Physical Therapy Documentation Software: 3 Key Features

Author: Adam Peacock

When it comes to clinical documentation, one of the biggest headaches for physical therapists is that every insurer requires something different. At a minimum, you’ll need to draw up SOAP notes, progress notes, and discharge summaries—but most insurers will ask for a lot more information before they process and pay your claims.

That’s why PT clinics are increasingly turning to physical therapy documentation software. Because if you’re not documenting accurately, you face major problems, such as:

  • Denied billing claims. Many clinics we speak to see at least 20% of their revenue go uncollected, mainly due to non-compliant documentation and other billing issues.  
  • Failed compliance. Without the right documentation, you’re also at risk of receiving medical necessity denials and failing clinical audits. Worst case scenario, you’ll need to repay the reimbursements you’ve received from your insurer. We know one clinic that had to pay back around $8,000 when they were using another EMR.
  • Higher costs of labor. Time-intensive documentation practices (and having to repeatedly enter data) means clinicians are working overtime, while billing teams have to continuously follow up on denied claims. 

Other PT documentation software providers will tell you how they make documentation quick, easy, and compliant. But that’s not enough for physical therapy clinics. When the stakes are so high, you want to be sure your software will get you paid. 

At StrataPT, we ensure that you get paid for >99% of what you claim, through compliant documentation you can trust. In this guide, we show you how that happens with our documentation software, StrataEMR.

What you need from physical therapy documentation software

Unfortunately, some PT practices still underestimate the urgency of having accurate clinical documentation, or are paralyzed by the complexities of CPT code combinations and ever-changing payer regulations. 

It’s true that documentation should be a straightforward and simple everyday task for clinicians—but that’s often not the case. So errors, oversights, regulatory conflicts, and incomplete documentation is common—and this has a direct impact on your bottom line. 

We built StrataEMR after seeing the day-to-day problems at the intersection of billing and documentation while working in a PT clinic. 

From our direct experience, we know three things that need to be at the center of your documentation software:

  1. It should facilitate effortless documentation for your entire clinical team.
  2. It should reassure you that your documentation is 100% compliant, so your treatment plans always get reimbursed. 
  3. It should give you full visibility into all key documentation and financial data, so you can track your performance.

It’s these three ideas that we built StrataEMR around. Keep reading to find out how it works. 

1. Documentation that’s truly effortless for clinicians and administrators

Documentation software must make a PT’s work easier. And the best physical therapy software makes sure that easy documentation contributes to better compliance rather than sacrificing it, keeping everyone on the same page. 

StrataEMR ensures compliance by providing you with guardrails and templates—so clinicians can be sure that what they’re documenting is what insurers need to process claims. 

Here’s how that’s implemented with StrataEMR: 

  • Automatically populated documentation. When you have a new patient, you’d typically copy information from their referral or intake questionnaire into your initial evaluations. Instead, with StrataEMR, you can save time and simplify the whole process by auto-populating your patient records with the information they provide. 

    This way, you’ll streamline data entry and know that you have all the info you need right in front of you.

  • Templates to ensure you’re including all the right details. Without a tool to help your administrators or billing department, someone needs to remember specific documentation rules for every patient and insurer. But this isn’t an efficient process—and it’s always prone to error.

    Alternatively, with StrataEMR, you can create templates and custom protocols up front, so you can trust that your clinical documentation fully supports your billing and satisfies payers—and medical necessity reviews will be approved.

    This is part of what we call the Billing Plan of Care, a unique feature from StrataEMR that makes sure you get paid for the treatment you provide. Think of it like a set of guardrails, to help clinicians produce clean, compliant, and correct billing that is in line with payer rules and the plan of care that has been established.

  • Workflow management tools for better collaboration. As clinicians complete the PT clinic documentation, it might need to be co-signed by a supervising therapist (or sending the plan of care to the referrer might be managed by another team member). Sometimes this causes bottlenecks or means that tasks get overlooked.

With StrataEMR’s workflow-based practice management system, you’ll reduce the risk of tasks slipping through the cracks. The software notifies your team in real-time when a previous task has been completed, and the whole flow is customizable, so it’s appropriate to your therapy practice. 

StrataEMR: Administrative and Billing Details

One of our customers, Brenton Hanes, managed to cut the documentation time for Genesis Physical Therapy down by at least 30%: 

“The EMR is simple and easy to use. The screens flow well… Very few visits are written off due to the advanced backend of keeping track of authorizations, scripts, credentialing and more. By having StrataPT help, we have freed up more space in our office so we can focus on the quality of patient care we provide to our patients. It has also freed up more time for business marketing which has helped bring in even more patients.”

By utilizing our billing platform, Genesis also increased their profits by 20%. 

2. Reassurance that what gets prescribed gets reimbursed

Most clinical documentation software will make it easier to manage plans of care. But where many platforms fall short is that they don’t always help you get paid. 

In fact, we’ve spoken to lots of PTs who aren’t being paid for even half of what they’re owed by payers. And that’s even when they’re already subscribed to medical billing software that should be supporting and chasing their claims (you can read about the downsides of different billing services in our post, Why Most Physical Therapy Billing Services Don’t Cut It.)

At StrataPT, we built an electronic medical records software that works with all of the essential clinical and compliance auditing up-front, rather than after your documentation gets submitted to insurers for approval. This way, you’re sure from the get-go that everything is documented in line with the requirements of payers.

  • The Billing Plan of Care. Often, clinicians issue a treatment or plan of care only to later find out that it can’t be billed according to a particular insurer’s rules. Unfortunately, that means you won’t be reimbursed for it.

    But this is a burden that physical therapy practices shouldn’t have to endure. With StrataEMR’s Billing Plan of Care, clinicians are alerted to any billing issues before they finalize documentation. If it’s not complete, they can’t submit it for processing.

    This way, non-compliant documentation can’t be sent through, saving further headaches down the line. 

  • Up-to-date billing codes, rules, and processes. You’ll know that CPT codes and billing rules are often changing, differing from insurer-to-insurer and from state-to-state. We do the legwork of keeping these billing processes up-to-date in your system at all times, so the only thing you need to do is get the documentation finalized. 

  • Our billing service. Even if your documentation is clean and complete, sometimes claims get denied. If that does occur, our team will chase insurers down to find out why the claim was denied so it can be updated and automatically rebilled. 

That’s part of the reason why our clients can get a >99% reimbursement rate

For example, one practice came to StrataPT after working with a billing company while using a separate documentation software. At the time, they had more than $200,000 in receivables older than 90 days—i.e. 65% of their accounts receivable (AR). Now, thanks to StrataPT, they have less than 4% of their AR older than 90 days—and we continue to pursue the outstanding amount.

Another clinic, The Therapy Place, enjoyed a 14% increase in net receivables within just 4 months of starting with StrataEMR, and the following quarter jumped 20%. “Our only regret is that we didn’t move sooner,” says Co-Owner, Chris.

3. Visibility over all documentation and financial data

Finalizing compliant documentation is one part of the puzzle. But at the same time, whether you’re running a small private practice or an enterprise-sized clinic or group, it’s important to know how your business is performing. 

For example, are some therapists seeing more compliance issues than others? How much is still in your accounts receivable? Are there more denied claims from particular insurers? 

This is all vital information for helping your clinic grow. With StrataEMR, you have all of the data you need on your documentation, compliance, billing, and more—in one place. 

  • Financial clarity. The StrataClarity Panel gives you visibility over your financial situation and how it’s affected by your documentation. You’ll see metrics including accounts receivable, average units per visit, and reimbursement averages by payer. 

    You can dig deeper to access information on every single transaction, including individual treatments, billing codes, and payments, for total clarity over the entire billing and revenue cycle management process.
Clarity Panel with StrataPT
  • Custom user permissions. You can completely customize access permissions with StrataEMR—so clinic administrators can see what they need, while directors of operations get a view over the data of every therapist in your group. 

  • Metrics on all parts of your business—not just documentation. See all critical information—on clinic marketing, referral channels, patient satisfaction, appointment scheduling, and more—all through StrataEMR. 

With all this information in the same practice management software, you can minimize silos between teams and ensure everyone has visibility on what they need.

Compliant documentation that gets you paid with StrataPT

Physical therapy documentation can be a headache. But worse, when it’s done with poor documentation software, it can even prevent you from getting paid for what you’re owed.

At StrataPT, our physical therapy EMR software offers user-friendly documentation and financial clarity. Most of all, we’re proud that we deliver a >99% reimbursement rate for claims that are made and documented through our software platform. 

Getting started with StrataEMR is a breeze. We’ll handle the migration from your existing practice management solution to our free HIPAA-compliant practice management software and run free training sessions so your team can learn how the all-in-one system works. Then, you’ll get a dedicated account manager to support and help your practice grow.

Schedule a free demo today.

StrataPT review from Next Step Rehab: "Next Step Rehab, PA, has been with StrataPT since September of 2017. Since then our revenue has increased greatly due to the fact they can send electronic claims to two of our bigger work comp clients. Billing is very smooth. Documentation has been a wonderful transition for the clinical side. The front staff loves the appointment software. Very easy to work in. We would recommend StrataPT to every clinic around."

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