Effective Documentation for Reimbursement of Cognitive and Swallowing – HomeCEU

Effective Documentation for Reimbursement of Cognitive and Swallowing Therapies

Effective documentation as a communication and justification tool

Effective documentation as a communication and justification tool 

Effective documentation provides the foundation for reimbursement, validates services, and serves as a clinical record. Although speech-language pathologists are most often associated with therapies for cognitive or swallowing difficulties, physical therapists occasionally encounter similar related needs. Often, these are found in populations like older adults, individuals recovering from neurological conditions, or patients with head and neck injuries. 

Interventions for these patients often demand highly nuanced record-keeping. This article explores effective documentation for reimbursement of cognitive and swallowing therapies for physical therapists. We review key elements of proper documentation, common pitfalls to avoid, and more. 

Related CE for physical therapists: Billing Basics for the Healthcare Professional: Coding and Reimbursement 

The role of physical therapy in cognitive and swallowing therapies 

Cognition and swallowing aren’t often areas of focus within the scope of physical therapy. However, both are connected to functional mobility, safety, and quality of life, areas in which physical therapists are heavily invested: 

  • Cognition and functional independence: Patients with cognitive deficits, like those following traumatic brain injury or stroke, often struggle with memory, attention, or executive functioning. These deficits can affect the patient’s ability to follow safety instructions, perform mobility tasks, or adhere to home exercise programs.
  • Swallowing and postural control: Dysphagia is influenced by postural stability, head positioning, and coordination of breathing with swallowing. Physical therapists play an important role in positioning, trunk control, and airway protection strategies that can directly impact swallowing safety. 

Documenting these interventions and strategies shows how different types of care, such as SLPs and PTs, are connected. It also shows why physical therapy interventions are medically necessary. 

Effective documentation as a communication and justification tool 

Documentation serves multiple audiences at once: other members of the care team, payers, regulatory agencies, and sometimes even patients and families. It must communicate both the what and the why to be effective: 

  • The “what”: What interventions were provided? For example, did the therapist implement dual-task training to improve ambulation while engaging cognition. Did they guide the patient in maintaining safe positioning to facilitate swallowing?
  • The “why”: Why were these interventions necessary? Here, physical therapists must clearly connect the intervention to functional goals and safety outcomes. This rationale is often what payers look for when determining medical necessity. 

Without strong documentation, even the most skilled interventions risk being undervalued or denied during the reimbursement process. 

Related CE for physical therapists: Supporting Your Skills in Documentation: Screens to Client-Centered Care in Long-Term Care Settings 

Key elements of effective documentation 

While payer requirements vary, certain elements consistently strengthen physical therapy notes involving cognitive or swallowing-related care, including: 

1. Patient presentation 

Accurate and detailed descriptions of the patient’s baseline status are important. This includes cognitive status, ability to follow commands, orientation, safety awareness, postural control, and current swallowing function as observed or reported. Establishing a clear starting point makes progress measurable. 

Example: “Patient demonstrates impaired attention, requiring moderate verbal cues to safely transition from sit to stand while attending to environmental stimuli.” 

2. Skilled interventions 

Physical therapists have to differentiate skilled care from routine or unskilled tasks. Instead of simply stating “assisted with sitting posture,” effective documentation should highlight the reasoning behind therapist involvement. 

Example: “PT provided manual facilitation of trunk extension to achieve midline posture, reducing anterior spillage during swallowing trials.” 

3. Functional goals 

Goals should be measurable, time-bound, and linked to functional outcomes. Payers can be especially attentive to how goals connect to independence, safety, and participation in daily activities. 

Example: “Within four weeks, the goal will be for the patient to demonstrate the ability to maintain upright seated posture with minimal cues for 10 minutes to support safe oral intake.” 

4. Objective measures 

Whenever possible, interventions should be tied to objective data such as standardized assessments, repetitions completed, time tolerated, or levels of assistance. This reduces subjectivity and reinforces medical necessity. 

Example: “Patient maintained chin-tuck posture for 6 out of 8 swallowing trials with tactile cueing, compared to 3 out of 8 during prior session.” 

5. Progress over time 

Reimbursement often hinges on evidence of progress, especially for programs such as worker’s compensation. Documentation should include tracking meaningful changes, even if it is small, while also noting barriers or reasons progress may be slower than expected. 

Example: “The patient demonstrated an increase in stability during the sit-to-stand exercise. However, patient was only able to complete 5 repetitions as compared to the prior session’s 7 repetitions due to bilateral quadriceps pain. An increase in muscle soreness due to a progression in the home exercise program has caused a temporary barrier in progress.” 

6. Interdisciplinary collaboration 

Physical therapists rarely deal with cognitive and swallowing issues without the help of other professionals. Notes that reflect collaboration with speech-language pathology, occupational therapy, nursing, or nutrition highlight the comprehensive nature of care. 

Example: “Co-treated with SLP to attempt supported upright positioning during thin liquid intake; patient tolerated 3 oz without signs of aspiration.” 

Common documentation pitfalls 

Even experienced physical therapists can have issues with documentation that risk denials or delays in reimbursement. Some of the most common pitfalls include: 

  • Vague language: Terms like “worked on posture” or “improved swallowing” lack specificity.
  • Lack of skilled justification: If a task appears routine, such as helping a patient sit up, without explanation of why a therapist's expertise was required, payers may classify it as unskilled care.
  • Failure to connect to function: Notes that do not link interventions to daily life tasks, independence, or safety may fail to demonstrate medical necessity.
  • Inconsistent progress tracking: Sporadic or inconsistent updates on progress can raise questions about the effectiveness or appropriateness of therapy. 

What payers are looking for 

Payers are looking for several things in documentation, including: 

  1. Medical necessity. Is the service reasonable and required for the patient’s condition? 

  1. Skilled nature of care. Does the intervention require the unique expertise of a physical therapist? 

  1. Evidence of progress. Is the patient improving, or is therapy preventing decline in a way that supports safety and function? 

When documentation addresses these questions directly, reimbursement becomes more likely. 

The role of documentation 

Rather than viewing documentation as a burden, physical therapists can see it to showcase their clinical reasoning and highlight their role in interdisciplinary care. For physical therapists involved with cognitive and swallowing-related therapies, effective documentation: 

  • Clarifies the value of therapy to payers and stakeholders
  • Reinforces the role of PT in holistic, patient-centered care
  • Provides a roadmap for ongoing intervention and collaboration 

In this way, documentation becomes more than a requirement. It becomes a professional tool that validates and advances the practice of physical therapy. 

Conclusion 

Effective documentation for cognitive and swallowing therapies requires more than simply describing what occurred during a therapy session. For physical therapists, it is an opportunity to demonstrate skilled reasoning, connect interventions to functional goals, and establish the medical necessity that supports reimbursement.  

By focusing on clarity, specificity, and alignment with payer expectations, physical therapists strengthen both their documentation and the perceived value of their role in patient care. 

This article was written by Mehreen Rizvi

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