The first version of Microsoft Word was released in October 1983—but it only became a massive commercial success in 1990. As you may already suspect, Word is now the most widely used word processing software in the world, boasting more than 1.2 billion users. And while it has completely changed how the modern workforce writes, creates, and collaborates, there is at least one segment of the workforce where it has no business being utilized: patient documentation.
Lately, we’ve seen a resurgence of DIY documentation solutions—like Microsoft Word—in rehab therapy. Coined the “new paper,” this trend is largely driven by two factors:
- The assumption (particularly among one- to two-provider clinics) that it’s more cost effective; and
- The minimal number of industry-wide compliance programs (e.g., FLR and PQRS are defunct, and MIPS applies only to a small subset of rehab therapists).
Regardless of the motive, documenting via a run-of-the-mill word processor isn’t a good idea—as it could potentially put your practice and patients at risk. Here’s why.
It creates major security concerns.
It’s not uncommon for providers to assume that because Microsoft offers HIPAA-covered entities a Business Associate Agreement (BAA), Word keeps their patients’ protected health information (PHI) secure. However, this is not always the case.
According to John Wallace, PT, MS, Chief Business Development Officer of Revenue Cycle Management at WebPT, “The main concern with BAAs is that anyone can sign them—and you have no way of knowing whether they’re qualified to do so. So, if the entity that signs this agreement fails to keep your patients’ or practice’s data secure, you could be in serious trouble.”
For context, providers that violate HIPAA standards face significant financial and criminal repercussions—including fines of up to $50,000 and imprisonment up to 10 years depending on the situation’s severity. This is why having a cloud-based EMR with a HITRUST certification (like WebPT) is critical as they ensure your software checks every security box you could ever think of—and more.
It’s not as cost-effective as you think.
Many rehab therapists who opt for Word documentation are motivated by the thought of cutting down on their budget and pocketing some extra cash. However, without using built-in safeguards that ensure accurate billing and documentation, you could potentially open up your practice to significant financial risk.
It muddies the billing and claims cycle.
The key to receiving maximum reimbursement for your services—and in a timely manner—is to produce clean claims, or claims that are “complete, accurate, and error-free.” But, it’s difficult to produce clean claims on Microsoft Word—or any other word processor for that matter. Word processors lack the integration capabilities needed to seamlessly sync with a billing software, leaving users to manually transfer patient data from software to software—on every single claim. This increases the likelihood of human error, thus upping your chances of experiencing claim denials or rejections.
Furthermore, the claim submission process requires more than a simple list of CPT codes. Providers also need to submit:
- Patient information,
- Coverage information,
- Daily notes, and
- Progress notes.
But if this information is spread across a number of disparate files or systems, it’s easier to overlook (or forget to submit) a key piece of data, which will ultimately result in a denial. These denial-causing hiccups cost you both time and money—likely negating the reason you opted to document in Word in the first place.
It hampers your ability to document defensibly.
Defensible documentation is not only needed to accurately track patient outcomes and bill for treatment, it’s also essential for safeguarding your clinic from an audit. Maintaining the documentation standards established by The Centers of Medicare and Medicaid Services (CMS) (and other commercial payers) becomes increasingly difficult without the help of native tools that guide you through the toughest parts of the documentation process, such as:
- Tracking the therapy threshold,
- Applying modifiers,
- Calculating units via the 8-minute rule, and
- Billing NCCI edit pairs.
Without an EMR to lean on, you must be even more vigilant when documenting to ensure your notes are detailed, accurate, and—of course—defensible. Otherwise, you run the risk of paying thousands of dollars in reparation fees should you find yourself on the wrong side of an audit.
It offers zero clinical support.
Today’s EMRs are far more nuanced than their predecessors, and do much more than simply house patient data (although, this is obviously still very important). Not only do they assist with billing and compliance, they also are often compatible with other practice management tools that drive business growth, enhance the patient experience, and maximize outcomes.
So, if you’re opting to document via “new paper,” you’re missing the boat on the robust clinical support EMRs can offer, including:
- Pre-loaded outcomes tests that can help you determine case complexity;
- Real-time updates in accordance with changing payer and regulatory requirements;
- Free educational resources that walk you through each regulatory change;
- Access to a bevy of pre-built templates that align with rehab therapist’s workflows, and help streamline documentation;
- Fully integrated features that automatically transfer patient data from one interface to the next;
- Improved access to financial data to better track practice growth and viability metrics; and
- The ability to add integrated solutions as you need them, thus ensuring that your practice and your tools grow together.
Learn how to set the right benchmarks for your PT, OT, or SLP clinic with these 34 KPI metric-tracking tips!
It doesn’t cover copyrighted outcomes tests.
Another not-so-obvious benefit to EMRs is that most pay for the copyright fees associated with a wide range of outcomes tests. For instance, the WebPT EMR covers the copyright costs for the Wong-Baker FACES® Pain Rating Scale and the Lymphedema Life Impact Scale. Without an EMR, you must pay for the tests you use in your practice. Failure to do so could result in a costly insurance audit and/or lawsuit.
Even cash-pay clinics should avoid documenting in Word.
Despite what their name may imply, cash-pay clinics still occasionally deal with payers, sometimes billing insurance companies on behalf of patients, or providing patients with a big ole superbill (that still gets sent to payers). For this reason, it’s best practice—and honestly just good manners—to create thorough, clean claims that are payer-friendly. Moreover, keeping defensible documentation on-hand is important for liability purposes. It’s critical to have the ability to defend your medical treatments and to prove you followed your state practice act—no matter your practice model.
Be that as it may, we understand that cash-pay and startup practices probably don’t require all the bells and whistles that come with a full-service documentation solution. Fortunately, plenty of EMRs (WebPT’s included) offer basic versions of their software at a lower cost. You can even take them for a spin to see which one is right for your practice!
At the end of the day, a patient note lays the groundwork for the entire medical record itself. And if it’s cobbled together using decentralized, unsecure resources, it’s less likely to offer you, your practice, and your patients the adequate support required to guarantee clinical success.