Documentation is a critical vehicle for conveying essential clinical information about each patient's diagnosis, treatment, and outcomes and for communication between clinicians and payers. Clinicians must efficiently respond to the questions that payers are asking about each service:
Because of the diversity of settings and payers, ASHA does not dictate a single format or timeframe for documentation. State or federal agencies governing health care or licensure for speech-language pathologists may have specific requirements; if those requirements are more stringent, they supersede requirements of facilities, payers, and employment contractors.
As the saying goes, "If you didn't document it, you didn't do it." Unclear, vague, or absent documentation can result in denials by payers and make it difficult for the reader to follow the clinical judgment underlying the diagnosis and treatment. Other areas of knowledge necessary for documentation include coding and billing, requirements of the federal Health Insurance Portability and Accountability Act (HIPAA), and other key issues addressed below.
Documentation plays a critical role in communicating to third-party payers the need for evaluation and treatment services (medical necessity) and why those services require the skill of the speech-language pathologist (SLP). Documentation requirements vary by practice setting and by payer. Medicare outpatient therapy documentation guidelines serve as the standard for many other insurance plans.
Documentation is read by clinicians as well as claims reviewers from varying backgrounds and experience; it is important that notes and reports are clear and legible and that they efficiently convey all of the essential information that is needed for clinical management and reimbursement.
Demonstrating medical necessity is an essential element of justifying reimbursement for SLP services. Medicare defines medical necessity by exclusion, stating that "…services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member are not covered …." (Centers for Medicare & Medicaid Services [CMS], 2014r-a). 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, 2014r-b). 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 therapist …" (CMS, 2014r-c).
Addressing the following elements provides justification for reasonable and necessary care and medical necessity.
Relevant documentation for establishing medical necessity may include
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, thus meeting the definition of skilled services.
SLPs use their expert knowledge and clinical reasoning to perform the skilled services listed below. SLPs
Recommendations for documenting skilled services include
Unskilled services do not require the special knowledge and skills of a speech-language pathologist. Skilled services that are not adequately documented may appear to be unskilled. Examples of documentation that do not describe a skilled service are listed below:
Medicare documentation guidelines may serve as minimum standards adopted by other payers. Documentation components required by Medicare include
Medicare also requires documentation to comply with requirements related to functional outcomes reporting for outpatient therapy services (commonly referred to as G-codes) and quality outcomes reporting for SLPs in group or private practice (currently called 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 those who are categorized as medically needy. Although documentation requirements may follow Medicare guidelines, each state can impose its own requirements. 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 Medicaid webpages.
Private payers do not follow a universal documentation template. SLPs are responsible for identifying the requirements of each payer. Documentation typically reports why the patient was seen, what was done, what was found, and what was recommended in a way that justifies the assigned diagnosis and procedure codes (see Coding/Billing for Reimbursement). Health plans reviewing claims will ask for documentation to justify the services delivered. Medicare documentation requirements may be useful as basic guidelines.
Billing codes are the key to submitting valid claims for reimbursement of health care services. Accurate 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 Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases (ICD) are the primary code 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® American Medical Association) codes, are used to describe procedures or services (e.g., voice evaluation, speech and language treatment). CPT codes for speech-language pathologists 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 patients (e.g., speech-generating device, tracheo-esophageal voice prosthesis). HCPCS codes for speech-language pathology related devices are available on the ASHA website and are updated quarterly.
ICD codes are used to report diagnoses or disorders (e.g., dysphagia, hypernasality). Speech-language pathology related diagnosis codes are available on the ASHA website and are updated annually.
Billing 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.
Clinical documentation is not only the means by which the SLP communicates critical information about the patient's diagnosis, treatment, progress, and discharge status to other providers; it also provides the information needed to justify services if the SLP is audited by a payer. Critical components include justification of
The International Classification of Functioning, Disability and Health (ICF) is a classification of health and health-related domains and is a framework for measuring health and disability at both individual and population levels. As the functioning and disability of an individual occurs in a context, ICF also includes a list of environmental factors. ASHA's Preferred Practice Patterns for the Profession of Speech-Language Pathology were developed to be consistent with this framework.
Comprehensive assessment, intervention, and support address the following components within the ICF framework:
Body Functions and Structures: Identify and optimize underlying anatomic and physiologic strengths and weaknesses related to communication and swallowing effectiveness. This includes mental functions, such as attention, as well as components of communication, such as articulatory proficiency, fluency, and syntax.
Activities and Participation, including capacity (under ideal circumstances) and performance (in everyday environments), involves the practitioner's performing the following services:
Environmental and Personal Factors: Identify factors that are barriers to or facilitators of successful communication (including the communication competencies and support behaviors of everyday people in the environment). Contextual factors are personal factors (e.g., age, race, gender, education, lifestyle, and coping skills) and environmental factors (e.g., physical, technological, social, and attitudinal).
For examples of functional goals, please see the ICF page on ASHA's website.
All documentation must be signed and dated and must include the credentials of the clinician providing services. Documentation of clinical interactions should present the events of a session and patient/client interactions, the type of therapy (e.g., group/individual/co-treatment, etc.), as well as any accommodations and modifications to clinical procedures. ASHA's Preferred Practice Patterns may provide guidance. Clinicians must also meet the documentation requirements of the facility and payer.
The evaluation report typically is a summary of the evaluation process, any resulting diagnosis, and a plan for service and may include the following elements
A treatment note is a record of a treatment session and typically includes the following information regarding the treatment session:
All documentation should reflect skilled services. Unskilled services are not reimbursable.
Goal: Improve speech intelligibility of functional phrases to 50% with minimal verbal cues from listener.
Unskilled treatment note: Pt continues to present with unintelligible speech. Treatment included conversational practice. Recommend continue POC.
Comment: This treatment note does not provide objective details regarding patient's performance.
Skilled treatment note: Pt continues to have unintelligible speech production; unable to consistently make needs known. Intelligibility at single-word level: 60%; phrase level: 30%. Pt benefits from SLP's verbal cues to reduce rate of speech and limit MLU to 1-2 words. Listener has better understanding if pt points to 1st letter of word first. Pt demonstrated improved self-awareness of intelligibility relative to last week's session.
Goal: Pt will produce one-word responses to functional wh- questions x 60% with min cues.
Unskilled treatment note: Pt produced word-level responses with 70% accuracy in treatment session with verbal cues.
Comment: This note does not include modification of the plan of care based on patient performance and does not detail skilled treatment activities.
Skilled treatment note: Word level responses to wh- questions to: self and ADLs: 70% accuracy semantically abstract questions: 50% accuracy. Benefits from phonological (initial syllable) cues but unable to self-cue successfully. Naming nouns is better than verbs. Performance improves when pt attempts written response to augment verbal output to facilitate phone-grapheme associations.
Goal: Pt will use compensatory strategies for orientation to time to reduce agitation with 80% accuracy when cued by staff.
Unskilled treatment note: Pt recalled events that occurred earlier today with 50% accuracy.
Comment: This treatment note does not support the short-term goal in the plan of care.
Skilled treatment note: Spaced retrieval techniques were used to train pt to locate calendar, check clock, and look on whiteboard for daily schedule. Pt responded to temporal orientation questions relating to personal history (x 50% accuracy) and schedule at current living environment (x 60% accuracy) with mod verbal cues provided by SLP/caregiver. Pt benefitted from verbal rehearsals to improve independence in use of compensatory strategies.
Goal: Pt will communicate with a speaking valve in place at phrase level x 10 utterances with appropriate vocal quality, pitch, and loudness to indicate wants/needs.
Unskilled treatment note: Pt tolerated speaking valve for 30 minutes.
Comment: There is no clear connection between the daily note and the short-term goal.
Skilled treatment note: Speaking valve was placed to help facilitate verbal communication. Pt repeated 10 phrases without visible signs or symptoms of respiratory distress for 30 minutes. Pt's SPO2 level maintained 99%-100% during the entire session.
Progress notes are written at intervals that may be stipulated by the payer or the facility and report progress on long- and short-term goals. These notes typically include
All documentation should reflect skilled services. Unskilled services are not reimbursable.
Short-term goal: Pt will use compensatory strategies to record upcoming appointments with 90% accuracy.
Unskilled progress note: Pt was given an appointment book for recording upcoming appointments. Continue established POC.
Comment: This note does not report the patient's performance and provides no description of modification or feedback.
Skilled progress note: A 3-step process was provided in writing to help Mrs. J go through the steps of recording appointments in her pocket calendar. She practiced with trial appointments until she replicated the 3 steps with 100% accuracy with minimal verbal cues.
Short-term goal: Pt will safely consume mechanical soft diet with thin liquids x 3 meals per day with = 1 overt s/s of aspiration to meet all nutrition/hydration needs.
Unskilled progress note: Pt has been tolerating mechanical soft/thin liquid diet well.
Comment: This progress note does not reflect change in status as a result of skilled intervention.
Skilled progress note: Pt has been seen for 8 treatment sessions during this period. Pt's diet was upgraded from puree/nectar thick liquids to mechanical soft/thin liquid diet. Pt safely consumed 3 trial meals at lunch with no overt signs and symptoms of aspiration. Pt requires mod verbal cues to safely implement compensatory strategies. The short-term goal has been updated to include trials of regular texture foods. Plan of care includes caregiver education prior to discharge.
Discharge summary notes are prepared at the conclusion of treatment and typically include
All documentation should reflect skilled services. Unskilled services are not reimbursable.
Unskilled discharge note: Pt has made progress during treatment. Pt and wife educated on use of swallow strategies for safety. Recommend discharge SLP services at this time.
Comment: This note does not detail skilled intervention, patient's functional change in status, or skilled aspects of caregiver training.
Skilled discharge note: Skilled SLP services for dysphagia management included caregiver education, therapeutic diet upgrade trials, instruction and training in compensatory strategies (pacing, full oral clearance, cyclic ingestion, relaxation technique for controlled breathing), and discharge counseling. Pt currently has orders for mechanical soft with thin liquids x 2 meals (breakfast/lunch) but remains on puree at dinner. Significantly reduced swallow safety noted in evening due to increased cognitive-behavioral changes associated with sun-downing. Pt and his wife educated re compensatory swallow strategies to improve safe and efficient swallowing with 100% return demonstration of strategies by his wife. SLP educated pt and family on the need to implement relaxation strategies while eating due to pt experiencing anxiety during mealtimes. Recommend pt returns home with home health SLP services to address swallow safety while maximizing efficient PO intake on mechanical soft diet with thin liquids.
ASHA does not prescribe a specific format for documenting, either in paper-based records or electronically; however, ASHA provides resources for clinicians, including clinical assessment templates.
Documentation should include information required by payers in addition to relevant clinical information. Succinctness and legibility are critical factors so that those reading the documentation can locate key information easily and read it quickly.
Any acronyms or abbreviations used should be consistent with facility policy on accepted medical abbreviations [PDF].
Health care facilities and other health providers adopt electronic medical records to standardize the collection of patient data, improve coordination of care, and facilitate reporting of quality measures.
Within medical facilities, SLPs should participate in the development of the templates that they will use for billing and clinical documentation, because templates developed by or adapted from other disciplines often lack the necessary focus or specificity to describe the patient's diagnosis and treatment. Documentation templates that rely exclusively on multiple choice checkboxes may succeed in cuing the clinician to complete required aspects of documentation, but run the risk of not being able to differentiate the patient's unique clinical characteristics and treatment plan. See Electronic Medical Records (EMRs) and Practice Management Software for Speech-Language Pathologists.
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 systems purchased for a health care facility.
Each state may have unique medical record retention laws that vary by setting or type of record. In addition, federal law (HIPAA), payers, and regulatory or accrediting agencies may have regulations governing record retention. SLPs should know all applicable regulations and abide by the most stringent. Laws regarding record retention are passed by the state legislature and may be found on the state's website or the department of health's website. Hospital medical records staff should also be knowledgeable about applicable laws and regulations.
HIPAA regulations do not include medical record retention requirements. However, HIPAA rules 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 Centers for Medicare & Medicaid Services (CMS) requires that patient records for Medicare beneficiaries be retained for a period of 5 years; see 42CFR482.24(b) [PDF]. Medicaid requirements may vary by state. Additional information about record retention rules [PDF] are available from CMS.
ASHA does not have a policy on retention of video or digital images, such as videofluoroscopic swallowing studies. SLPs should consult their facility policy for guidance.
ASHA's Code of Ethics Principle 1, Rule M states: "Individuals shall adequately maintain and appropriately secure records of professional services rendered, research and scholarly activities conducted, and products dispensed, and they shall allow access to these records only when authorized or when required by law" (ASHA, 2010r). Further, the Issues in Ethics: Misrepresentation of Services for Insurance Reimbursement, Funding, or Private Payment prohibits misrepresenting coding or clinical information for the purposes of obtaining reimbursement (ASHA, 2010).
The medical record is a legal document. Changes made to the medical record should be dated and initialed by the original documenter, not erased, deleted, or whited out. If a clinician has evidence that an administrator or other colleague has altered that clinician's documentation to reflect incorrect information or without properly noting the changes, then the clinician should consider his or her ethical obligation to report the behavior and to protect his or her license and certification.
The purpose of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) is to make it easier for people to keep health insurance, ensure the confidentiality and security of protected health information (PHI), and help the health care industry control administrative costs. Health care providers and other entities who conduct electronic transactions or 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 transition to the 10th Revision of the International Classification of Diseases (ICD-10).
The Joint Commission released a revised set of standards on patient-centered communication in 2010. The standards outlined "effective communication, cultural competence, and patient- and family-centered care as important components of safe, quality care" (The Joint Commission, 2010, p. 4). In order to demonstrate compliance with the Joint Commission requirements [PDF], documentation is important. Information that should be documented includes
(The Joint Commission, 2010)
Do I have to include my credentials (e.g., CCC-SLP) in my signature?
Clinical records are legal documents, and the signatures of those entering information should reflect their roles within the organization. The official title of the profession is "speech-language pathologist," which may be spelled out or included in the abbreviated credential CCC-SLP for certified individuals. Facility rules may also specify the need to include information about licensure or additional credentials. SLPs holding an advanced degree in another field, such as psychology or business, should specify their credentials appropriately. See Use of Graduate Doctoral Degrees by Members and Certificate Holders.
Does the SLP supervisor need to cosign all documentation completed by a student? What about a clinical fellow?
All student documentation should be cosigned by a qualified provider, as defined by the payer and/or state licensure board guidelines.
If CFs are granted provisional licensure in the state, then they do not need to have their documentation cosigned. In states that do not have provisional licensure for CFs, Medicare views them as students and requires 100% supervision by a licensed SLP. In these instances, the supervising SLP would have to sign all notes as the qualified provider.
Facility policies and state licensure boards may have additional requirements. ASHA's requirements for CF supervision do not address medical record documentation.
Who "owns" the documentation—the clinician who wrote it or the facility/company?
The answer is situation-specific and highly dependent upon state laws and contract language. For example, if the clinician is an employee, then the records likely belong to the employer. If the clinician is an independent contractor, ownership of the physical record will depend upon contract terms. In situations where the clinician is a partner in the business, ownership of business property may vary by state laws and contract terms.
What do I do when I am asked to complete documentation for a colleague who has moved on when I was not previously involved in the case?
Ideally, clinicians will complete all documentation prior to leaving a job. It may be possible for another clinician to review prior notes and treatment logs to put together the necessary information. The author should be clearly identified, and the facility may note the treating clinician's departure in the record so that it is clear to anyone reviewing the chart. If there is not sufficient information to complete the documentation (such as no record of treatment dates), then the facility should make note of that in the record and report that to payers or other reviewers, as appropriate. Attempting to recreate records without sufficient information may result in false information and fraudulent billing.
What do I do when my administrator alters or requests that I alter my documentation?
The proper way to make changes to documentation after the fact is to either create a new entry with the information that has changed or to draw a line through the incorrect information and sign and date the change without removing or obliterating what had been written. Any addendum should include the date the change is being entered into the record and the name and signature of the person making the change, as well as the reason for the change.
If a clinician is asked to change information because it is incorrect or incomplete (e.g., wrong date, wrong treatment goal, or forgot to note something of importance), then using the procedure described above should suffice. If, however, there are other reasons for the change then the clinician needs to consider the legal and ethical implications before making any changes.
Clinicians should not misrepresent services or findings as this may constitute fraud and may violate the Code of Ethics and licensure laws. If a clinician has evidence that an administrator or other colleague has altered that clinician's documentation to reflect incorrect information or without properly noting the changes, then the clinician should consider his or her ethical obligation to report the behavior and to protect his or her license and certification.
Should I release copies of the test protocols when requested by clients?
Patients (or legal guardians in the case of children) have a right to review their medical records, as allowed by HIPAA. They may also have a right to copies of the record; however, limitations on what they can have copied may exist, such as legal restrictions.
One such restriction is copyright laws. Publishers of tests often have copyright restrictions regarding photocopying protocols; such information may be available on the publisher's website or by contacting the publisher directly. For more information on this issue, see:
Are my informal data tallies (such as check marks for accurate response to help me determine progress) considered part of the medical record?
According to the American Health Information Management Association(AHIMA, n.d.), source data that are interpreted elsewhere generally are not considered part of the designated record set. Check marks or other informal means of recording data during the treatment session are likely meaningless to anyone other than the treating clinician; however, the interpretation of that data (e.g., "Patient was able to complete cloze sentences with 70% accuracy with minimal cues") is meaningful and is considered part of the record.
American Health Information Management Association. (n.d.). Fundamentals of the legal health record and designated record set. Retrieved from http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048604.hcsp?dDocName=bok1_048604.
American Speech-Language-Hearing Association. (n.d.). International Classification of Functioning, Disability and Health (ICF). Retrieved from www.asha.org/slp/icf/.
American Speech-Language-Hearing Association. (2004a). Preferred practice patterns for the profession of speech-language pathology. Available from www.asha.org/policy/.
American Speech-Language-Hearing Association. (2004b). Medical necessity for speech-language pathology and audiology. Retrieved from www.asha.org/siteassets/uploadedfiles/practice/reimbursement/mednecfifinal3.pdf.
American Speech-Language-Hearing Association. (2010r). Code of ethics [Ethics]. Available from www.asha.org/policy/.
American Speech-Language-Hearing Association. (2010b). Issues in ethics: Representation of services for insurance reimbursement, funding, or private payment. Retrieved from www.asha.org/Practice/ethics/misrepresentation-of-Services/.
Centers for Medicare and Medicaid Services. (2014r-a). Medicare benefit policy manual, chapter 16, section 20. Retrieved from www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c16.pdf.
Centers for Medicare and Medicaid Services. (2014r-b). Medicare program integrity manual, chapter 13, section 13.5.1. Retrieved from www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c13.pdf.
Centers for Medicare and Medicaid Services. (2014r-c). Medicare benefit policy manual, chapter 15, section 220.2B. Retrieved from www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf.
The Joint Commission. (2010). Advancing effective communication, cultural competence and patient- and family-centered care. Retrieved from www.jointcommission.org/assets/1/6/
World Health Organization. (2001). International Classification of Functioning, Disability and Health (ICF). Retrieved from http://www.who.int/classifications/icf/en/.
Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the page:
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association (n.d.). Documentation in Health Care (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Professional-Issues/Documentation-in-Health-Care/.