Charting Resources

Quality documentation is essential in physical therapy to highlight medical necessity and skilled care, ensure clear communication, and demonstrate patient response to treatment. Quality documentation also supports reimbursement, maintains legal and ethical standards, and reinforces professional accountability.

This resource guide outlines best practices and tips for charting at Luna, helping you maintain accurate and compliant documentation while optimizing efficiency.

For assistance with charting, please send a message to the Clinical team.

Sections:

1. Tips for Successful Auto-Charting

2. Charting Interview Questions: Initial Visits

3. Charting Interview Questions: Progress Visits

4. Charting: Goals and Assessment Tips

5. How to Discharge Your Patient's Care Plan

6. Got a Chart Rejected? Here's Why...

7. Can You Bill 4 Units in 45 Mins? Yes!

8. Ensuring Accurate Injury Types

1. Tips for Successful Auto-Charting

What is the difference between Auto Charting and Manual Charting?

• Auto Charting consists of therapists answering 5-10 targeted questions in an interview style format.
• Once a visit is started and finished, an auto-charting interview call may occur.
• Under the ‘Charts’ tab, the visits which need interview are listed. Once a visit is selected, a therapist is able to view previous charts to assist for recall.
• Manual charting is documentation through typing in all information or utilizing ‘voice to text’ to enter responses. Manual charting may be started during the visit.

Where can I find a list of interview questions to expect for Auto Charting?

• A list of Initial Visit and Progress Visit Interview Questions can be found below, and also in Lunaversity Resources in the document titled "Auto-Charting Questions." These can help prepare you for your responses to each question after every unique patient visit.

Do I have to re-speak all information or can I carry forward sections?

• Prior to starting an interview, you may select the "Carry Forward" button to enable carry forward for the "Objectives" and/or "Procedures" section. Please note, the carry forward feature can be used up to 4 consecutive visits before requiring updates.
• Clicking on arrow icon to left of “Procedures” or “Objectives” populates a text box showing what was documented for the previous visit. You may edit/add in text box before starting interview, and info will carry forward into chart.
• Therapists also have the ability to state “Carry Forward” during the interview for sections such as: Objectives, Plan, Goals, Procedures, and Diagnosis, to carry over information from the previous chart.

Do I have to choose Auto-Charting for every visit?

• No, you can choose Auto-Charting or Manual Charting for any visit. However, you can only choose one method per visit.
• Some therapists find it easier to complete an Initial and Progress Visit manually, while completing standard visits via auto-charting.

How can I best prepare for my Interview?

• Choose a quiet environment with strong reception.
• A pause of > 6 seconds will prompt the interview to proceed to the next section.
• If the call moves to a new section before you were ready, you may continue speaking on the previous section and our Charting team will organize it appropriately during the review process.
• Complete the interview as soon after the visit has ended as possible to decrease errors and increase efficiency.
• If you are unable to finish the interview, you may hang up to save progress and restart the call to pick back up where you left off.
• Prior to submission, ensure procedures and times are updated on standard visits.

2. Charting Interview Questions: Initial Visits

What are the Subjective Questions and how can I best answer?

• What is your patient’s chief complaint and pain scale at its best and at its worst?
• What is the date of onset, onset type, and mechanism of injury?
• Give a specific date, not simply “chronic.
• Describe the current and prior level of function, and the aggravating/relieving factors.
• Provide any input on social history, work history, and living situation if available.
• Where does your patient live? Stairs? With whom?

What are the Objective Questions and how can I best answer?

• Provide your insight on Posture assessment and Gait Assessment if appropriate.
• Assess gait speed, toe clearance, heel strike, assistance level, assistive device used.
• Provide Range of Motion and Strength assessment findings with any associated symptoms.
• ROM/Strength of joints above and below injury site, BILATERALLY.
• Provide details about any Neurological testing, Special test, and Functional test findings.
• Include BP, HR, and RR if indicated.
• List any details about your palpation findings.

Provide the Assessment, patient’s Rehab Potential & Barriers of Rehab.

• What is the reason for ongoing skilled medically necessary therapy?
• Explain why this patient cannot recover without your skill.
• Include cueing/assistance for any procedures required.
• Patient’s potential for meeting goals is? Specific Barriers including PMH?

Provide 3 Short Term & 3 Long Term Goals.

• Specify how many weeks/timeline to reach goals (3 weeks STG vs 8 weeks LTG).
• Ensure the goals are functional and measurable. Use PSFS or other outcome measures.
• Goals should relate to documented limitations, impairments, and function.

What is the Plan, Recommended Duration, and Frequency for your patient?

• Be specific with frequency, duration, and total number of expected visits.
• List all the treatments you plan to perform during this plan of care.

List the Procedure Codes

• Indicate Evaluation complexity (Low, Moderate, High) and time spent specifically on the evaluation portion of the visit.
• Keep in mind that at least 20 minutes should be assigned to moderate and high evaluations to justify the complexity
• List the additional CPT codes and the time spent for each procedure type.
• Provide specific exercises with sets and reps.

Lastly, what is the Diagnosis for this patient?

• Primary diagnosis should be directly related to patient’s functional deficits and their Injury Type (located under name).
• Diagnoses should be as specific as possible.
• Diagnoses should speak to the medical necessity.
• Ensure medical diagnoses are diagnosed by physician.

3. Charting Interview Questions: Progress Visits

How do I know when a patient has a Progress Visit Scheduled?

• A progress visit is scheduled every 10th visit for your patient in the Luna App.

Can I bill for a Re-evaluation on Progress Visits?

• A Re-evaluation is not billable simply because it is a standard Progress Visit. Certain parameters must be met and include, but are not limited to: a decline in status, drastic improvement, lack of response to the treatment, or significant new clinical findings. It requires a REVISED Plan of Care.

Importance of Plan

• The Progress Visit is used as a Plan of Care for Medicare and Direct Access patients. The Progress Visit is sent to doctors for signatures to continue plan of care as needed for Medicare and Direct Access compliance.
• It is imperative the therapist provides the most up to date information in the Progress Visit chart, specifically updating frequency and duration with explanation of medical necessity and justification for continued skilled care.

Progress Visit Auto-Charting Questions

• Provide SUBJECTIVE updates for your Progress visit. Include specific details on patients progress, response to treatment and ongoing complaints.
• Provide OBJECTIVE measure updates for the progress visit.
• Objective measures MUST be updated on a Progress Visit.
• State your ASSESSMENT on patient’s progress and ongoing need for skilled care
• Paint the full story here. Explain where patient began, where they are now.
• Have you closed the CLOF/PLOF gap, how?
• What can patient do better because of therapy and what can they still not do, requiring more therapy?
• Ensure to update Short term and Long term GOALS as met, partially met or not started. Add additional goals and estimated weeks to achieve the new goals if appropriate.
• Show progress with % Met or MET.
• Update your PLAN with the most accurate number of additional visits, duration and frequency for ongoing care.
• Explain what procedures have been utilized thus far and what you procedures you continue to plan to utilize for this plan of care.
• Now state the PROCEDURES codes with associated time for each code. List the specific treatments or exercises under each code.

4. Charting: Goals and Assessment Tips

Do I have to update my Assessment portion each visit?

• Yes, Assessment is required to change with each patient visit.
• “Tolerated treatment well” is not a statement which provides evidence of need for skilled PT or medical necessity and should not be the basis of ongoing assessments.

What are the CMS/APTA guidelines for writing a defensive Assessment?

• The Initial Visit Assessment should include a summary of the therapist’s analysis of the condition evaluated, clinical reasoning for treatment, and the prognosis of the patient to achieve goals.
• Daily Visit Assessment should include patient response to treatment, communication with other providers, any changes in clinical status and relevant information such as assistance levels and cueing which may support medical necessity for need of continued skilled therapy.
• The Progress Visit Assessment should include assessment of progress which ties in objective measures, barriers which might have slowed progress, and remaining impairments pointing to need for continued skilled therapy.

What are Luna’s expectations regarding Goals?

• A Luna therapist should include 2-3 Short Term and 2-3 Long Term Goals.
• Though CMS does not require STGs, it does state STGs should be included into progress notes and daily documentation. To ensure quality documentation, it is a Luna expectation that STGs are included in the evaluation, thereby making them a part of other dates of service as expected by CMS.
• Goals should be updated and documented in EVERY Progress Note.

What should be included in functional goals?

• Who? “Patient"
• What? “Will increase hip strength”
• How Much? “to 4-/5”
• Why? “to allow safe navigation of stairs within home”

What are CMS/APTA guidelines for Physical Therapy Goals?

• Pertain to the functional impairment findings of the Initial Visit
• Reflect the final level of expected functional abilities of the patient.
• Realistic and have a positive effect on everyday quality of life of a patient.
• Function-based and written in objective, measurable terms.
• Include a predicted date for completion.

5. How to Discharge Your Patient's Care Plan

Why is it important to formally discharge a patient from care?

Documenting a discharge in outpatient physical therapy is an essential part of the treatment process. It involves summarizing the patient's progress, outlining the goals achieved, and providing a comprehensive record of the care provided. Documenting a discharge is crucial for:

• Maintaining a complete treatment record
• Ensuring continuity of care
• Meeting legal and ethical requirements
• Evaluating treatment effectiveness
• Facilitating insurance reimbursement
• Contributing to research and quality improvement efforts at Luna

How do I formally discharge a patient at Luna?

• Discharge documentation can occur at any visit, provided that the SOAP note, goals, and treatment plan accurately reflect the discharge status, and there are no further scheduled visits. Using the word "discharge" within your documentation is helpful for our charting team to easily recognize a discharge note and facilitate the formal discharge process.
• The Clinical team will designate the visit as a discharge visit once these criteria are met. Upon marking the case as discharged, the patient will be provided with a progress form to gather final outcome scores. Kindly remind your patient to complete the form to help us collect data that reflects their treatment outcomes.

How do I discharge a patient if I’ve already completed my chart?

If you have already completed your chart and did not document a discharge you can utilize the Patient Dashboard feature within your therapist app to update your chart to reflect a discharge. To do this:

• Locate and choose the patient requiring discharge.
• Go to the Visit Plan and select the 'Schedule or Discharge' button.
• Select an appropriate discharge reason.
• Provide a discharge summary.
• Confirm that the patient is informed of the discharge.

Once submitted, the discharge reason and summary will be seamlessly inserted into your patient's chart, and the patient will be formally discharged from care.

Actions to Avoid

• Discharging without notification: Do not discharge a patient without clearly communicating the discharge.
• Allowing a patient to Auto-discharge: All patients auto-discharge 30 days from their last completed session if no future sessions are scheduled and no discharge is documented. Auto-discharges negatively impact your Discharge badge!

6. Got a Chart Rejected? Here’s Why…

Why are charts rejected?

• When a therapist completes a manual chart or an Auto-Charting interview in the Luna App, the chart is submitted for review. Using a technology enabled screening process, the chart is evaluated for defensible documentation.
• If insufficient information is noted or required updates are missing, it may reflect lack of medical necessity and hence the chart is rejected so that you can make edits. This chart screening process supports you to generate high quality documentation.

Where can I find the reason my chart was rejected?

• Under the Charting tab, rejected charts are found under the “Needs Edits” section with a red flag in the left corner. Click on the patient’s NAME to see the rejection reason.

What are some reasons for Initial Visit chart rejections?

• Frequency, duration, and total number of expected visits missing from the plan.
• Evaluation complexity (High, Moderate, Low) and time spent specifically on eval portion of the visit missing. Note: Mod and high complexities require 20+ minutes.
• Lack of 3 functional, measurable, and timebound Short and Long Term Goals.
• Insufficient description supporting the CPT codes and the time billed for the CPT code.
• Assessment lacking rehab potential, barriers to rehab, and skilled reasoning that indicates medical necessity for the defined plan of care.

What are some reasons for Progress Visit chart rejections?

• Objective measures not updated to demonstrate change.
• Goals not updated at the Progress Visit to demonstrate progression.
• Assessment lacks sufficient updates to demonstrate need for updated plan or ongoing visits.
• Lack of supporting documentation for billing a CPT code.

What are some reasons for Standard Visit chart rejections?

• No updates are made to Subjective & Assessment section of the chart.
• Missing billing times for the specific CPT codes.
• Misunderstanding of the SPM vs Medicare 8 minute rule and how to appropriately bill for time spent with the patient.
• Procedures missing minimum required information such as reps, sets, distance and cueing for gait, or specific soft tissue and mobilization methods for manual therapy as examples.
• Billing for less than the expected timeframe of a skilled Luna visit (45 or 55 minutes, depending on payer) without explaining patient behavior/symptoms limiting that visit.

7. Can You Bill 4 Units in 45 Mins? Yes!

What is the SPM Billing Method?

• The SPM (Substantial Portion Method) is a billing approach used by many commercial payers (e.g., Aetna, BCBS, Cigna).
• It allows you to bill one unit of a timed CPT code if 8 or more minutes were spent delivering that specific intervention.
• This method does not consider total visit time — instead, each service stands alone for billing purposes.

What is the difference between SPM Method and 8 Minute Rule?

• Federal payers, like Medicare and Medicare Advantage, require the 8 Minute Rule - even as secondary payers.
• A typical 55-minute Medicare visit with a Luna patient supports medical necessity and allows for billing 4 units under the 8 Minute Rule, which takes into account your total treatment time.
• SPM does not consider total time — instead, each CPT code can be billed if performed for at least 8 minutes.
• In a 45-minute commercial visit with a Luna patient, you can bill 4 or even 5 units appropriately using SPM.

What are some examples of using the SPM Method?

Patient was treated for 41 minutes. Following the Medicare 8 Minute Rule, 3 units can be billed based on total treatment time with patient. With SPM, each intervention code can stand alone for a total of 4 units.

Patient was treated for 48 minutes. As per Medicare 8 Minute Rule, total treatments time is less than 53 minutes, so 3 units are billable. Utilizing SPM, 25 minutes were spent on manual therapy [25 minutes -15 minutes (1 unit) = 10 minutes as remainder (10 min > 8 min) which results in the billing of 1 more unit]. Therefore, 2 units of manual therapy and 2 units of gait are appropriately billed.

8. Ensuring Accurate Injury Types

What is a Patient’s Injury Type?

• The Patient's Injury Type is the body part / region that will be the primary focus of treatment.
• The Injury Type is located under the patient’s name in the Luna app.

What are examples of Injury Types I might see?

• Neck
• Upper Back
• Lower Back
• Shoulder/Arm
• Hip
• Knee
• Knee - JR (Knee Joint Replacement)
• Hip - JR (Hip Joint Replacement)
• Ankle/Foot
• Pelvis
• Other (Gait, Balance, Weakness, Wrist/Hand)

Why is an Injury Type important?

• The Injury Type dictates what type of Outcome Measures your patient completes.
• Therapists should ensure the Injury Type is correct during the first visit, prior to charting/documentation. This will prevent a delay due to incorrect Functional Outcomes being given and decrease work for the therapist.

What should I do if the Injury Type is incorrect?

• In your app, message Clinical Charting team with the request for the Injury Type to be changed to reflect the correct body part.
• Best practice is to do this prior to charting the Initial Visit and assigning exercises so the case accurately reflects the correct Functional Outcome and the therapist’s charting efforts are unaffected.