Experts from several top software manufacturers share the latest features available for physical therapy documentation solutions.

Compiled by Physical Therapy Products Staff

Technology has allowed physical therapy clinics to streamline many daily tasks, improving efficiency and allowing more time for client interaction. Documentation is no different. With this in mind, Physical Therapy Products asked manufacturers to share how updates to documentation software solutions are helping meet the changing needs of therapists and clinics.

Participating in this Q&A are Sharif Zeid, business director, MWTherapy; Marc Dinkel, demand generation manager, Net Health; Steven Presement, president, Practice Perfect EMR + Management Software; Dom Simonetta, marketing manager, TheraOffice; and Heidi Jannenga, PT, DPT, ATC, co-founder and chief clinical officer, WebPT.

What features in your company’s documentation software have the most resonance with your customers right now?

Sharif Zeid, MWTherapy: Patient portal, marketing tools, EMR customizability, and comprehensive reporting are top of mind right now for PT practices. We hear from practices every day about the importance of these three pieces. Patient portal is an extremely important part of our system because it allows the practice to save time and get the patient more involved in their care—it’s a win-win. It also reduces pressure on staff and the need to have more staff, especially when hiring is so difficult these days. Practices have a strong focus on marketing and patient acquisition, and EMR is a crucial part of those efforts. Customization is so important for the number-one desire: faster documentation. And, finally, today’s modern practice wants to flex the data they have to drive business decision-making as well as clinical outcomes. Those four things are where it’s at for 2022.

Marc Dinkel, Net Health: Our customers want faster documentation for returning patients and those seen by multiple disciplines (PT, OT, SLP). Customizable, specialized documentation workflows and templates provide highly granular documentation for PT, OT, and SLP, including niche practices such as lymphedema, vestibular, pelvic health, and pediatrics. Net Health Therapy enables a 5-minute evaluation because therapists can edit text instead of writing notes from scratch and can focus on documenting exceptions. We simplify the task of creating complete, compliant, and personalized documentation, which improves therapist satisfaction. Text shortcuts, History Import to import previous documentation into the current clinical note, and collection work-files that allow for account follow-up are very popular.

Steven Presement, Practice Perfect: Customization and access. First, our clients love the fact that they can create their own templates, or customize the templates that we have provided to tailor-make their evaluations, re-evaluations, plans of care, etc, to better reflect the services they provide and feed the specific needs of their local medical community. They are no longer having to try to shove a square peg into a round hole. Secondly, the new ability allowing clinics to provide clinical documentation to their patients, securely, through our patient portal, has been well-received as patients require and are entitled to access their own medical records. The ability for patients to upload documents directly to the clinic has also proven to be quite valuable.

Dom Simonetta, TheraOffice: Since the early years, the documentation feature that has resonated most with clients is document templates. This truly allows providers to customize the structure of the note to fit their workflow and their treatment style, not to mention save them a lot of time. More recently, our patient portal has been a customer favorite as it allows patients to fill out most of the subjective information before they set foot in the clinic for their initial visit. Additionally, practices can choose to send functional tests to be completed within the portal. Both the subjective information that the patient entered in the portal as well as the functional test score will import into the initial evaluation, saving providers time when it comes to inputting data.

Heidi Jannenga, WebPT: Most recently, WebPT has launched Digital Patient Intake and Electronic Benefit Verification to streamline the patient experience. With Digital Patient Intake, as soon as there is a new initial evaluation on the books, the patient will automatically receive an email and/or text with a user-friendly online intake form so patients can complete paperwork online. Digital Patient Intake integrates seamlessly with the WebPT EMR, so patient information flows directly into the corresponding chart. That means less time spent transcribing—and it even helps lower the risk of unintentional HIPAA violations. Plus, clinicians get a jump start on their SOAP notes, with fields like medical history, pain scales, and injury information populating automatically as soon as patients submit their forms. With Electronic Benefit Verification, staff can access all the insurance information they need online and all insurance information is automatically transferred to the patient chart, eliminating manual errors from retyping information.

How is your company’s software product helping clinics get paid for the services they provide?

Sharif Zeid, MWTherapy: We help clients get paid for their service by being an all-in-one. We delivered the first modern PT software system that encompassed the “big-3,” which includes scheduling, EMR, and billing all under one roof. By having everything under one roof, MWTherapy features checks and balances to ensure every visit’s cycle is complete from documentation, to charge-entry, to claim submission, to payment, to reporting. We combine this with code and claim scrubbing tools as well as other advanced automation features (such as KX modifier tracking) to make sure the clinics are compensated for the services they provide.

Marc Dinkel, Net Health: Net Health Therapy has a robust configurable coding and compliance engine that automatically applies optimal coding for services/payors, units, claim adjustment reason codes, accounting rules, and job scheduling—no manual entry or calculations required. This helps clinicians save time documenting and clinics ensure accurate and timely reimbursement for services provided, taking the guesswork out of billing. Tailored to meet clinics’ needs, Net Health Therapy for Clinics increases our clients’ agility, allowing them to easily manage coding and billing complexities, even for the largest providers, so no clinic must worry about outgrowing its EHR.

Steven Presement, Practice Perfect: The successful reimbursement of services starts the moment a charge is entered into Practice Perfect and doesn’t end until the money is in the bank. First, during the actual entry of the charge, flags can be set up to indicate if a specific payor does not accept a specific CPT code. Then we cross-check the timing of each charge to make sure that too few and/or too many units weren’t entered based on the appointment length. Next, we ensure that all of the appropriate information has been entered with the charge, including the ICD-10 codes. Does the charge exceed the client’s funding or authorizations? Practice Perfect indicates and tracks any funding issues as the charge hits the patient’s account. Once charges are entered, they are scrubbed once again before being submitted to the insurer and/or clearinghouse, an extra level of protection to catch potential issues before the claims go out the door. Practice Perfect also offers a strong set of Accounts Receivable tracking reports and Follow-Up triggers to make sure that claim processing and payment promises do not fall through the cracks and to instantly be reminded if a stakeholder, a payor, or a patient breaks a payment promise. Finally, when payment is made it can be processed automatically and then followed-up with reports that indicate any potential short payments that were made.

Dom Simonetta, TheraOffice: Every provider has experienced the frustrations associated with adding charges to their notes. TheraOffice’s intuitive “Suggest Charges” feature allows therapists to, with the click of a button, see what they should be billing based on what was entered in the treatment section of the note. This eliminates the manual process of selecting codes, editing units, adding modifiers, etc. Essentially, it ensures that the activities and exercises that were performed during the visit are being coded correctly to help ensure proper reimbursement. Additionally, TheraOffice allows users to add CPT and charge checks to help catch codes that may or may not be billable based on the patient’s insurance. Both of these features instill confidence in our providers that they are billing accurately and, in turn, will be paid appropriately for their services.

Heidi Jannenga, WebPT: WebPT’s billing software empowers providers to fully own and optimize each clinic’s billing—from selecting the right codes and modifiers to leveraging customized reports to identifying billing gaps and trends. Clinics can even offload billing entirely with WebPT’s RCM service. WebPT’s team of regionally specialized billing experts is constantly working claims, following up with payors, and fighting to ensure providers receive every dollar they deserve. With WebPT, providers can be sure they are creating defensible documentation that supports billing practices and protects clinics in the case of an audit or appeal. And because everything lives on one platform, members can see charges out and payments in with no double data entry or hand-keyed reporting. WebPT also offers tools to help providers assert their value as healthcare providers. WebPT Outcomes allows therapists to objectively prove outcomes to third-party payors and, thus, effectively negotiate for higher reimbursement rates and better contracts.

What percentage of your clients choose to customize their own templates? What are they typically trying to achieve through customization?

Sharif Zeid, MWTherapy: Virtually 100% of clients seek to customize their templates. The goal is to make it fast, make it easy, make it compliant, and to come up with a professional final note that can help get more patients from referrers. With MWTherapy, clinics can customize as much and as often as they like so templates are never static or stale. Changes can be made to accommodate new clinical techniques, a new referrer’s request, new protocols, or other clinical initiatives.

Marc Dinkel, Net Health: All clients can easily create their own documentation templates based on actual documentation in order to save time and improve accuracy. Net Health Therapy allows our customers to create user preferences based on diagnoses, and ensures documentation is complete and compliant with payor rules/regulatory requirements.

Steven Presement, Practice Perfect: The number of clinics that make use of customization is a harder one for us to gauge since Practice Perfect is completely self-service; the clinic doesn’t require us to do their customization. So, as a result, we don’t necessarily know how many clinics make use of this feature. Based on the number of inquiries that we receive from our existing clinics, we can certainly tell that the number is on the rise and growing dramatically. Customization is usually employed by a provider to better reflect their own twist or take on clinical documentation, to highlight something key, to better “speak the language” of their local physicians, or perhaps reflect on something unique that they offer or in which they specialize, and to make their documents stand apart from the cookie-cutter documents that currently proliferate the scene.

Dom Simonetta, TheraOffice: I can confidently say that 98% of our documentation users spend time creating their own templates. During the onboarding phase, our implementation specialists make it very clear that the more time and effort providers pour into developing custom templates, the less time and effort it will take to complete a note when the patient is sitting in front of them. Templates are all about saving time and avoiding retyping the same information note after note. This is especially helpful if a therapist specializes in treating patients with a certain injury or condition, as it allows them to have the skeleton of the note complete before the patient even arrives at the clinic.

Heidi Jannenga, WebPT: Rehab therapy has many subspecialties which require their own protocols, tests, and documentation fields. Members can easily and dynamically add note content using pre-built templates geared toward rehab therapy and various subspecialties. They can even add multiple problems, goals, and planned procedures with one click. This—coupled with the fact that WebPT is lightning-fast and user-friendly—makes documentation a breeze.

What changes has your company made to its documentation software solutions to meet the needs and requests of physical therapists, such as for the Merit-Based Incentive Payment System (MIPS) for Medicare Part B providers?

Sharif Zeid, MWTherapy: MWTherapy is constantly evolving to help practices meet new challenges and capitalize on new opportunities. At the heart of our system is the feedback that we receive from PTs. In recent years, we’ve added a large number of new features including things like personalized, customized new modules, advanced copying tools, and more. We’ve also been making continuous updates to our user interface without increasing clutter and other time-wasting elements. Responding to PT feedback is really important to us as a company.

Marc Dinkel, Net Health: We have made several beneficial changes to Net Health Therapy. Automated application of modifiers—KX, 59, and Assistant for both single and cross discipline—reduces claim denials for missing modifiers and eliminates the manual documentation requirement on clinicians. The required/recommended sentences tool has been added to help clinicians document the necessary numerator value for MIPS measures by identifying patient encounters that meet the criteria for a measure’s denominator. We’ve also created interoperability with QCDRs. Enhancements have been made throughout the application to provide clinicians with the following benefits: reduced clicks, improved user experience, modern look and feel, streamlined workflows, improved documentation speed and accuracy, and ensuring compliance.

Steven Presement, Practice Perfect: Certainly the addition of the document exchange on the patient portal has been a more recent and crucial change to our documentation system along with the refinement on the MIPS reporting system and our association with a MIPS registry, Patient 360, to seamlessly enable MIPS reporting directly from Practice Perfect with literally a few clicks of a button. Clinicians are prompted to enter the G-Code MIPS scores at the prescribed intervals within Practice Perfect, leaving nothing to chance, and then those scores are submitted directly to the registry at whatever interval they select without any double entry or extra steps whatsoever.

Dom Simonetta, TheraOffice: Here at TheraOffice, we pride ourselves on listening to customer requests and responding to industry trends in a way that allows therapists to remain compliant and effective with their treatments. When MIPS was first implemented in 2019, we built in a MIPS Wizard that allows clinics to set up their database depending on if and how they are participating in the program. Since 2019, we have changed MIPS reporting measures based on rule changes. Perhaps one of the most coveted features in relation to MIPS is the ability to choose whether or not providers should receive a hard stop if measures were missed or skipped during an evaluation. If the hard stop is enabled, therapists cannot lock a note until all MIPS measures are satisfied. This greatly increases the chances of providers filling out notes correctly and not missing measures that could potentially hurt their score. Over the years, outside of MIPS, we have also developed handy features such as the document history tool, treatment progressions, and the ability to send information from any grid box to the goals section in the plan of care. We are also very excited for our new plan of care tracking tool, which was requested by so many, coming in our next update.

Heidi Jannenga, WebPT: MIPS and other Medicare compliance requirements have grown increasingly complex. With WebPT there’s no need to remember every single Medicare requirement, because the software remembers it for you. From therapy threshold-tracking and in-note functional limitation reporting to 8-minute rule calculations and built-in NCCI edits, WebPT has simple, user-friendly solutions for every Medicare regulation that applies to outpatient PTs, OTs, and SLPs. WebPT offers registry-based MIPS reporting for both individuals and groups along with providing comprehensive education around the pros and cons of MIPS participation. PTP

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