Audits may not be a PT’s worst nightmare—but they’re pretty dang close. They’re costly, time-consuming, and downright stressful. And with the number of audits ramping up in 2021, PTs need to ensure that their documentation is ship-shape, lest their claims get targeted for review. The best way to avoid an audit (or successfully survive one) is to defensibly document from the get-go, creating detailed records and iron-clad SOAP notes that you can present to auditors—or anyone who could benefit from reviewing patient records.
If you’re not sure how to go about improving your notes, no worries! We’ve got some tips (and some SOAP note examples) for you right here!
1. Document up to Medicare’s (and other payers’) standards.
First and foremost, all audit-resistant SOAP notes must be documented up to the standards of your payers—whether you’re contracted with Medicare, Medicaid, or any other commercial insurance. While documentation requirements may vary a bit from payer to payer, many of them mimic Medicare’s standards in some way, shape, or form. Essentially, this means that you can cover many of your bases by meeting Medicare’s documentation standards (though this isn’t foolproof, of course).
Some of the most important documentation standards to meet per Noridian (a Medicare Administrative Contractor) revolve around communication and treatment justification. Specifically, “medical information should be clear, concise, and reflect patient’s condition.” Beyond that, documentation should “substantiate [the] service performed” as well as the “required level of care.” Let’s take a peek at what that looks like in practice.
Say a man is eight weeks post left total hip arthroplasty via a posterior approach. He received home health services for two weeks and transitioned to outpatient physical therapy services in week five of his recovery.
Part of today’s treatment focused on the patient’s postural control of his trunk and hips in mid-stance (97112, neuromuscular re-education).
Some PTs may be tempted to provide documentation for this patient that looks like this.
- Single-leg mid-stance on involved leg in parallel bars; 5 trials for 1 minute each
However, this documentation isn’t up to Medicare’s standards because it doesn’t explain why the PT chose to provide this exercise—nor does it explain how the PT contributed to this treatment. Here’s an example of better (and more defensible) documentation.
- Single-leg mid-stance on involved leg in parallel bars w/ hand touch for safety; 5 trials for 1 minute each; manual cues to sustain hip abductor contraction
You got it!
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2. Make sure your SOAP note is more than just an exercise session.
Even though physical therapists specialize in exercise medicine, treatment is so much more than an afternoon spent at the gym. For this reason, your SOAP notes shouldn’t look like a workout routine. Instead, they should contain context for the treatment (including your medical reasoning) and explain how you actively contributed to the patient’s care. In other words, you want to demonstrate why payers should reimburse for your medical expertise.
A 33-year-old woman is receiving outpatient physical therapy services for right patellofemoral pain syndrome that interferes with her ability to lead crossfit programs. Interventions during this visit include lower-extremity flexibility and strengthening exercises, for which the therapist bills one units’ worth of 97110 (therapeutic exercise).
Speed and succinctness are helpful for PTs who treat many patients throughout the day—but that speed shouldn’t come at the cost of thorough documentation. Here’s an example of notes that have too little detail, to the point where they resemble an exercise session.
- Straight leg raises – 2 sets of 15 reps w/ 10-pound cuff weights
With a little extra context, a PT can better justify their treatment and demonstrate to payers (or the physicians who may review these records) just how much value a PT can provide. Here’s a revised—and more detailed—example of the note.
- Straight leg raises – 2 sets of 15 reps w/ 10-pound cuff weights; emphasis on setting quad before lifting weight
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3. Account for all your time spent treating the patient—including assessment and management time.
Far too many PTs underestimate the number of units they can bill for a patient’s treatment. This is because many providers (not just PTs) forget that CPT codes account for more than just raw treatment time. In fact, per billing expert John Wallace, these codes account for assessment and management time. Specifically, this includes:
- “The hands-on part of the intervention named by the code (e.g., therapeutic exercise);
- The supplies required to deliver the intervention; and
- The assessment and management time necessary to deliver the service.”
That said, it’s critical to include an explanation for this time in your documentation. This can help you justify your billing should it come under scrutiny.
A 58-year-old non-binary person is receiving outpatient physical therapy services for adhesive capsulitis of their left shoulder that interferes with their ability to babysit their three-year old and one-year-old grandchildren. One of the interventions provided during this visit is glenohumeral (GH) joint mobilization. At the conclusion of this visit, the therapist plans to bill 97140 (manual therapy techniques) for this portion of the treatment.
The following documentation example is non-defensible—but more than that, it doesn’t account for (or defend) the billing of assessment and management time.
- Axial traction and I/P glides
In contrast, this documentation describes the patient’s status, the reasoning for the treatment, and the time spent providing a joint pain assessment.
- Remains hypomobile in inferior posterior planes w/ pain = 5/10
- I/P glides grade 2-3; long axis manual distraction grade 4; lateral glenohumeral distraction grade 3
- Patient reports pain decreased to 2/10 with joint play assessment following intervention
4. Provide enough detail that your colleague could hypothetically reproduce your treatment.
If you think about it, SOAP notes are basically a communal resource. You, as a provider, use them to document your treatment. Patients can review them to track their medical progress. Payers and auditors review notes to verify that your claims are correct. And finally, your colleagues use these notes if they ever need to step in to treat your patients. (Everyone’s gotta go on vacation sometimes!) The point is that these notes must be legible and comprehensible to anyone who sets eyes on them. So, instead of resorting to jargon and shorthand, use simple terminology and expand upon your notes until anyone can decipher their contents.
A 46-year-old man is receiving outpatient physical therapy services to address upper-cervical neck pain with headaches triggered by upper-cervical trigger points. One of the interventions provided during this visit was joint and soft tissue mobilization for the cervical spine, for which the therapist billed CPT code 97140 (manual therapy).
Again, it is all too easy to provide too little information in your documentation. The following example simply does not have enough detail.
- Joint and soft tissue mobilization to cervical spine and surrounding tissue
An intervention of this nature should be paired with documentation that looks a little more like the following.
- Hypomobility noted at C3-C4 and C4-C5
- Axial manual traction; grade 2 side gliding to affected areas
- Soft tissue mobilization w/ contract-relax technique for side bending and rotation bilaterally
- Improved segmental mobility following treatment
When it comes to home life, some people say “Happy spouse, happy house!” But when it comes to your PT clinic, it’s more like “Happy auditor, happy wallet-er.” Well, it may not actually rhyme, but you get the point. Defensible documentation (and by extension, SOAP notes) is a necessary component to safeguarding your practice from damaging audits. And the key to documenting defensibly is simply to take your time and communicate.