Documentation is a critical vehicle for conveying essential clinical information about each client/patient's diagnosis, plan of care, intervention, and outcomes. It serves to detail communication between clinicians for care coordination and transfer of care and also between clinicians and payers. Any type of documentation to be shared with clients/patients or family members/caregivers should be readable, understandable, and written in plain language. See Health Literacy.
ASHA does not dictate a single format or timeframe for documentation. State or federal agencies governing health care, education, or licensure for audiologists may have specific documentation requirements; if those requirements are more stringent, they supersede requirements of facilities, payers, and employment contractors.
Unclear, vague, or absent documentation can result in negative consequences such as inappropriate or inadequate intervention or referral, reduced continuity of care, denials by payers, and misrepresentation of the clinical judgment underlying the given diagnosis and intervention.
The acronym ACUTE may be used to recall five important principles in proper documentation for audiology services:
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:
Relevant documentation for establishing medical necessity may include the following details (ASHA, 2004):
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
Recommendations for documenting skilled services are as follows:
Clinical documentation includes justification of the following service attributes:
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.
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:
ASHA's 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:
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
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
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
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 Medicaid Toolkit.
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.
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.
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:
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).
See 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:
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:
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).
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.
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.
The 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'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
According to the Federal Trade Commission (FTC), a purchase agreement for hearing aids will include the following:
See 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.
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.
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
American National Standards Institute. (2010). Specification for audiometers (ANSI S3.6-2010). New York, NY: Author.
American Speech-Language-Hearing Association. (2004). Medical necessity for speech-language pathology and audiology. Retrieved from www.asha.org/siteassets/uploadedfiles/practice/reimbursement/mednecfifinal3.pdf
American Speech-Language-Hearing Association. (2006). Preferred practice patterns for the profession of audiology [Preferred Practice Patterns] . Available from www.asha.org/policy/.
American Speech-Language-Hearing Association. (2010).Issues in ethics: Representation of services for insurance reimbursement, funding, or private payment. Retrieved from www.asha.org/practice/ethics/misrepresentation-of-services/.
American Speech-Language-Hearing Association. (2016). Code of ethics [Ethics]. Available from www.asha.org/policy/.
Centers for Medicare and Medicaid Services. (2014-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. (2014-b). Medicare program integrity manual, chapter 13, section 13.5.1. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c13.pdf
Centers for Medicare and Medicaid Services. (2014-c). Medicare benefit policy manual, chapter 15, section 220.2B. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf
Family Educational Rights and Privacy Act of 1974, 20 U.S.C. § 1232g (1974).
Health Insurance Portability and Accountability Act of 1996. Pub. L. No. 104-191, 110 Stat. 1938 (1996).
Individuals with Disabilities Education Act, 20 U.S.C. § 1400 (2004).
Moore, B. J. (2010). Documentation for SLPs and audiologists in schools [Audio program]. Rockville, MD: American Speech-Language-Hearing Association.
The Joint Commission. (2010). Advancing effective communication, cultural competence, and patient- and family-centered care. Retrieved from www.jointcommission.org/assets/1/6/aroadmapforhospitalsfinalversion727.pdf
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 of Audiology Services (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Professional-Issues/Documentation-of-Audiology-Services/.