Legal and Ethical Considerations in Documentation

APTA Code of Ethics - 8 Principles

1. PTs shall respect the inherent dignity and rights of all individuals

2. PTs should be trustworthy and compassionate in addressing needs of clients

3. Pts shall be accountable for making professional judgments

4. PTs shall demonstrate integrity in their relationships with everyone

5. PTs shall fulfill their legal and professional (ethical) obligations

6. PTs shall enhance their expertise through lifelong acquisition and refinement of knowledge

7. PTs shall promote organizational behaviors and business practices

8. PTs shall participate in efforts to meet the health needs of people

APTA Core Values

Accountability

Altruism

Compassion/Caring

Excellence

Integrity

Professional Duty

Social Responsibility

Accountability

Active accpetance of responsibility of diverse roles & obligations

Altruism

Placing patient needs ahead of your own

Compassion/Caring

Being empathetic to another experience

Excellence

Understand personal limits, use sound judgement, clinical reasoning

Integrity

Be truthful and fair & adhere to ethical principles

Professional Duty

Commit to meet obligations and provide effective PT services

Social Responsibility

Promote mutual trust

Legal Considerations

State/Feds delegate authority to healthcare agencies to regulate professionals, practices, and enforce laws due to expertise required

- medicare, JCAHO

Michigan Public Health Code

Records must be maintained for 7 years

A Patient is entitled to inspect/recieve a copy of their medical record upon request

Michigan Public Health Code Sec 17824

pt w/ Rx

- Refer pt back to HCP who issued prescription for treatment if out of scope

- Consult w/ HCP who issued the prescription if they don't respond reasonably to treatment

pt w/o Rx

- Refer pt to ANY appropriate HCP for treatment if out of scope

- Consult w/ APPROPRIATE HCP if pt. don't respond reasonably to treatment

Act 268 of Michigan Public Health Code

PT may engage in treatment of pt w/o Rx

- for 21 days or 10 treatments OR if pt is seeking PT for purpose of preventing injury or promoting fitness

Payer Considerations

Improper coding and billing can result in audits, fines, or revocation of credentials

- Federal = Medicare/Caid

- Private = Aetna, BCBS

- not proving billed services, not medically necessary, billing for tech or aids, PTA w/o supervision

All documentation must support billing

PT supervision of PTAs

NO more than 4 PTAs per PT

NO more than 3 aids, techs, or ATs under PT

Total = 7 people max

Direct Supervision

In building or available by phone for consulting

Chart Audits

large part of process for authorization of care

Top 10 Payer Complaints about Documentation

Poor legibility

Incomplete Documentation

No documentation for DOS

Too many or confusing abbreviations

Documentation doesn't support billing

Does not demonstrate skilled care

Does not support medical necessity

Does not demonstrate progress

Repetitive daily notes, no change in pt status

Interventions w/o time clarification

97110 CPT code

therapeutic exercise

97112 CPT code

Neuromuscular re-education

97140 CPT code

manual therapy

97530 CPT code

therapeutic activities

97535 CPT code

Self-care/Home Management Timing

How much $ was wasted on unnecessary services in 2009?

$750 BILLION (Now = 760-935 BILL)

- on excessive administrative coasts, fraud etc

Fraud

Intentional deception or misrepresentation that a person makes to gain benefit to which they are not entitled

- Falsify, bill for services not provided

Abuse

Payment for services or items the provider is not entired to (medically unnecessary) and for which the provider has NOT intentionally misrepresented facts

Waste

Incurring unnecessary costs b/c of deficient management practices

Misuse or overuse of resources

Providing more expensive services that don't produce better outcomes

- Duplicating services provided elsewhere

Ethical Conduct

Individual = honest about units, minutes, document why/why not billing a certain way (late/ leaving early)

Organizational = pressure to do modalities on all pts, productivity

Societal = biases, sterotypes

Quality Assurance in Documentation

Conducting in-house quality assurance measures can help reduce legal-, professional-, or payer-based ramifications associated w/ poor documentation or unethical practices

Tips for Chart Audits

The record must demonstrate

- pt was good candidate for PT

- Condition warranting PT is documented

- POC is appropriate

- ALL interventions are clearly detailed

- Records clearly document patient progress

- Services are:

- Based on MR

- Able to yield positive outcomes

- Performed w/ appropriate frequency

- Ordered by physician

- Concluded at the appropriate time