Surviving an Audit


How an Electronic Medical Record system can help you dot your i’s and cross your t’s when it comes to therapy documentation.

By Karen Christen, PT, and David McMullan, PT

Therapy documentation is extremely complex. Therefore, it should come as no surprise how difficult it is for a clinic to achieve 100 percent Medicare compliance. Physical therapists must know a great number of concepts and complete numerous forms while simultaneously treat patients. The two biggest auditing challenges associated with therapy documentation are capturing the required information and supporting what a therapist bills patients and third-party payors with clinical documentation, including Medicare as well as other third-party payors. From a Medicare perspective, these are the two most scrutinized areas of documentation and where the highest level of audit failures occur.

When documentation does not support the charges a clinic generates or support how much time is spent with a patient, whether intentional or not, it is considered false billing or fraud by Medicare. From Medicare’s perspective, insufficient billing raises a red flag, which, in turn, can change what would have been a simple audit into a much more expansive audit, including a broader range of patients over a longer period. The result is potentially higher penalties. For clinics that rely on paper documentation versus an electronic medical record (EMR) system (also referred to as an electronic health record system or EHR), the task of ensuring sufficient documentation is that much more difficult.

The Pitfalls of Paper

In a paper world, policies and plans are put in place to ensure all the correct boxes are checked and necessary details are included. This usually involves the development of templates, which list a variety of required components. Clinical staff and therapists are trained to ensure required sections are never missed. Yet, no matter how much due diligence is done, the risk that someone will forget or are unaware when a form is required for a specific patient/payor combination. In a paper world, no prompts help clinicians along the way nor blocks prohibit them from moving on to the next question or page when previous areas are left blank.

Medicare guidelines also require therapists to prove, through detailed documentation, the total amount of time a patient was seen and the total amount of treatment time. The total amount of one-on-one time with each patient dictates how many time-based codes can be billed. The goal is to ensure that the total treatment time is at minimum equal to—and preferably more than—the total one-on-one time. In a paper world, these are challenging to manage and maintain, often calling for time-consuming manual cross-referencing. However, a good EMR will automatically capture this information. Treatment detail is documented within the system, including how much time a therapist spends with a patient. With just a few taps on a tablet or clicks on the keyboard, therapists can dictate whether it is a one-on-one service or not. The EMR system will also alert therapists if one-on-one time is higher than the total treatment time. The EMR system captures all documentation details and allows staff to review the document for inaccuracies, which can be corrected when identified.

Another documentation challenge is Medicare’s required Plan of Care, which is essentially a therapist’s authorization to treat a patient. The Plan of Care is comprised of specific timelines and guidelines that must be completed either prior-to or during a patient’s initial visit. Plans must be sent to the referring physician for review, certified, signed, and sent back to the facility in a timely fashion for a patient’s treatment to be authorized. Creating a Plan of Care in a paper environment is another time-consuming, labor-intensive process that requires a lot of follow-up to ensure all authorizations are received within the required timeline. A good EMR system will significantly speed things along and ensure all required authorizations are received.

When a Plan of Care is generated through an EMR system, tracking mechanisms document when it was created, when it went to the physician, when it was signed, and when it was returned to the clinic. System prompts will alert staff to delays and track progress along the way to ensure the appropriate authorization to treat is received and all visits and services are covered appropriately from an authorization perspective.

For a paper-based facility, achieving Medicare compliance is significantly more difficult. Deploying a therapy-focused EMR system can help clinics achieve compliance and simplify processes, which will save time and money.

FHN’s Audit Success

The number one reason Freeport Health Network (FHN) moved from paper to an EMR system was the goal of becoming compliant—secondary reasons included time savings, better charge capture, legibility, and ease of getting documentation to physicians. Just two months after deploying an EMR system, the decision was justified—FHN was audited and easily passed.

Prior to deploying the system, FHN relied entirely on paper documentation and compliance with Medicare documentation regulations was below par. Trying to keep physical therapy, occupational therapy, and speech therapy in mind while treating patients proved to be too much. For example, Medicare requires lots of repetition, goals written out on an intermittent basis, and treatment details. Medicare also requires a discharge summary, which isn’t always done during a visit. It is not uncommon for a patient to call and say they feel great; therefore, they aren’t coming back. Even when a patient doesn’t come in for a final visit, Medicare still requires detailed documentation regarding what was said during the call. These summaries require a re-write of everything, from when the patient first came to the therapist, what the therapist saw, what was said, what was done, what happened along the way, and where the patient is today. FHN also was moving in the direction of becoming Joint Commission accredited, which is more stringent than Medicare, elevating the need for clinicians to “get documentation right.”

Aware the difficulties of achieving compliance via paper documentation, a task force was put in place at FHN to educate staff on what compliant documentation requires. The team looked at a number of EMR systems. While they found certain aspects of some products appealing, some were prettier while others were seemingly faster, the main priority was a system that ensured the smallest details were not missed.

Since deploying an EMR system, daily notes take significantly less time, discharges are a breeze, there is less running around the clinic transitioning between patients, and scheduling is much easier. Chart reviews are stress-free, as well, while discharges take literally seconds because documentation is created along the way with each and every visit. Clinicians simply open the note and sign it. This was huge for staff, some who easily had 30 charts that needed to be discharged. Prior to deploying an EMR system, discharges were often backlogged because they were tedious when done on paper.

Easing Audit Pains with EMRs

Previously, a Medicare audit required clinical staff to randomly pull 10, 15, or 20 charts. The auditor would thumb through the documents ensuring compliance was met. Illegibility and missed information were not uncommon. As mandates become increasingly more complex and electronic documentation more common, passing an audit in a paper world is a difficult task. The legibility of an EMR automatically improves audits because it is easier to read and find information. Documentation is typically more thorough because of the logic built into EMR system, which helps prevent missing data. However, it is important to note, not all EMR systems are created equal.

Too often, clinicians get so caught up in a system’s ease-of-use that they forget about compliance. There must be a balance between ease-of-use and functionality. Clinical staff members want a system that is easy and efficient, but the system should not be so easy that it is not compliant, nor should it be too burdensome or rigid. For example, a system that is compliant for Medicare should not force all of the same Medicare rules onto every single payor. This act can overburden documentation requirements and efficiency because it has only one rule set that has to be applied to everybody. At the same time, the system should not be so flexible that the clinicians themselves have the ability to miss compliance requirements, just to finish their notes quickly.

Therapists have an obligation to provide the best care for their patients. They must also ensure— and prove—billing practices are appropriate with the service provided through clear, concise documentation. A good EMR system can help therapists achieve both.

Karen Christen, PT, is director of rehabilitation, occupational health, and pain services for FHN.

David McMullan, PT, is a PPS member and vice president of product management in the therapy division of SourceMedical. He can be reached at

Copyright © 2018, Private Practice Section of the American Physical Therapy Association. All Rights Reserved.

Are you a PPS Member?
Please sign in to access site.
Enter Site!