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You Audit Know: 5 Documentation Tips to Protect Your Practice From Audits

Good documentation can help protect you from the fallout of an audit. Here’s everything you oughta know about it.

Melissa Hughes
5 min read
November 12, 2021
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Audits have been the talk of the town in 2021—and for good reason. The Centers for Medicare and Medicaid Services (CMS) has ramped up audits this year—in part because audits were put on hold during most of 2020 to help ease the burden of the pandemic, and also because the Biden administration plans to expand Medicare and crack down on fraudulent billing. 

In any case, rehab therapists have been the target of many of these audits, and it’s left them asking, “How the heck do I avoid this scrutiny?” The reality (in at least one of WebPT’s previous compliance officer’s eyes) is that you can’t technically avoid an audit because Medicare is always actively analyzing claims. But it is possible to reduce the burden of a dedicated audit and help yourself avoid monster-sized penalties. The secret lies in having extremely excellent documentation. 

1. Document at the point of service whenever possible. 

It’s an old song and dance that nearly every healthcare provider knows by heart: “I don’t have time to do my documentation right now. I’ll do it at the end of the day.” Although, to be totally fair, sometimes there isn’t a good opportunity to document at the point of service. Perhaps a patient with a complex case requires your full attention during an appointment, or you’re managing multiple patients during a group therapy session. 

But documenting at the point of care (whenever possible) is incredibly important because memory is far from infallible, and the further away you get from a patient’s appointment, the more likely you are to forget crucial details that you need to include in your documentation to justify your treatment to payers and auditors. 

Tips and Tricks

Best practice is to get in the habit of documenting while you’re working with the patient. “The key is to document when it feels natural and organic,” says Meredith Castin, PT. “It might mean typing the patient’s subjective report on your tablet while he or she reports subjective measures during a stretching or cardio warmup. It might mean documenting exercises and repetitions during the session, rather than after.”

And if you’re worried that patients might feel neglected as you jump back and forth between your screen and the clinic, just be sure to set expectations at the beginning of the appointment. Say something along the lines of, “every time you see me typing, I’m recording information about your case into your medical record.” Most patients will be totally understanding—and appreciate your due diligence!

2. Use universal abbreviations and lexicons. 

Auditors are not psychic (surprising, I know)—and sometimes they don’t have a history as healthcare professionals at all. In fact, to become a Medicare auditor, all you need is a bachelor’s degree “in a relevant field such as medical coding, accounting, or business administration.” Medicare auditors don’t even need to be certified coders to get a job—that’s just a bonus for recruiters. 

What I’m getting at here is that, to perform their jobs, auditors will likely memorize common abbreviations and lexicons that are used across the healthcare industry—but that’s it. They probably won’t have the medical background needed to puzzle out unique abbreviations and uncommon language that they might encounter in a patient chart. Therefore, if your abbreviations lack the necessary context, they might struggle to recognize the value and medical necessity of your care. That’s why it’s critical to use generally accepted language and names. For an easy-to-reference list, check out this article

3. Make your documentation count; don’t use filler words!

Creating thorough documentation takes long enough—so there’s no sense in filling up a patient’s chart with filler words that fail to support either the services charged or the number of units billed. Phrases like “tolerated well” and “patient is progressing according to POC” mean very little to an auditor, as there is: 

  1. No numerical representation of patient progress, and 
  2. No explanation of what value this brings to the patients. 

So, what should documentation actually look like, then? Take this example of a well-written functional goal that Heidi Jannenga, PT, DPT, ATC, shared in another article: “Patient will demonstrate sufficient AROM in (R) shoulder in order to reach to (and above) shoulder level for independent hair care, without pain < 3/10.”

That single sentence gives an auditor lots of information to work with—both in terms of numbers to track as well as in meaningfulness to the patient. 

4. Illustrate exactly how your patients are progressing toward their goals. 

Documentation is your one shot to prove to auditors (and more commonly, payers) that your treatments are: 

  • Medically necessary, 
  • Effective, and 
  • Skilled interventions that require the expertise of a therapist. 

To that end, be sure that every visit note illustrates exactly how your patients are progressing toward their functional goals. As John Wallace, PT, MS, said in a recent webinar, “This could be as simple as recording patients’ responses to their treatment. Other examples that illustrate progress include improvements in impairment measures and other evidence of functional improvement.” 

Outcomes assessments and hard data will be your friend here—but remember to skip the jargon and explain everything in a way that anybody could understand. 

5. Document defensibly. 

The absolute best way to chase off auditors and safeguard your clinic from nasty penalties is to document defensibly. I’m double-dipping a little bit with this tip, as defensible documentation rolls up with some of the suggestions I’ve already posed—but that makes it no less important! As Wallace said, “Your documentation is the vehicle for communicating patient care and progress—and for justifying your services.”

I know, I know. You’re asking what the heck it means to create defensible documentation. Well,  defensible documentation is

  • Legible, 
  • Easily understood, 
  • Packed with data that supports the treatment plan, 
  • Complete with all of the information that auditors and payers need to confirm medical necessity and effectiveness, and
  • Compliant—among other things! 

Here’s an example of what defensible documentation can look like—pulled straight from our toolkit.

Audits may strike fear into the bravest therapist’s heart, but as long as you document thoroughly, it’s totally possible to reduce their burden and to protect your practice from fallout.

Got any questions? Feel free to drop ‘em below, and our team will do its best to find you an answer! 


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