Blog Post

PT Documentation Success Starts With Avoiding Coding Mistakes

The necessity of a strong PT practice documentation discipline is a must if any physical therapy operation hopes to be a success.

Heidi Jannenga
5 min read
May 1, 2011
image representing pt documentation success starts with avoiding coding mistakes
No items found.
Share this post:


Get the latest news and tips directly in your inbox by subscribing to our monthly newsletter

The necessity of a strong PT practice documentation discipline is a must if any physical therapy operation hopes to be a success. It is virtually out of the question to not have a strong PT practice documentation system in place to keep up with government regulation for Medicare reimbursements and to satisfy the documentation needs of insurance companies who will provide the revenue for the continued service you offer to your clients.

It isn’t enough to simply fill out your PT documentation, because not understanding the proper way to present patient information can lead to unnecessary denial of payment when claims are submitted. Therefore, the first step any PT practice clinician can do to raise the success rate of your PT documentation and reimbursements is to assign your most experienced staff member to the task and limit who completes your PT documentation forms.

It takes experience and an understanding of the coding and what insurance and government agencies will and will not accept when submitting PT documentation for payment. Of course, any PT practice will undergo turnover. Keep a regular training program going so that you have an understudy learning the ropes of PT documentation, then that person can step in and do a good job if your primary PT documentation expert is out for a time or has to leave your employ.

A second key to success with your PT documentation is also very important because it is the cause of a large amount of rejected forms. That common mistake is using ambiguous language when documenting a patient’s issues or treatment. An ambiguous statement like “The patient is improving” is not adequate. In order to be approved, documentation must be specific and show measurable progress that can be gauged against the initial assessment and the stated goals of the therapy.

The third and most important tip on being successful with your PT documentation is to be scrupulous about using industry standard coding and abbreviations. There are industry standards in place that are quite specific and using that coding will speed your PT documentation through the reimbursement process. Be sure you have available the necessary coding so that this aspect of PT documentation is an easy one to take care of.

Finally, fill out all pertinent PT documentation either while you are with the patient or directly afterwards. By not delaying and turning the task over to a staff member, you are more assured the report will be accurate. You can verify that the coding and choice of language is correct. You also get the task out of the way so that the proper forms can be submitted promptly for payment, thus improving the cash flow to your clinic.

"Prior to WebPT everything in our office was handwritten, often with poor quality and difficult to read. Many of our staff never used a computer before and they have adapted well. Records are cleaner nowand we have less questions from payers."  Bob Bacci, Bacci & Glinn PT



KLAS award logo for 2024 Best-in-KLAS Outpatient Therapy/Rehab
Best in KLAS  2024
G2 rating official logo
Momentum Leader Winter 2024
Capterra logo
Most Loved Workplace 2023
TrustRadius logo
Top Rated 2023
Join the PXM revolution!

Learn how WebPT’s PXM platform can catapult your practice to new heights.

Get Started
two patients holding a physical therapist on their shoulders