Physical Therapy Documentation – Protecting Oneself From Medicare Fraud

The incidence of Medicare fraud has been steadily rising over the years.  Some mistakes are purely clerical while others are with intent.  When it comes to physical therapy documentation or for any other medical needs, it needs to be complete and accurate. Protecting oneself and one’s practice should always be a priority for any medical professional.

There are some do’s when it comes to protecting yourself from fraud through careful physical therapy documentation.

Submit claims that are accurate and using the right codes.  Accurate physical therapy documentation is a must as it protects the provider from possible liability or fraud troubles.  It also ensure the highest level of quality of care leading to the safety of the patient.

The office of the Inspector General is responsible for auditing and evaluating incorrect medical billing and coding.  They will check the physical therapy documentation with regard to upcoding, unbundling, medical necessity of procedures or treatment, validity of all services billed and any duplicate billing.

Simple typos or misses are not valid excuse for any physical therapy documentation mistakes.  Good documentation protects the health of the patient, ensures that they get the best possible care, prevents any duplication and prevents any unnecessary treatment.

Diligence when doing physical therapy documentation needs to be done since healthcare delivery is getting more complex.  There are instances wherein a patient is going to different medical professionals and any information missing might lead to a wrong diagnosis.  A complete medical record has to be accessible to all medical practitioners who are treating the patient.

Physical therapy documentation needs to be accurate, complete and legible.  Providers need not rely on memory if all information are written down. This is essential in making clinical decisions regarding the patient’s treatment plan.

Accurate physical therapy documentation offers protection to providers.  When reviewing claims, the Inspector General will verify if treatment are indeed done.  If a service performed was not documented, then if follows that it was not done.  Claim can be easily denied due to this reason.

Also they will check for the rationale on performing a particular diagnostic test.  This can help in establishing a medical necessity.  Also, the physical therapy documentation should be clear on the test outcomes as it can help in supporting the need for any subsequent care at a later date.

Accurate documentation is vital to a patient’s medical records.  It is beneficial not only to the patient but also to the physical therapy business in terms of protecting one’s self from any possible legal issues from Medicare or dissatisfied patients.


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