Clinical Documentation, Coding, and Billing

ABSTRACT

Practitioners must be aware of ever-changing requirements for documentation and correct diagnostic and procedural coding for billing. These requirements are often dependent on the setting, and clinicians who practice in more than one setting have to understand multiple regulations and guidelines. Some practices are dictated by the payer, such as precertification or using a specific form (e.g., HCFA 1500) to submit the charges. Documentation of services provided encompasses evaluation reports, treatment plans, recertifications, and discharge summaries. Different forms and formats are required in different settings and by different payers. The clinician must document in a clear and concise format that can be understood by others. When documentation is completed accurately and well, reimbursement for services is more likely.

KEYWORDS

Coding - documentation - billing

REFERENCES

• 1 Paul D. Clinical Record Keeping in Speech-Language Pathology for Health Care and Third-Party Payers. Rockville, MD; American Speech-Language-Hearing Association 1994 Updated by Hasseldus A 2004
• 2 Kander M, Lusis I, White S. Medicare Handbook. Rockville, MD; American Speech-Language-Hearing Association 2004
• 3 American Speech-Language-Hearing Association .Preferred Practice Patterns for the Profession of Speech-Language Pathology. 2004 http://Available at: www.asha.org Accessed Nov 25, 2005
• 4 Centers for Medicare & Medicaid Services .Medicare Benefit Policy Manual. http://Available at: www.cms.hhs.gov/manuals. Accessed Nov 25, 2005
• 5 American Speech-Language-Hearing Association (ASHA) .http://Available at: www.asha.org Accessed Nov 25, 2005
• 6 American Speech-Language-Hearing Association (ASHA) .Code to the Highest Degree of Specificity to Avoid Denials. Asha Leader Online. http://Available at: www.asha.org Accessed Nov 25, 2005
• 7 American Medical Association .Internal Classification of Diseases. Physician ICD-9-CM 2004. Chicago, IL; American Medical Association 2003
• 8 American Medical Association .Current Procedural Terminology 2006. Chicago, IL; American Medical Association 2005
• 9 Swigert N B. The Source^® for Dysphagia Updated and Expanded. East Moline, IL; LinguiSystems 2000
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• 12 Swigert N B. The Early Intervention Kit. East Moline, IL; LinguiSystems 2004

APPENDIX A SPEECH-LANGUAGE PATHOLOGY DOCUMENTATION CHECKLIST

• Evaluation

• Identifying information (name, birth date, age, patient number)

• Date (and for some payers: time)

• Medical and communication/swallowing diagnosis and ICD-9 diagnostic code(s)

• Procedure code(s)

• Reason for referral

• Medical history related to referral

• Behavioral observations

• Clinical findings

• Hearing acuity

• Screening for other communication disorders

• Recommendations

• Frequency/Duration of treatment

• Prognosis

• Full signature with credentials

• Treatment Plan/Certification/Recertification

• Identifying information (name, birth date, age, patient number)

• Medical and communication/swallowing diagnosis and ICD-9 diagnostic code(s)

• Problem areas to be addressed

• Date treatment initiated

• Estimated amount, frequency, and duration of treatment

• Reasonable expectation to meet treatment goals

• Date of report

• Long-term goal(s)

• Short-term goals

• Treatment objectives

• Full signature with credentials

• Certification statements for Medicare:

• The Speech-Language Pathology (SLP) services are, or were, furnished while the patient was under a physician's care

• A plan for furnishing such services is, or was, established by the SLP and periodically reviewed by a physician.

• The SLP services are, or were, reasonable and necessary for the treatment of the patient.

• A line for a physician signature

• Discharge Summary

• Identifying information (name, birth date, age, patient number)

• Medical and communication/swallowing diagnosis and ICD-9 diagnostic code(s)

• Problem areas addressed

• Date treatment initiated and terminated

• Date of report

• Long-term goal(s) and summary

• Short-term goals and summary

• Treatment objectives and summary

• Summary descriptive statement

• Full signature with credentials

• Progress Notes

• Identifying information (e.g., name, birth date, patient number)

• Date of service (and for some payers: time)

• Procedure code(s)

• Subjective data

• Objective data

• Analysis of patient's performance (use comparative statements)

• Plan for next session (be specific)

• Full signature with credentials

APPENDIX B SPEECH-LANGUAGE PATHOLOGY OUTPATIENT EVALUATION

APPENDIX C SPEECH-LANGUAGE PATHOLOGY TREATMENT PLAN/CERTIFICATION

APPENDIX D SPEECH-LANGUAGE PATHOLOGY RECERTIFICATION

APPENDIX E SPEECH-LANGUAGE PROGRESS NOTES

From Swigert[9] [10] [11] [12]; reprinted with permission of LinguiSystems.

APPENDIX F SPEECH-LANGUAGE PATHOLOGY DISCHARGE SUMMARY

1 In a Comprehensive Outpatient Rehabilitation Facility or CORF, the plan must be established by the physician/NPP.