Physical Therapy Billing | Future EMR – What can we expect in 2020?

Physical Therapy Billing | emrBy Yuval Lirov, PhD and Michael Walsh, PT (first published in Impact, April 2012)

Future physical therapy patient documentation systems will be faster, easier to use, cheaper, and better integrated in your entire practice. But how much faster? How much easier? How much cheaper? Are such improvements predictable and where can we look for guidance? What specific requirements can we expect patient visit documentation systems meet in the next 10 years?


What are real costs of documentation systems? Should we limit our accounting to fees we pay to vendors?

Well, if it takes you 15 minutes to document a visit and you see 100 patients a week, then you spend 1,250 hours a year documenting visits. If your reimbursement is $100 per hour, then effectively you lose $125,000 a year time you spend away from your patients or from your family documenting patient visits.

In other words, the real cost of documentation is not the fees you pay your software vendor. The real cost of documentation is the hours you waste away from your patients or from your family documenting patient visits.

If you don’t allocate those hours, you are breaking compliance rules risking your license. If you do spend hours documenting patient visits, you still risk failing post-payment insurance company audits, because some notes are missing data or violate compliance rules.

So traditional documentation systems are both ineffective and inefficient. Worse, they also slow down your practice workflow. Has anybody looked for alternatives?


Sure, vendors have experimented with alternative technologies for EMR, most notably voice recognition software. But they have limited capability because they too require long time to document a visit.

What if there was a way of documenting your visits in 15 seconds…on the iPad.

What if it took only 30 minutes to learn how to do it? Now just to be clear, by 30 minutes, I don’t mean 30 minutes of torture where you try to cram in systems manuals, different screens, and computer system menus. I don’t mean using any of the traditional ways computer system are taught in schools, universities, or private tutors.

What if there was a way to learn documentation so easily that you could start documenting your visits immediately?

Lots of providers believe learning must be a struggle, it must be difficult, it must be complicated. They fear new systems.

This is simply NOT TRUE. To understand it, let’s look again at the traditional documentation system. When you use the traditional documentation system, each time you meet the patient, you must read the notes.

As an analogy, if you look at a fighter plane cockpit, you will see hundreds of dials that the pilot must process and use to instantly make life and death decisions. What decisions could he reached on time if the pilot had to read massive volumes of data instead of his instruments?

The answer is simple: fighter pilots do not read. They KNOW what looks right so the brain only needs to register the few differences and move on.

Hundreds of millions of car drivers around the world drive their cars and continuously check their speed without having to read a single word. They do not read while driving. They know what looks right and what looks wrong.

Here is another simple example: when you look at T = 98.6, you know that it means normal human temperature. You don’t need to read one word at a time: “patient’s temperature is normal”

To put it another way, if you can’t get the patient’s health status in a single glance at the health chart, you are using a badly organized chart. Using badly organized charts is prohibitively expensive.

A better approach to documentation can be summed up in a single principle: when you know what looks right, everything else is easy. When you know what looks right, you could know the patient status by simply looking at the chart in a split second and document a visit – in 15 seconds.


A solid charting system does not start with a bunch of menus. It starts with a thorough understanding of documentation process.

Let’s start with patient’s check-in. The first step is simple: get the previous visit note. In other words, accessibility is the first key aspect of electronic notes system – you must be ALWAYS able to find your previous notes. Without accessibility to your notes, you immediately expose your practice to three kinds of risks:

  1. Legal – you automatically lose a malpractice lawsuit
  2. Post-payment audit – you automatically owe insurance money back
  3. Patient relationship management and growth – you are less likely to impress the patient with the results, losing any chance for a referral.


Your next step is to review the note. You must be able to do it on an iPad at a glance. No reading, which distracts you from intuitive thinking – just looking and seeing the status. Knowing what looks right without reading saves time. Eliminating reading frees your mind for the important tasks – communicating with the patient and doing your real job…treating the patient.

You must see all the key patient information on a single page, including care plan compliance and billing information. Also, directly from the note, you must be able to see the patient’s outstanding balance, and past and future patient’s appointments.

Now,  to document your current visit, you touch the buttons to update the previous note with current information: no writing is required because it slows you down. In a couple of touches, your new note is ready!

Your next step is to create the insurance claim and submit it. To keep from accumulating homework, you should be able to complete the claim before the patient even leaves the office.



Patient relationships must be managed. That’s really the ultimate way to improve the overall patient experience and, ultimately, grow your practice profitability. The key for managing patient relationships is being able to:

  1. identify risk situations, when the patient relationships are likely to break down, such as no shows, no future appointments, or unpaid balance
  2. establish policies handle such risks, for instance, calling the patient or sending an updated statement
  3. handle those situation in real time as you discover them and without postponing them to an undefined future.

The trouble with traditional management is the reliance on memory. It simply does not work because we are unable to recall hundreds of details that pertain to each individual situation on time. Memory reliance is ineffective for patient relationship management.

To define the correct workflow, we must first focus on the potential problem areas during the documentation process. The first opportunity for a breakdown is at the review of the SOAP note: what if the procedure requires a pre-authorization? What if the patient owes an outstanding balance? What if the patient accumulated no-shows or does not have a scheduled future appointment?

Next, your new insurance claim may contradict coding and billing rules, lack documentation, or miss a billing code for a documented treatment.

You cannot memory-manage or rely on the memory of your assistants to manage thousands of such exceptions. Your system must be able to discover and post every such exception in a separate ticket on a specially designed practice Workbench. The resulting process flow has two levels: the top level (in Blue) describes the provider’s actions, while the bottom level (in Pink) shows the exceptions discovered automatically by the system. Each such exception generates an action ticket for followup.

This Action Ticket Workbench or the Practice Workbench must be integrated into the total practice workflow, along with Scheduling and Billing, so that every member of your staff can work it as needed.



Without Accountability, there is no way to ensure that you have documented and billed for every patient visit and that you have discovered and resolved every problem along the way. The system must monitor your compliance and hold you accountable in real time. Otherwise you will be creating extra homework for yourself each time you see a patient.


You must be able to customize your notes to match your practice specifics. After all, only 10% of the notes (what we call “building blocks”) cover 90% of the visits! You also must be able to create shortcuts to further speed up your patient visit documentation.


Current documentation systems are neither effective nor efficient because they require reading, which is slow and unintuitive. The future PT documentation systems will enable note completion and billing in seconds while the patient is leaving the office. Their implementation requires four key principles: Accessibility, Integration with practice workflow, Accountability, and Customization.


Michael Walsh, PT, practices physical therapy in Dover, Delaware at Mike Walsh Physical Therapy. He can be contacted at
Dr. Yuval Lirov, CEO, Vericle, Inc., can be contacted at

Physical Therapy Practice Profitability | Real Cost of EMR

Calculate physical therapy practice profitability by discovering the real cost of documentation and EMR.

“The real problem is that even with a 20-minute SOAP note, I need a tremendous amount of time just for documentation. Peter wearily continued, “If I had 4,000 visits a year, I could make $312,000 a year. But even with the best documentation system I would need an hour to document 3 visits. That’s 1,333 hours a year just for documentation!”

“Wait a minute, Peter,” Alicia said, raising her voice. “those 1,333 hours ARE the evenings and weekends you miss with your family. When you see patients, your average revenue is $156 per hour. But when you document their visits you make zero, nada, zilch! Peter I think our mistake is that you only focus on increasing the number of patients you see. I understand you must invest time for documentation compliance. But we should find a way to reduce that unproductive time which pays you nothing.

“I do understand your rational Alicia, but the best documentation system only gets us down to 20 minutes per note. That’s still a problem. It places us in a dilemma to either spend 1,333 hours documenting or see fewer patients and lose revenue. What should we do?”

“Peter, let’s first figure out the REAL cost of your current documentation system. Alicia continued, “Let’s see if the computerized documentation system is better. Then we can think about our next step. Does it sound like a plan?” Peter relented and agreed with Alicia.

“So, if your average revenue for patient care only is $156 per hour, then that’s the best you can do. Every other activity dilutes the revenue. Now lets estimate the COST of other activities in terms of the best value you could be getting by seeing the patients. Does that make sense Peter?”

“First, let’s see how long it takes you to write an average note with your current system. An hour? So you see Peter, you are spending that time writing a note instead of seeing a patient for $158 per hour. How many notes do you write per year? 2,000? OK, then your current manual documentation system costs you $316,000 every year. Do you care to know how much that is in 10 years? Right! Three million, one hundred and sixty thousand dollars . . . That’s a very expensive compliance requirement, would you agree Peter?”

“Next, let’s estimate the documentation cost of your 20 minute notes. One 20 minute note will cost you a third of your best performance revenue, or $52. If you multiply $52 by your total annual visits, which is 2,000, that’s $104,000 in annual documentation costs. Care to extrapolate that into a decade? That would be over One Million and forty thousand dollars. That’s better than three million but still VERY expensive.”

“So, what can we do? Where can we find a documentation system that costs less?” Peter sounded discouraged as he felt his rosy plans being crushed by the cold hard facts of Alicia’s reasoning.

“Well Peter,” said Alicia, relieved that she was able to get Peter to finally think about the business side of his practice, “We must find a documentation system that does not take more than 3 to 5 minutes for a single note. Just imagine, if we had a system that took 5 minutes per note, you could do 12 notes an hour. In other words, your per note cots would be “only” $13 per note. Therefore, documentation of your entire year would cost you $26,000, or $260,000 over a decade.” chimed Alicia. “Now that’s a cost we can live with!” exclaimed Peter.

“And in terms of hours,” added Alicia, unable to hold her excitement, “you would only need 167 hours to spend on visit documentation for entire year. That’s just a tad over 3 hours extra a week! Imagine being able to work almost regular hours and still see 2,000 patients a week.”

“So, Peter,” concluded Alicia, “until we find such a system, you have to choose between your family and your practice.”

What do you think? Is Alicia right in her calculations?

Do you know of a PT-specific documentation system that could make Alicia’s and Peter’s dreams come true?