This module covers documentation for audiology services in different health care settings.
Documentation is a critical aspect of patient care. It provides communication among service providers who participate with the plan of care, ensuring continuity of service. Documentation reflects services provided, and is necessary for accurate coding and billing. It is also used with utilization reviews, for compliance, and data collection. The patient record is a considered a legal document.
Documentation must accurately reflect all patient care. It must reflect and support the services provided as well as the diagnostic codes assigned. Documentation also needs to be clear to the reader, posted in a timely fashion and error free. It might help to use the acronym ACUTE as a mnemonic for: accurate, code-able, understandable, timely, and error free.
It is not uncommon for third party payers to request documentation to support the services for that you have billed to them. If third party payers do not see documentation for a billed service, their assumption is that the service was not provided. Always remember the health care provider's proverb, “if it wasn't documented, it wasn't done!” Documentation is needed for all contacts with patients whether it be face-to-face, by phone, electronically, or by mail. Remember, all documentation must also be dated and signed.
The reason for the patient's visit must be specified, regardless of the nature of the encounter. On an initial encounter, the nature of the presenting problem and pertinent past, family, medical, and social history must be documented.
Documentation must include the procedures performed using CPT codes and the diagnoses and disorders using ICD-9-CM codes. The patient's record must also include current and prior findings, assessment, clinical or diagnostic impressions, plan of care, rationale for recommendations or care, and decisions and documentation of progress for any changes in treatment. If services are provided in a facility where Joint Commission guidelines are mandated you must document preferred learning modality, barriers to learning, understanding of materials presented, and how determined.
Documentation for habilitation or rehabilitation services include the plan of care (or plan of treatment), objective measures of the patient's progress, reasons for the treatment approach, and preferred learning, barriers to learning, understanding of material presented and how you determined these findings. Again, all chart notes and other documentation needs to dated and signed.
Documentation must be timely. You should complete your documentation of an assessment on the same day and of treatment immediately following the visit. Documentation also needs to be complete and easily understood by the reader. Avoid over abbreviation or use of jargon. Templates can be used, however accuracy and personalization is essential.
Once a service has been provided and documented, procedural codes that most accurately reflect the services are assigned. Documentation must demonstrate the complexity, skill, and time required to perform the service. Services provided must be consistent with the diagnosis. For example, if the diagnosis is for “broken Leg,” providing “central auditory processing evaluation” is not appropriate. Additionally, services must be appropriate for provider type. This may vary by third party payer. For example, you may have provided treatment for an auditory processing disorder, billed under 92507 (“treatment of speech-language voice communication and/or auditory processing disorder: individual”). However, Medicare classifies audiologists as providers of diagnostic services and does not recognize audiologists as providers of “rehabilitation services.” On the other hand, speech-language pathologists are qualified to provide therapy services and can bill Medicare for services described in 92507. There may also be other payers who recognize only speech-language pathologists as qualified to bill for 92507.
Some third party payers require prior authorization or a physician referral or order before you can bill for services. For example, Medicare requires a written order from the physician before you can see and bill for your services. Obviously, you should not bill for services you know are not covered. However, there are certain instances where a denial is required for other purposes, such as to bill a secondary insurance or to balance bill a patient. For example, some United Auto Workers payers will not pay for audiology services if a patient is over the age of 65 and Medicare has not been billed first. Medicare will reimburse for audiology services if the purpose of the evaluation is to assist a physician in determining diagnosis and/or medical or surgical care. Medicare will not pay for services if the purpose of the evaluation is to determine whether amplification is or is not appropriate. So, when billing Medicare for an evaluation related to amplification, you must use a code that signifies to Medicare that you understand that this is not a covered benefit but that you need a denial to be able to bill a private health plan. Your documentation must reflect that you have billed Medicare in order to receive a denial in order to bill a secondary insurance or other third party payer.
Audiology services can, of course, be provided in a variety of health care settings including private practice, hospital, physician office, university clinic or rehabilitation or skilled nursing facilities. In all settings, the documentation must accurately and completely reflect the services rendered.
The actual type of documentation requirements may differ depending on the setting. However, the nature and scope of the documentation needs to be such that, if requested, complete information can be provided to third party payers to support the services billed. A comprehensive audiologic evaluation report will often suffice. If a complete evaluation report has not been written, chart notes and/or data presentation, including an audiogram, with notes reflecting interpretation of the services may be sufficient.
Typically, outpatient settings require an evaluation report and clinical notes. If further services are provided, documentation must identify the need for those services and, of course, what those services were.
The outpatient evaluation should include a history, a detail of the services you provided, interpretation of your findings and your recommendations.
Again, the outpatient evaluation must have an original signature and the dated period. Do not use a name stamp or facsimile signature. However, electronic signatures are acceptable. Medicare states that a physician's signature is not required on orders for clinical diagnostic tests that are paid on the basis of the Medicare physician fee schedule. This applies to audiology services as well. It is also acceptable to include the date of dictation, along with the date of the evaluation.
Documentation in university clinics tend to be lengthy and detailed. The information contained is typically more than adequate for third party payers. However, other settings, reports tend to be much shorter and less detailed. Shorter and less detailed is fine, provided the documentation is appropriate, adequate and able to withstand an audit.
Documentation in a physician's office often includes the audiogram and notes, which may be made on the same page. Again, this is fine if it is what is appropriate for the office and third party payer. At a minimum, the documentation must be sufficiently detailed to describe what you have done, including tests administered, patient counseling, and recommendations made.
Documentation for inpatient evaluations may include an audiogram and handwritten notes, or may be entered into an electronic system. Regardless of the system of reporting, there needs to be documentation of all services provided.
School districts may require a certain report format. Regardless of the format, if your evaluation or treatment is being paid for by a third party, you must make sure your documentation describes all services provided. You may want to review Module Eight on Advocacy and School Finance for other information related to billing by the schools.
Hearing aid evaluation and dispensing services must include documentation for the evaluation and any additional documentation required by the third party payer for amplification. You'll also need to make sure your documentation complies with state regulations. Individual states may require certain language to appear on sales invoice agreements and other documents.
Clinical notes become legal documents. All contact with and regarding your patient needs to be documented whether the communication is face-to-face, by phone, electronically, or by mail. This includes communication with other health care providers, third party payers, care givers and so forth. Phone encounters include conversations with the patient, review of findings with the referring physician, and discussions with other health care providers. For example, you may speak with a child's speech-language pathologist about classroom seating.
Some medical settings have software for documentation that provide templates for you to fill in various information. Typically, these templates and software programs have been written to accommodate documentation required for various purposes, including third party payers. Your responsibility is to make sure the data you input is accurate and that your CPT codes are consistent with your ICD-9 codes and so forth.
Your documentation should be reviewed to ensure that it is complete and provides necessary information. This checklist can serve as a guide to review your documentation.
More information is available at the links below:
At this time please proceed to Module Five, which covers coding, documentation, and additional reimbursement reporting requirements for speech-language pathology, or Module Six, which covers coding, documentation, and additional reimbursement reporting requirements for audiology.