Clinical Notes: Everyone’s Favorite Topic
March 2021 Issue
The importance of good clinical notes has been a topic of discussion for O&P practitioners for several years. Clinical notes are key to effective communication, painting the story for patient care, as well as ensuring your claims withstand an audit. Practitioners have reported that half of their time is now dedicated to documentation, so it might as well be time well spent.
In February 2018, CMS acknowledged that O&P clinical notes are formally part of the patient's official medical record. Despite that great achievement, your clinical notes still need to be corroborated by the medical record, but hey, we're getting there. Your clinical notes are included in insurance prior authorizations, payment audits, and litigating lawsuits. I have read thousands of orthotists' and prosthetists' clinical notes over the years, and to be honest, there is room for improvement.
Orthotists and prosthetists have challenges in creating comprehensive clinical notes that also document all the required criteria for coverage for two reasons:
Limited or no access to the patient's medical records for review
More burdensome CMS documentation requirements, including corroborating documentation that O&P providers have no direct means to provide or authority to demand
Without access to the patient's medical record for review, practitioners create a patient history by patient report, which can be missing important details. Instead, in addition to the physicians' prescription, practitioners' administrative staff can request that the patient provide permission to request the physician's clinical notes.
It helps if you think about the reader when writing clinical notes. There are usually four types of readers: colleagues, physicians, auditors, and billers.
- When a colleague reviews your notes, he or she is likely thinking, "What can this note tell me that will quickly get me up to speed so I can decide how best to continue treating the patient?" The note needs to be comprehensive yet concise, and in a well-designed format so that another practitioner can easily find what he or she needs to know, such as weakness, gait issues, history of past orthotic/prosthetic devices, etc.
- When a physician reads clinical notes, he or she is thinking, "So this is what O&P clinicians focus on in their clinical notes." Every medical professional has a focused area of expertise, and your expertise needs to be obvious. What they are looking for should also be easy to find.
- Auditors are all thinking the exact same thing, "What can I find to deny payment of this claim?" This is why you need to be confident that all the required criteria are well documented.
- The O&P billing specialist is thinking, "Does this clinical note provide a comprehensive picture that I can use to justify payment for this claim? Can I overturn a denied claim and win an appeal with the documentation in the patient's chart?" Make sure they can confidently answer yes to those questions.
You can create templates to ensure you are documenting all the required criteria for coverage, with specific paragraphs dedicated to each requirement: patient history, ambulation, weakness, deformity, potential to benefit functionally from the prescribed device, previous orthotic/prosthetic management, activity levels, ADLs, patient goals, etc. Consistently use the template as the basis of your documentation, and thoroughly edit and evaluate the details you include for each claim.
As I'm sure there will be continued discussion on clinical notes for many more years, I hope this helps your process.
Erin Cammarata is president and owner of CBS Medical Billing and Consulting. She can be contacted at email@example.com.