However, this POC is subject to modification as the patient progresses in therapy.ĭocumentation is read by clinicians as well as claims reviewers from varying backgrounds and experiences it is important that notes and reports are clear and legible and that they efficiently convey all the essential information that is needed for clinical management and reimbursement. Documentation principles should also be followed to accurately document the provision of elective services that may not be deemed “medically necessary” (e.g., accent modification).ĭocumentation follows a plan of care (POC) that is established after clinical assessment. Medicare outpatient therapy documentation guidelines serve as the standard for many other insurance plans. Documentation requirements vary by practice setting and by payer. Other areas of knowledge necessary for documentation include coding and billing, requirements of the federal Health Insurance Portability and Accountability Act of 1996, and other key issues addressed below.ĭocumentation Principles in Health Care Settingsĭocumentation plays a critical role in communicating the need for evaluation and treatment services (medical necessity) to payers and justifying why those services require the skill of the SLP. Unclear, vague, or absent documentation can result in denials by payers and make it difficult for the reviewer to follow the clinical judgment underlying a diagnosis and/or treatment. If state or federal requirements are more stringent than those of facilities, payers, and employment contractors, SLPs follow the state or federal requirements. State or federal agencies governing health care or licensure for speech-language pathologists (SLPs) may have specific requirements. Does the documentation clearly support a specific and effective treatment for the patient’s condition?ĪSHA does not dictate a single format or time frame for documentation because of the diversity of settings and payers.How does this service add value to the patient’s interdisciplinary care and overall health?.Are the goals and treatment functionally relevant?. Is it a service requiring the knowledge and skills of a speech-language pathologist?.Documentation should proactively answer questions that payers ask about services, such as the following: Documentation is a critical vehicle for conveying essential clinical information about each patient’s diagnosis, treatment, and outcomes and for communication between clinicians, other providers, and payers.
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