Documentation and Payment in Physical Therapy

These flashcards cover key concepts regarding documentation procedures and payment processes in physical therapy, essential for effective practice and understanding of reimbursement.

Assessment

The section of a note where the therapist summarizes the patient's response to interventions and how they are progressing toward established goals.

Goal Achievement

Documenting whether the patient has met specific treatment goals and providing details about the current status in relation to those goals.

Third Party Reimbursement

Payment made to healthcare providers by an entity other than the patient, such as an insurance company.

Reimbursement

Payment by the patient or their insurer to the healthcare provider for services rendered.

Medicare

A federal insurance program primarily for individuals aged 65 and older, as well as some younger individuals with disabilities.

Documentation

The act of recording the details of patient care and treatment, which is crucial for reimbursement and clinical communication.

Frequency and Duration

The schedule and length of physical therapy sessions intended for patient treatment.

CPT Code

Current Procedural Terminology codes used for billing medical procedures and services.

Objective Data

Quantifiable information presented in a therapy note, such as measurements of pain, range of motion, and other functional abilities.

Plan

The section of a therapy note where future actions for patient care are outlined, including goals for upcoming sessions.

Patient Driven Payment Model (PDPM)

The payment system used for skilled nursing facilities that determines rates based on patient characteristics and needs.

Advance Beneficiary Notice (ABN)

A document a provider gives to a Medicare patient to inform them that a service may not be covered by Medicare.

Medicaid

A program providing health coverage to eligible low-income individuals and families, funded jointly by state and federal governments.

Insurance Authorization

Approval from an insurance company required for coverage of specific treatments or services.

Patient Reported Outcome Measures (PROMs)

Clinical tools used to assess the effectiveness of treatment through the patient's perspective.

Subjective Data

Information collected from the patient about their condition, symptoms, and experiences regarding treatment.

Plan of Care

A detailed plan outlining the treatment goals and methods for a patient, including frequency and modalities to be used.

Subjective

• Pain

• Consent to treat

and

• How pt. arrived to clinic

or

• HWP compliance

objective

everything in treatment

Assessment

• Reaction to/ tolerated treatment

• Have met goals or not

• Any progress towards goals or lack of

• MENTION THE GOALS ALWAYS

SPTA

goes after your signature

pain

is subjective unless it is a questionnaire.

Assessment

where pain goes if you ask for it after treatment

Subjective

more quantitative than qualitative

subjective 

comes from 

• patient

• family member 

• caregiver (nurse, tech, etc.)

Subjective

The nurse clears the pt. for therapy. What kind of statement is this?

subjective

The nurse suggests that you should only do bed exercises with pt. What statement is this?

Subjective

The pt. says they have been compliant with HEP. A family member says the pt. has not meant compliant with HEP. What statement is this?

Subjective

You write “The pt. required encouragement to participate in therapy.” What section of the SOAP note would this be in

Subjective

If you document that the pt.’s family has requested PT on behalf pt. What kind of statement is this?

Subjective

A NEW complaint, issue , or pertinent info the pt./caregiver/ family member tells you would go in what section?

Subjective

Pt. status (pt. fully dressed and sitting up right, pt. presented to clinic ambulating with rolling walker)

subjective

pt. reaction to previous interventions (“i was sore for two hours after the last session”)

subjective

pt. perception of symptoms (pt. says they feel better today)

subjective

pt. emotional, cognitive status (Pt. believes the year is 1942 and told the PTA to “f***k off.”)

subjective

A new goal the pt. wants to achieve (Pt. wants to play golf)

subjective

something the pt. wants to do, like a new goal. 99.9% of the time, you are already working on being able to achieve this anyway.

subjective

provide who gave you the info for this section (pt., family member, caregiver, ect.)

quotes

used when reporting pt.’s cognitive, emotional status or attitude towards therapy

physical therapy, physical therapists assistant 

Are NOT proper nouns. DO NOT capitalize.

objective

anything you do or observe as a FACT

objective

saying a wound is clean and dry

objective

educating the pt. or their family

objective

“pt. was educated on smoking cesation.”

objective

make info easy to find in this section (data points)