Defensible Documentation:

The healthcare landscape is ever changing, and the last 2 years have been no exception. Therapists are now, more than ever, responsible for justifying our necessity in the care of our patients. We know that we are necessary, but often have a difficult time communicating that outside of our immediate circle of influence. In this course, we will discuss defensible documentation, something that most therapists consider a necessary evil, but is absolutely essential to justification of our role in the healthcare team and to reimbursement. We will explore the reasons we document, the mandatory components of documentation, the inevitable pitfalls to successful documentation, and ways to ensure defensible documentation. As we move forward in a healthcare system that is ever evolving, our efforts to shape the landscape around us begin with our ability to document effectively. In the state of Tennessee in February, 2020, a provider of skilled nursing services entered an agreement to repay $9.5 million of Medicare funds because their services were determined to be unreasonable, unnecessary and unskilled. As a business owner who bills Medicare and other commercial payors, this frightens and saddens me. As a therapist, I know that what I am doing is reasonable, necessary and skilled, but I must be able to communicate that to others. Documentation is our main means of communicating!