It’s easy to get into a documentation rut as a PT or an OT, billing the same codes for therapeutic exercise or manual therapy over and over again. But you might be selling short the skilled treatment you provide as a licensed therapist. You can and should use higher reimbursed CPT codes such as Therapeutic Activity, CPT code 97530.
Writing better documentation — the kind that reflects your skills — may take a little bit of practice, but in this article I’ll show you the best way to upgrade your documentation so you can get the reimbursement rate your treatment deserves.
Defining CPT code for Therapeutic Activity 97530
Many therapists steer clear of CPT code 97530 because they’re unsure what qualifies as “therapeutic activity.” And the CMS definition of therapeutic activity doesn’t help: “the use of dynamic activities to improve functional performance.” (And yes, they actually define therapeutic activity with the word “activity.” Thank you CMS for that clear-as-mud definition.)
Here’s a better way to think of it: a therapeutic activity is any action that ends in “ing,” like the following examples:
These actions all refer to functional activities you probably use all the time during your session. So when you sit down to write your notes, simply think “-ing.” Those dynamic activities will help guide the rest of your documentation throughout the different components of your SOAP note.
How to Use Therapeutic Activity 97530 in your SOAP note
There are four components to a SOAP note, and that means there are four opportunities for you to support your billing code with clear, descriptive documentation. Let’s look at each of these components one by one.
With the right prompting, your subjective note can almost write itself. For example, at the beginning of each session, I always ask my patient “What things are still too difficult for you to do because of your shoulder, back, knee issue, etc. ?”
And they usually mention actions such as “stepping up and down the stairs” or “squatting into a chair.”
Meanwhile, I quickly write their answer down. Not only will this pretty much cover my subjective notes, but it will also help me justify why I’ll be working on specific tasks recorded in my objective section.
The objective section of your SOAP note describes the exercises and stretches you used to measure your patient’s limitations, including specifics such as weight lifted, range of motion achieved, or balance statistics.
However, you can still use the objective note to support your use of a therapeutic activity code. You just have to choose specific words in your documentation to keep the focus on the functional limitation your patient mentioned earlier.
For example, let’s say your patient identified “reaching into the cabinet” as something they have difficulty doing without losing balance (from your subjective section). In the objective note, you may include something like this: “The patient was unable to perform reaching activities with a 1# weight without experiencing a loss of balance.” That -ing word, “reaching,” will be the common thread throughout your note, linking your patient’s everyday limitation with the clinical movements and exercises you’ll use to assess and treat their balance.
Remember, you’re shaping your treatment around improving functional performance, the definition of therapeutic activity. Although you can support that intent in your subjective statement and objective findings, you can express it even better in the assessment section.
Think about the assessment section as the “why” behind your treatment. This is where your therapy education truly shines.
As you write your assessment, reflect on why YOU—a skilled therapist—are required to be there during that patient’s session. They could have just followed a balance training video on youtube, so why did they come into the clinic? What did you add?
Consider: Did you provide any cues? Did you direct or correct their movement? Did you notice any limitations or even improvements as they performed each task?
And then reflect on what their performance means for their recovery. How does their ability to perform the activities in the clinic translate into their ability to do so safely and independently at home or in the community?
Your assessment should address all these things—not just the treatments that were done, but how they were done, why they were done, and what your takeaway is as a licensed therapist.
Example of Therapeutic Activity 97530 Assessment Statement
Here’s an example of an assessment statement that supports the skill of a therapist billing for a unit of therapeutic activity:
“The patient was unable to perform reaching activities with a 1# weight without experiencing a loss of balance. Repeated trials improved stability, but further training is recommended to improve safety while reaching overhead. Continued progression of balance training and strengthening is required for safe handling of household items in overhead cabinets.”
In this example, I address the patient’s limitations, offer an interpretation of whether or not the patient demonstrates an ability to improve, and provide a recommendation to help the patient achieve their goals. And that leads us to the final section of the SOAP note, the Plan.
A cohesive SOAP note will support your intention throughout your documentation, including your Plan for the patient.
In my previous example, I can use the last sentence to describe the Plan section of my SOAP note: “Continued progression of balance training and strengthening is required for safe handling of household items in overhead cabinets.”
I would then add: “Work on single leg stability and dynamic reaching tasks with varying weights in the next session.”
Granted, this method of documentation means you’ll be writing more than the boring, standby statement: “Patient tolerated treatment well, continue with PT per plan of care.” But what does that statement really say? Not much, and it certainly doesn’t reflect your specialty skills or support a higher billing code.
Intentional Notes Speed Documentation Time
In my experience as a practicing PT, I’ve found that approaching each section of my note with a cohesive intent actually made my documentation easier and faster. By choosing words and phrases that support a particular, therapeutic activity, I promise you’ll write with more ease and confidence.
Plus, by writing better notes, you can support your skilled treatment with skilled documentation and achieve 10-15% higher reimbursement, all from using higher-level CPT codes such as therapeutic activity.
Upgrade Your Notes with Documentation Templates
But if you want to spend less time writing even better documentation, then take a look at my documentation templates. These time-saving templates provide over 60 assessment samples, 80 goal-writing samples, and documentation phrases you can use to jumpstart your note-writing. With my templates, you can write more efficiently, code more lucratively, and save up to an hour every day on documentation. So check it out at PTProgress.com/templates.