Quick Reads

Accurate clinical documentation is business-critical, ensuring your clients get the proper care at the right time and that you are CMS guidelines complaint. Unfortunately, because of gaps in modern documentation, lapses in treatment for behavioral disorders often go undiscovered until after a client leaves. These lapses risk malpractice claims since failure to identify and remedy poor care while the client is present for services weakens your ability to amend it.

When clients pay through Insurance as a funding source, insurance Payers scrutinize each therapy session. Weak documentation can lead Payers to deny coverage for the entirety of a client’s Therapy. Precise documentation reduces denials by keeping an accurate and ordered record of medical needs and treatment before submission for payment.

Here are some best practices that will help you improve your clinical documentation for applied behavioral analysis (ABA).

Recognize Clinical Documentation Missteps

While documentation standards have improved in many areas, some pieces of information consistently receive less attention than needed. Here are some areas often overlooked by clinicians.

• Necessity: With insurance payments, Payers are thorough in their medical necessity review. As such, documents must show the therapist’s judgment and logical plan in describing treatment protocols. ‍
• Critical care elements: Once you have established necessity, accurately label every treatment under the needed category.
• ‍Progress report: Keep records of a client’s progress over time. Also, detail the evaluation method used to make assessments.
• ‍Consent: Informed consent from the parent or guardian is integral to achieving reimbursement. These forms are necessary for TeleABA therapy in more traditional settings like Clinic, In-Home, or School.

Perform Internal Audits

External audits, especially from Payers, can cause significant financial and legal repercussions for an ABA practice. To prevent this, an ABA organization should have routine internal audits. Let your therapist team know when these audits will occur. Explain the standards you will be using to review the clinical documentation and achieve them. If your unit fails an audit, construct a plan to reach your goals by a set date. Then, once they consistently meet your standards, perform random audits throughout the year.

Increase Automation

Robust automated systems such as electronic health records (EHRs) are integral to ABA clinical documentation. In addition, these systems give cloud access to clinical records from other locations reducing the amount of repetitive paperwork.

Ambient computing is a type of artificial intelligence programmed to comprehend and fulfill human needs. An example of this is ambient clinical intelligence (ACI), developed by Nuance and Microsoft. This software can observe a clinician and client interaction, parse out the relevant information and automatically enter it into the EHR. 

Programs like this ACI are crucial to the future. A 2019 study shows physicians claim 40% of burnout from EHRs. According to Nuance’s website, physicians report the program reduced burnout by 70%. While still impractical for most small to mid-sized practices, modern ambient computing is a leap toward increasing efficiency and reducing clinician fatigue.

Improve Training

Automation is the future of clinical documentation. However, these systems currently can only function with human accompaniment. Also, technology is only an enabler for the clinician and can never be our replacement.

Plutus Health works with you to streamline medical billing and provide inputs on better clinical documentation. If you are struggling with billing, collection, and denials management, our expert team takes care to get faster and the best reimbursement possible and increase your practice’s performance.

Key Takeaways

1.     Importance of clinical documentation and impacts of External Audits

2.     Learn crucial areas of information that can prevent denials.

3.     Schedule routine internal audits.

4.     Adopt modern technology to reduce clinician stress and increase efficiency.

5.     Ensure your staff learns and adapts to modern standards of practice.