It’s still January!  It’s still appropriate to talk about setting goals.  As a therapist, when I hear the phrase “set goals” my eyeballs immediately roll back in my head.  Let’s not talk about *those* types of goals.

Let’s talk about personal and/or small business goals.  I prefer to think of it as a vision for where you want to end up.  It’s so much easier to visualize yourself doing the things you love to do a year from now than it is to sit down and write a goal.   I recently read an inspiring article from David Stowell’s  Business tip of the Week for Private Practice Owners, “ The Two Secret Things You MUST Do After You’ve Set Your Goals for 2014”

He shared some cool statics on goals collected through a research study conducted by Dave Kohl, a professor emeritus at Virginia Tech:

•  80 percent of Americans say they don’t have goals
•  Another 16 percent do have goals but they don’t write them down
•  Less than 4 percent write down their goals
•  Less than 1 percent who have goals review them regularly

Obviously the folks in the last group are more successful at meeting their goals and not surprisingly they make significantly more money in their lifetimes than those who don’t have goals (nine times more money according to David Stowell.)

Okay, so you see yourself doing the things you love to do a year from now and you write down on paper what those things are.  You’ve got your goals.  So What?

According to Stowell you also have to have a plan to accomplish your goals.  These are the two secret things you must to for success:                                                                                                                                                                                                                       1) Create an Action Plan

2) Put those Action Items on your Calendar with a fixed date.

Now all therapists know how to break a long term goal (your vision) into shorter goals that can be accomplished in a few weeks (your action plan), and we all know how fixing a date to a goal works out…  The date will be a bit off.  Don’t worry about that detail.  Hold on to your vision and execute your plan.

I once heard a quote, “Vision without planning is daydreaming. Planning without vision is drudgery.”  Best of luck with your Vision for this year and your plan to get there!

We all have to write daily notes.  A few find this task enjoyable, most do not.  So what is the purpose of the daily note and what needs to be included in our notes for reimbursement for services?  There are many reasons we write daily notes. We write notes for record keeping, to objectively track progress, for interdisciplinary communication, for reimbursement; really, for a variety of reasons based on any combination of factors.  While reimbursement is only one of them, it is an important one.  For the most part, if you have satisfied the requirements for reimbursement, then your documentation is likely sufficient for everything else.

When submitting daily notes for reimbursement, whether it is within a medical setting or when submitting to Medicaid for a student, the notes go to a billing clerk who may or may not know about therapy.  They do, however, have a list of rules about the criteria for paying for services.  If your documentation has been requested, this clerk is looking to see that you have followed the rules for billing reimbursement.

According to the Medicare Benefit Policy transmittal 52, June 30^th,2006 these are the requirements for daily note documentation:

“Documentation is required for every treatment day, and every therapy service. The Treatment Encounter Note must record the name of the treatment, intervention, or activity provided, the time spent in services represented by timed codes, the total treatment time (including the untimed code services) and the identity of the individual providing the intervention. The format may vary depending on the therapist and the clinical setting.”

“Documentation of each treatment encounter will include the following required elements:

• Date of treatment;

• Total timed code treatment minutes and total treatment time. The amount of time for each specific intervention/modality(activity) provided to the patient is not required, as it is indicated in the billing, but the billing and the total timed code treatment minutes must be consistent. Identification of each specific intervention/modality provided and billed, for both timed and untimed codes. Frequency and intensity of treatment and other details may be included in the plan of care and need not be repeated in the treatment encounter notes unless they are changed from the plan; and

• Signature and professional identification of the qualified professional who furnished or supervised and list of each person who contributed to treatment during that encounter (i.e., the signature of Kathleen Smith, LPT, supervisor, with notation of the assistance of Judy Jones, PTA, when permitted by state and local law).“

Daily notes are therapist’s way of recording each encounter with an individual and demonstrating that skilled intervention took place.  The notes must demonstrate quantifiable progress toward a functional skill.    You are not required to have an elaborate assessment, detailed plan, or detailed inventory of the non-billable services that you provided in your daily notes.  These things are just a bonus!

If you decide to add or change a goal in between progress reporting periods, you need to include a statement of why you did that.  For example, the original plan was for speech sound production, expressive language production, and problem solving.  The individual is having difficulty identifying problems. So, you decide to add a goal for identification of non-verbal communication of facial expressions to address recognition of when a social problem is occurring.  Another example might be that the articulation goal has been met and you are advancing to a higher level of linquistic complexity.  Your justification can be a short statement as long as it is clear why the change is needed.

The following things are optional for daily notes, although it is good to include them as they happen for our colleagues benefit, and they need to be in the progress summary if they are not in the daily notes.  I like to report them as they happen in my daily notes:

• Patient self-report;
• Adverse reaction to intervention;
• Communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist, etc.)
• Significant, unusual or unexpected changes in clinical status;

If you include the requirements for a Progress Summary in your daily note, you do not need to create an additional document.  These are the requirements for a Progress Summary that you can also include in your daily note:

• Must provide Justification for Medical Necessity
• Must provide objective measurable data
• Assessment of progress toward each goal
• References to modifications to approach or plan of treatment if appropriate
• Current levels for goals (including prior level and target level of function)
• Goals need to be numbered or lettered so that they are easily identifiable from one report to the next.
• Completed long term goals can be deleted.
• Short term goals can be added, deleted, or changed as needed.

*The clinician (not an assistant) must provide treatment at least once every 10 days and sign the progress report, unless there is an unexpected discharge.

If a time interval for the treatment is not specifically stated, it is assumed that the goals refer to the plan of care active for the current interval of treatment. If a body part is not specifically noted, it is assumed the treatment is consistent with the evaluation and plan of care.

You can use JOTx therapy to document your progress summary every session if you include numbered goals containing prior level of function, target level of function and current level of function (this will copy into your plan automatically if you have entered them once) and add detail to your assessment section regarding medical necessity of services, progress toward each goal, and justification for modifications to your approach if you have done that.  I include the session number on all my notes as well, but apparently this is not required.

In general, state Medicaid services and local insurance carriers also adopt the Medicare rules, although it is always best to check your own state requirements.

Writing a concise, yet complete daily note can be a challenge for even the most seasoned therapist.  It can be beneficial to review the requirements from time to time as a reminder and to stay on top of the latest changes.

Happy Documenting!

We seem to be inundated with information and discussions about the new HIPAA regulations and Final Rule. It’s being talked about on listservs and forums, in therapy clinics, and there were even courses about HIPAA compliance at the ASHA convention. Despite all the information and chatter I have found myself a little overwhelmed and wondering if I’m truly complying with all aspects of the law within my practice. I’m confident that as SLPs we’re following general confidentiality and client privacy rules. But, am I following all the rules that are applicable for my business? Is my practice ready if I were to be audited?

These are the questions that inspired me to research further. And what did I find? Well, I was excited to find that resources are plentiful! And many are truly terrific. Not only are there resources that are user-friendly but structured and descriptive as well.

The first go to location is the US Department of Health and Human Services website. In addition to having the lengthy (yet somewhat overwhelming legal documents for HIPAA laws) there are also many summaries of the law and links to additional resources and trainings. Perhaps the most useful resource for questions about getting my private practice in compliance was the HIPAA Security Series. These are a series of 7 documents that educate about various areas of the security rules from the basic standards to risk analysis and assessment. The 7th installment of the series is titled “Implementation for the Small Provider” (http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/smallprovider.pdf). Can you imagine how excited I was when I found this resource?!

According to the HIPAA Security Series to be in compliance private practices should:

1) Complete a Risk Analysis and Assessment: This step requires a thorough analysis and assessment of where confidential PHI (protected health information) is located in the business, who has access to it and how it’s managed. This includes paper files and electronic files. Security procedures then need to be implemented to reduce the risk of the PHI being accessed inappropriately. Some examples are noting that PHI is kept in locked file cabinets and the key is only accessible by those employees working directly with the client for treatment, insurance or billing purposes. Another is that electronic PHI is used in the form of treatment notes and billing done via a password protected computer and/or iPad with data encryption software. Each employee has their own password.

2) Implement Workforce Security and Employee Policies: The business needs to have a plan for who will supervise employee compliance with security measures regarding PHI. There must also be policies and procedures in place for sanctions if an employee fails to comply. An example might be that the policy is for the office manager to supervisor all HIPAA/PHI compliance and that each employee has their own password for the computer system. If an employee was found to leave his/her password written on the workstation then the employee will receive a written notice of noncompliance with the security measures. If done more than once suspension or further penalties could result.

3) Implement Security Awareness and Training: There needs to be a training program in place for all employees in regards to not only HIPAA rules but also the specific security measures that are in place for the clinic/business. An example could be annual HIPAA training for all employees in addition to an annual review of the facility handbook regarding confidentiality measures such as password protection.

4) Implement Facility Controls: Policies and procedures need to be implemented to safeguard and limit physical access to files (paper and electronic) at the facility. This could be policies and procedures about use of locked doors, security system, and security cables on the computer. There should also be maintenance policies and records to specify how repairs to the building/facility (such as hardware, door locks, etc) are completed in order to document protecting of PHI.

In addition to these items I found that a private practice should have policies and procedures surrounding PHI protections at workstations (ie. privacy screens, automatic log-off controls), disposal of hardware and electronic devices to b sure PHI is eliminated, and policies for back-up of PHI data.

5) Contracts for Business Associates: All outside entities and vendors that work with you and your clients that have access to PHI need to have a signed agreement in place. Sample business associate agreements are available at http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/contractprov.html

As overwhelming as this can be upon first glance it seems the HIPAA requirements are quite common sense. They seem to be practices that are for the most part already occurring in the clinic. It appears that it goes back to the age old saying of “if it wasn’t documented it didn’t happen”. It appears we just need to be sure to write down (as policies and procedures) all the routine rules and practices that we use in the day-to-day operations of our clinic.

Additional Resources for HIPAA regulations and trainings:

http://www.asha.org/Publications/leader/2013/130401/Policy-Analysis–New-Patient-Privacy-Rules-Take-Effect/
http://www.asha.org/eweb/OLSDynamicPage.aspx?title=HIPAA:%20Protect%20Your%20Clients%20and%20Yourself%20(On%20Demand%20Webinar)&webcode=olsdetails
http://www.hhs.gov/ocr/privacy/hipaa/understanding/training/
http://www.asha.org/practice/reimbursement/hipaa/
http://myhipaatraining.com/courses.html
http://www.hipaatraining.com/hipaa-training-for-healthcare-providers.aspx

Just what we needed! Four more codes to keep track of! Actually if you are using JOTx, we keep track of them for you. Starting in January 2014, the following codes will replace 92506 speech language voice evaluation for the US therapists:

· 92521 Evaluation of speech fluency (e.g., stuttering, cluttering)
· 92522 Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria);
· 92523 Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language)
· 92524 Behavioral and qualitative analysis of voice and resonance

Interestingly there isn’t a code for just language evaluation. The assumption is that most of the time a language evaluation is performed in conjunction with evaluation of speech. If you perform a language evaluation without assessing speech sound production, you should add the 52 modifier to code 92523 when submitting the billing. That means that you will be paid less for that service. If you don’t like the idea of being paid less, then plan ahead. Include assessment of speech in your evaluation documentation.

If you bill Medicare, these new codes are also subject to the therapy cap and MPPR.

Another consideration with these new codes is that when you get a doctor order for therapy, the type of evaluation that you are performing should be specified. Some insurance companies might go for the global order for speech therapy to evaluate and treat as needed. A phone call to clarify the preferences of the insurance providers you work with is the best way to stay compliant with policies. If you don’t feel you have time for that, the next safest thing to do is check with the Medicare guidelines. They tend to be the most stringent and other insurance companies tend to follow the trends that they set.

It was such a pleasure to attend the ASHA convention in Chicago this year! Hearing Ben and Jerry speak at the opening session was a treat! What personalities! I like people with high entertainment value. They obviously know how to have a good time yet still take care of business. I would have loved the opportunity to hang out with them for a while. Their opening comments underscored the necessity of teamwork. The science of ice cream making and of course selling it, service delivery.

Those two friends are obviously very different people. Complimentary of each other, and still I’m sure they had their disputes. Their words of wisdom for us, “Subjugate your ego.” You have to know your strengths and weaknesses. Assemble a team that rounds out your weakness.

As a small business owner, I appreciate how challenging it can be to do those things. You want a good reputation for your business. You may even be aware of your strengths and weaknesses. Finding people that you trust to either work for you or collaborate with can take time. I often turn to my ASHA colleagues for wisdom when making these decisions.

Here are some great ways to network:
-have a network of local therapists and meet regularly.
-stay connected through professional organizations like the American Academy of Private Practice in Speech Language Pathology and Audiology
-love the ASHA special interest list serves! They connect a network of brilliant and experienced SLPs who are happy to share their knowledge.
-Give back to your community. Local volunteer opportunities and charitable donations are an excellent way to connect with other professionals in the area.