and a claims reviewer for Michigan BCBS, says many private health plans have specific guidelines for documentation. Rolnick recommends that clinicians obtain a copy of these criteria from the health plans for which they provide services.
Is there any way to streamline the documentation process?
A.
Facilities must have systems that make appropriate documentation quick and simple for the clinician. At William Beaumont Hospital, Rolnick reports that each clinician is equipped with a computer with access to an online documentation system. Clinicians can type or dictate therapy notes and progress reports. Some facilities have moved to a "checklist" type of documentation, which can save time, but may not always provide the information needed by a reviewer to make a coverage decision.
Maureen Thompson
is ASHA’s director for private health plans advocacy. For more information on documentation, contact her through the Action Center at 800-498-2071, ext. 4431, by fax at 301-897-7356, or by e-mail at
mthompson@asha.org
.