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 since 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.
In case you need a quick refresh, SOAP is an acronym for subjective, objective, assessment, and plan. If you’re unsure how to improve how you write SOAP notes, we’ve got some SOAP note tips (and some examples) for you right here!
1. Document up to Medicare’s (and other payers’) standards.
All audit-resistant SOAP notes must be documented up to the standards of your payers—be they Medicare, Medicaid, or any other commercial insurance. While documentation requirements may vary slightly from payer to payer, many mimic Medicare’s standards. This means you can cover many of your bases by meeting Medicare’s documentation requirements (though this isn’t foolproof, of course).
Some of the most essential documentation standards per Noridian (a Medicare Administrative Contractor) revolve around communication and treatment justification. But don’t worry about memorizing every rule. Using an EMR like WebPT can assuage much of this headache with built in Medicare compliance and plan of care (POC) alerts.
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 (CPT code 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—within the objective section—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 stabilization.
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. Plus, using an EMR with integrated flowsheets can allow you to focus more on medical reasoning.
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 unit’s worth of CPT code 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
3. Account for all your treatment time—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 patient is receiving outpatient physical therapy services for adhesive capsulitis of their left shoulder that interferes with their ability to babysit their toddler-aged grandchildren. One of the interventions provided during this visit is glenohumeral (GH) joint mobilization. After this visit, the therapist plans to bill CPT code 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 A/P glides
In contrast, this documentation describes the patient’s status, the reasoning for the treatment, and the time devoted to joint pain assessment.
- Remains hypomobile in inferior posterior planes w/ pain = 5/10
- A/P glides grade II-III; long axis manual distraction grade 4; lateral glenohumeral distraction grade III
- 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.
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 record. 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.
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, our SOAP note tips are to 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 needs more detail.
- Joint and soft tissue mobilization to the 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 II side gliding to affected areas
- Soft tissue mobilization w/ contract-relax technique for side bending and rotation bilaterally
- Improved segmental mobility following treatment
5. The assessment section and plan for the next visit show your skill and the need for PT, so don’t use filler words.
The justification for why PT is needed and how the session was a billable skill comes from the assessment and plan sections. But beware of filler words. Phrases like “tolerated session well” or “continue POC” may get the note completed in record time, but neither of these shows skill or are defensible. Instead, include specific details of why the session went well—or what needs to be improved upon—and provide specific details of how you plan to progress this patient toward their goals.
A forty-five-year-old police officer has been coming to physical therapy for a calf strain and has completed six weeks of therapy thus far. Presently, the patient is able to perform all their basic duties and has begun to return to light jogging activity. The therapist feels the patient needs an additional two weeks—the last two weeks on the plan of care—to be ready for discharge.
The patient has been progressing well, and there have been few hurdles to goal attainment for this patient at this time. In a hurry, a PT may be tempted to finish a quick note with filler words.
- Assessment: the patient tolerated the session well and has resumed jogging activity without incident.
- Plan: continue POC for the last two weeks.
Based on the information provided in this SOAP note, another PT or an insurance auditor may assume the patient’s goals are fulfilled, or the patient is at least to a point where they can be discharged to a home exercise program and finish on their own. Either of these options may lead to a negative patient experience and outcome. The patient is a police officer and needs to be able to do more than just jog when working, but the documentation does not support this fact. Instead, the PT should have documented something more like this.
- Assessment: the patient has made steady progress toward their goals of resuming full activity required of a police officer. As of now, the patient has yet to resume full running activity, which is a required task for active-duty police officers. Skilled PT is necessary to continue to meet this functional activity goal.
- Plan: continue with the present POC with a gradual return to full running and sprint tolerances in the clinic. Implement HEP exercises to progress this accordingly.
When it comes to home life, some people say, “Happy spouse, happy house!” But for 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 for physical therapy) is necessary to safeguard your practice from damaging audits. And the key to documenting defensibly is simply to take your time and communicate. So follow these SOAP note tips, and you’ll have a better shot at staying in auditors’ good graces.