The acronym ACUTE may be used to recall five important principles in proper documentation for audiology services:
- Accurate (in description)
- Code-able (CPT, ICD, DRG)
- Understandable (to a variety of readers)
- Timely (written at the time the client/patient was seen)
- Error free (legal document)
Documentation is read by clinicians, other professionals, and claims reviewers with varying backgrounds and experience. It is important that notes and reports are clear and legible, efficiently conveying essential information needed for a variety of purposes. See
Interprofessional Education/Interprofessional Practice (IPE/IPP) for more information regarding professional collaboration and communication.
The purposes for documentation include supporting clinical decisions, communicating to and between interested parties, contributing to educational documentation for students receiving services, and receiving proper reimbursement for services.
Demonstrating medical necessity is an essential component in documentation for audiology services. Medicare defines medical necessity by exclusion, stating that "services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member are not covered" (Centers for Medicare & Medicaid Services [CMS], 2014a). Medicare further itemizes circumstances for reasonable and necessary services in Local Coverage Determinations as "safe and effective, not experimental or investigational . . . , appropriate . . . in accordance with accepted standards of medical practice . . . , furnished in a setting appropriate to the patient's medical needs and condition; . . . ordered and furnished by qualified personnel" (CMS, 2014b). Medicare stipulates that "the services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a [qualified health care professional]" (CMS, 2014c).
Justification for reasonable and necessary care and medical necessity can be achieved by addressing the following criteria:
- Reasonable: Services are provided with an appropriate amount (number of times in a day), frequency (number of times in a week), duration (number of weeks or total sessions), and accepted standards of practice.
- Necessary: Appropriate services are provided for the client/patient's medical diagnosis and prior level of function.
- Specific: Services are targeted to particular goals.
- Effective: Services are provided with an expected functional improvement to be achieved within a reasonable time (or maintenance of function in the case of degenerative conditions), with the client/patient's prior level of function serving as the baseline.
- Skilled: Services provided require the knowledge, skills, and judgment of an audiologist.
Relevant documentation for establishing medical necessity may include the following details (ASHA, 2004):
- Medical/behavioral history—pertinent medical history that influences the audiologic intervention, concise description of client/patient's functional status prior to the onset of the condition requiring audiology services, and relevant prior audiologic and/or speech-language intervention.
- Diagnosis of hearing, vestibular, tinnitus, and related disorders—the diagnosis established by the audiologist.
- Date of onset—date of onset of hearing, vestibular, tinnitus, and/or related disorder.
- Physician referral/order.
- Initial evaluation and date.
- Evaluation procedures used by the audiologist to diagnose hearing, vestibular, tinnitus, and related disorders.
- Individualized plan of care and date established.
- Intervention notes/progress notes (frequency depends on payer and facility policy).
- Updated client/patient status reports concerning the client/patient's current functional abilities/limitations.
Medicare (and other plans that adopt Medicare documentation guidelines) stipulate that services eligible for reimbursement must be at a level of complexity and sophistication that requires the specific expertise and clinical judgment of the qualified health care professional.
Unskilled services do not require the unique knowledge and skills of an audiologist. Skilled services that are not adequately documented may appear to be unskilled.
Audiologists use their expert knowledge and clinical reasoning to perform the skilled services listed below. Audiologists
- analyze medical/behavioral data to select appropriate evaluation tools/protocols to determine hearing/vestibular/tinnitus diagnosis and prognosis;
- design a client/patient-centered plan of care that establishes device recommendations, long-term and short-term measurable functional goals, and discharge criteria for habilitatative and rehabilitative services;
- engage clients/patients in practicing communication strategies, with or without devices, while explaining the rationale and expected results;
- ensure client/patient and family/caregiver participation and understanding of diagnosis, device, intervention plan, communication strategies, and realistic expectations;
- provide fitting and verification for hearing aid users;
- provide services related to middle ear implants and bone-anchored hearing devices;
- provide programming and verification of cochlear implants;
- train client/patient and others in the use and care of communication systems and/or devices;
- develop a communication program to be carried out by the client/patient and family/caregiver at home, which may include assistance through technology and computerized learning tools;
- train caregivers to facilitate carryover for optimal performance of trained skills and/or generalization of skills; and
- determine when discharge from habilitative or rehabilitative programs is appropriate.
Documenting Skilled Services
Recommendations for documenting skilled services are as follows:
- Use terminology that reflects the audiologist's technical knowledge but is still understandable to individuals who are not audiologists.
- Indicate the rationale for the type and complexity of test or activity.
- Document results and outcomes with professional interpretations.
- Document device analysis and programming as well as training provided to the client/patient and family/caregiver on device programming.
- For a habilitative/rehabilitative program, report objective data showing progress toward goals, such as accuracy of task performance or level of independence in task completion.
- Specify counseling or education provided to client/patient and family/caregiver as well as client/patient and family/caregiver response.
- Clarify decision making regarding modifications to plan of care.
Clinical documentation includes justification of the following service attributes:
- Medical necessity — Are the services provided reasonable and necessary to address a clinical question?
- Skilled services — Are they services that can be provided only by a qualified audiologist?
- Functionality — Do the recommendations or services address goals that are relevant to the client/patients' educational or vocational needs, safety, health, and independence in their environments and to their specific communication needs and partners?
- Value — Do the services improve quality of life and save costs through prevention and intervention, increased safety, or increased independence and participation in activities of daily life?
Audiologists will be increasingly accountable for justifying the value of their contribution to the coordinated care of the interdisciplinary/interprofessional team and to the client/patient's functional outcomes as payment models move away from fee-for-service and toward bundled care and efficiency-based-outcome and quality-of-life models.
Components of Clinical Documentation
Required components of clinical documentation vary and are dependent upon factors such as setting, service(s) provided, and legal factors. Documentation of all clinical interactions, whether diagnostic or interventional, will recount the following details:
- Date of encounter
- Procedures performed
- Client/patient and family/caregiver participation
- Subjective and objective data
- Clinical interpretations
- Accommodations and modifications to clinical procedures
- Client/patient and family/caregiver counseling and education
- Credentials and signature of practicing clinician
Preferred Practice Patterns for the Profession of Audiology (ASHA, 2006) may provide guidance.
Clinical documentation may include evaluation reports, intervention notes, progress notes, and discharge summaries. Documentation requirements are dependent upon the setting and the specific services provided. Not all audiologists will use all types of documentation.
The evaluation report is a summary of the evaluation process, the resulting diagnosis, and a plan for service or discharge. It may include the following components:
- Reasons for referral, including record of orders, referrals, and medical clearances, as needed
- Case history, including prior level of function, medical complexities, comorbidities, and type of support system
- Review of auditory, visual, motor, ambulatory, and cognitive status as it may relate to device use (e.g., hearing aids) and intervention planning
- Standardized and/or nonstandardized methods of evaluation, including subjective and objective data
- Analysis, integration, and interpretation of information to develop prognosis, including functional status, outcomes measures, and projected outcomes
- Recommendations, including the following items:
- Referrals to other professionals or agencies.
- Plan of care, including
- technology recommendations (e.g., hearing aid fitting, hearing assistive technology systems);
- intervention type, amount, frequency, and duration; and
- long-term and short-term functional goals, including client/patient and family/caregiver input.
- Date of service
- Provider signature and credentials
An intervention note is used to document a device fitting or other client/patient encounter following the diagnosis. The documentation must be sufficiently clear as to justify services provided and recommendations given.
An intervention note may include
- relevant client/patient information (e.g., diagnosis);
- skilled services provided;
- client/patient response;
- objective data on progress toward functional goals;
- professional interpretation of data;
- client/patient and family/caregiver education and counseling;
- date of service; and
- provider signature and credentials.
A progress notes is written for clients/patients who are receiving regular habilitation or rehabilitation. Progress notes are composed at given intervals (often determined by payers) and assess the progress toward long-term and short-term goals. These notes typically include
- skilled services provided;
- client/patient response, including any home programming;
- objective measures of progress toward functional goals;
- changes to the goals or plan of care, if appropriate;
- number of client/patient encounters and location(s);
- date(s) of service; and
- provider signature and credentials.
A discharge summary may be required to detail the intervention provided, the reason for discontinuing services, and the client/patient status at the time of discharge if the plan of care covers multiple client/patient encounters (e.g., early intervention services). Not all cases will require a discharge summary.
Discharge summary notes typically include
- goals and progress toward goals;
- skilled services provided;
- objective measures (e.g., pre-intervention and post-intervention evaluation results, outcomes measures);
- functional status;
- client/patient and family/caregiver education provided;
- reason for discharge;
- recommendations for follow-up;
- date(s) of service; and
- provider signature and credentials.
Although Medicare does not reimburse audiologists for audiologic treatment services (e.g., vestibular rehabilitation, auditory rehabilitation),
Medicare documentation guidelines may serve as minimum standards adopted by other payers. In addition to the documentation requirements described above, Medicare also requires that documentation and claims reporting comply with requirements related to the
Physician Quality Reporting System (PQRS).
Medicaid is a joint federal- and state-funded program to assist states in providing medical care to low-income individuals and to those who are categorized as "medically needy." Medicaid services are included as part of a free and appropriate public education to those children who are eligible. Medically necessary services may be delivered in health care settings or in schools. Documentation requirements for Medicaid may follow Medicare guidelines. State-specific guidelines can be found in the state's Medicaid plan and/or Medicaid guidance documents (e.g., the state provider handbook). For more information, go to ASHA's
Private payers do not use a universal documentation template, and requirements vary. Documentation typically includes the reason for the client/patient visit, services completed, findings, and recommendations in a way that justifies the diagnosis and procedure codes (see
Coding for Reimbursement). Medicare documentation requirements may be useful as a set of basic guidelines.
Coding/Billing to Support Reimbursement
Correct coding is the key to submitting valid claims for reimbursement of health care services. Proper clinical documentation provides the justification for the codes submitted. If information presented in the documentation is inadequate or does not align with the billing codes, claims may be denied. The Health Care Common Procedure Coding System (HCPCS) and International Classification of Diseases (ICD) are the primary coding systems used by health care providers and third-party payers in the United States.
- HCPCS Level I codes, more commonly referred to as Current Procedural Terminology (CPT®; developed by the American Medical Association) codes, are used to describe procedures or services (e.g., audiologic assessment, aural rehabilitation).
CPT codes for audiologists are available on the ASHA website and are updated annually.
- HCPCS Level II codes, typically called HCPCS ("hick picks") codes, are used to report supplies, equipment, and devices provided to clients/patients (e.g., hearing aids).
HCPCS Level II Codes for audiology related devices are available on the ASHA website and are updated quarterly.
- ICD codes are used to report diagnoses or disorders (e.g., noise-induced hearing loss, tinnitus).
ICD Diagnosis Codes are available on the ASHA website and are updated annually.
Procedure and diagnosis codes are recorded on a claim form submitted either electronically or on paper to third-party payers. Medicare, Medicaid, and most private health insurance plans use the
CMS-1500 [PDF] claim form for noninstitutional providers (i.e., office setting) and the
CMS-1450 [PDF]—or UB-04—form for institutional providers (e.g., hospital, comprehensive outpatient rehabilitation facility). See also
Medicare Part B Claims Checklist: Avoiding Simple Mistakes on the CMS-1500 Claim Form.
Documentation in educational settings is used to convey essential clinical information about each student's diagnosis, intervention, and outcomes, and to address the questions that payers and/or stakeholders may ask about each student encounter:
- Is it educationally and/or functionally relevant?
- Is it a service requiring the knowledge and skills of an audiologist?
- How does this service add value to the student's education, interdisciplinary care, and/or overall health?
The structure of the documentation must ensure compliance with the Individuals with Disabilities Education Act (IDEA; IDEA, 2004) and state regulations. High-quality documentation protects school districts and service providers in mediation and due process situations. IDEA requires regular reporting of students' progress on individualized education program (IEP) goals supported with data. Educationally oriented documentation includes diagnostic and clinical assessment results as well as the significance of the diagnostic outcomes regarding the child's ability to learn in a classroom or other educational setting. An educationally oriented comprehensive plan of care is developed when intervention is necessary.
When billing Medicaid for services provided in the school setting, the standards of Medicaid documentation apply. Separate documentation may be needed to address educational requirements (e.g., for the IEP).
Documentation in Schools for more information on documentation in educational settings, the IEP process, and educational record retention.
The International Classification of Functioning, Disability and Health (ICF) is a categorization of health and health-related domains and is a framework for measuring health and disability at both individual and population levels (World Health Organization, 2001). The ICF includes a list of environmental factors to consider because an individual's abilities and limitations of function occur within a context. ASHA developed
Preferred Practice Patterns for the Profession of Audiology (ASHA, 2006) to be consistent with this framework. See
ASHA's ICF page for more information.
By engaging in comprehensive assessment, intervention, and support, audiologists address the following components within the ICF framework:
Health Condition: Identify the disorder or disease.
Body Functions and Structures: Identify and optimize underlying anatomic and physiologic strengths and weaknesses related to hearing and balance effectiveness. This includes inner, middle, and outer ear functions as well as components of communication, such as understanding speech in quiet and in noise.
Activities and Participation: This component includes capacity (under ideal circumstances) and performance (in everyday environments), and it involves the audiologist performing the following services:
- Assess the hearing- and balance-related demands of activities in the individual's life (contextually based assessment).
- Identify and optimize the individual's ability to perform relevant/desired social, academic, and vocational activities despite possible ongoing hearing and related health conditions.
- Identify and optimize ways to facilitate social, academic, and vocational participation associated with the given health condition(s).
Environmental and Personal Factors: Identify circumstances that are barriers to or facilitators of successful performance (including the support behaviors of everyday people in the environment).
For examples of functional goals, see
ASHA's ICF page.
ASHA does not prescribe a specific format for documentation, either in paper-based records or electronic records. However, health care professionals can use a common documentation format—known as the SOAP note—to ensure that they have captured all relevant information related to a client/patient encounter. The SOAP note captures the following information:
- Subjective findings
- Objective findings
Any acronyms or abbreviations used in documentation should be consistent with facility policy on accepted medical abbreviations (see ASHA's list of
Common Medical Abbreviations [PDF]).
Templates and Electronic Documentation Systems
Health care facilities and other health care providers have adopted electronic medical records to standardize collection of patient data, improve coordination of care, and facilitate reporting of quality measures.
Medicare requires electronic submission of billing information if the practice employs more than 10 full-time employees. Solo practitioners or small practices may require less complex software solutions for documentation than those purchased for a large health care facility.
Within medical facilities, audiologists may seek to participate in the development of the templates used for billing and clinical documentation. Documentation templates that rely exclusively on multiple-choice checkboxes may cue the clinician to complete required aspects of documentation; however, this will risk less differentiation of the patient's unique clinical characteristics and intervention plan. Templates and documentation systems should include a mechanism to ensure that the information is personalized for the patient receiving care by reflecting their needs, goals, or recommendations. See
Electronic Medical Records (EMRs) and Practice Management Software for Audiologists. The audiogram as a stand-alone document is no longer acceptable documentation.
ASHA's Code of Ethics Principle 1, Rule O states, "Individuals shall protect the confidentiality and security of records of professional services provided, research and scholarly activities conducted, and products dispensed. Access to these records shall be allowed only when doing so is necessary to protect the welfare of the person or of the community, is legally authorized, or is otherwise required by law" (ASHA, 2016). Further, the
Issues in Ethics: Misrepresentation of Services for Insurance Reimbursement, Funding, or Private Payment statement prohibits misrepresenting coding or clinical information for the purposes of obtaining reimbursement (ASHA, 2010).
A medical record is a legal document. Changes made to the medical record should be dated and initialed by the original documenter. Erroneous text may have a single line placed through it and may not be erased, deleted, scratched out, or whited out. The corrected text can be written next to it or as an addendum before that entry. See
Documentation in Schools for information on IEPs as legal documents.
Medical Record Retention and Storage
Each state may have unique medical record retention laws that vary by setting or type of record. Federal law, such as the Health Insurance Portability and Accountability Act (HIPAA; HIPPA, 1996), must be considered. Payers and regulatory or accrediting agencies may have regulations governing record retention. Audiologists should know all applicable regulations and should abide by the most stringent one(s).
CMS requires that patient records for Medicare beneficiaries be retained for a period of 5 years (see
Code of Federal Regulations (CFR) [PDF]). Medicaid requirements may vary by state. For additional information, see this
CMS Record Retention [PDF] document.
ASHA does not have a policy on retention of video or digital images, such as vestibular recordings. Audiologists should consult their facility's policy for guidance.
The purpose of the
Health Insurance Portability and Accountability Act of 1996 (HIPPA) is to improve the efficiency and effectiveness of the nation's health care system by ensuring the confidentiality and security of protected health information (PHI). Health care providers and other entities who handle PHI must comply with certain HIPAA regulations, such as rules surrounding patient privacy and PHI, the use of the
National Provider Identifier (NPI), and the use of the
10th revision of the International Classification of Diseases (ICD-10). HIPAA regulations do not include medical record retention requirements. However, they do require the application of appropriate administrative, technical, and physical safeguards to protect the privacy of information for as long as the records are maintained. The 2013 HIPAA update strengthened enforcement activities and penalties for HIPAA violations that apply to covered entities and their business associates. See
Health Information Privacy: Frequently Asked Questions for more information.
Family Educational Rights and Privacy Act (FERPA; FERPA, 1974) is the federal law that addresses access to student records. This law ensures that parents and guardians have an opportunity to have records amended and gives families some control over the disclosure of information from the records. According to FERPA, educational records are records that are (a) directly related to the student and (b) maintained by an educational agency or institution or by a party acting for the agency or institution [20 U.S.C. 1232g(a)(4)(A); Moore, 2010]. The legislation provides clarification on parent and guardian access to student records, in addition to limiting the transfer of records. Audiological reports and progress notes that are maintained in the child's educational record are governed by FERPA in regard to release to outside entities.
The Joint Commission
The Joint Commission's revised set of standards on patient-centered communication outlined "effective communication, cultural competence, and patient- and family-centered care as important components of safe, quality care" (The Joint Commission, 2010, p. 4). Compliance with the
Joint Commission standards [PDF] includes considerations on documentation. Documented information should include
- the patient's communication needs, including preferred language, use of hearing aids, or need for augmentative or alternative communication (AAC) device or communication board;
- need for the use of an interpreter;
- cultural or religious beliefs that potentially influence services that the audiologist will provide;
- any changes or modifications to standardized testing tools (including translation); and any accommodations made during intervention services to address the linguistic, cultural, or religious beliefs of the patient (The Joint Commission, 2010).
Contracts and Warranties for Hearing Aids
According to the Federal Trade Commission (FTC), a purchase agreement for hearing aids will include the following:
- A statement regarding the trial period and refundable fees. The state may require, and/or the audiologist may offer, a 30- to 60-day trial period.
- A statement regarding the warranty, including details such as length of warranty, possibility of extension, coverage of maintenance and repairs, and how it will be honored.
- A detailed price quote for hearing aids and other inclusions, such as testing.
Federal Trade Commission: Consumer Information on Buying a Hearing Aid for more information.
The Food and Drug Administration (FDA) regulates the manufacture and sale of hearing aids. Before selling a hearing aid, the audiologist should acquire a written statement from the client/patient, signed by a licensed physician, regarding medical evaluation and clearance for the suggested device or a medical waiver signed by a fully informed adult client/patient and meeting FDA requirements. See
Code of Federal Regulations for more information.
Contact your state Attorney General's office for state-specific laws governing hearing aid sales and stated or implied warranties.
Equipment and Test Environment
It is essential that all audiometric equipment be calibrated, be functioning properly, and be used in an acceptable test environment to ensure accurate test results as specified in American National Standards Institute/Acoustical Society of American (ANSI/ASA) Standard S3.6-2010 (ANSI, 2010, or current standard). The audiologist may be responsible for keeping records for verification that these standards are being met.