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Standard of Care Outpatient Therapy: Will you Prevail?

May 05, 2021
Documentation, Billing, & Coding By Zenobia Knight

The Healthcare Providers Service Organization (HPSO) reviewed a case study where the treating physical therapist, who was also the owner of the practice, prevailed in a lawsuit.


documentation audit


The allegation was improper management over the course of treatment following total hip arthroplasty (THA) surgery. A motion to dismiss the case based upon the physical therapist’s defense experts’ reports and testimonies was denied and a jury trial ensued. At the conclusion of the six-day trial, the jury concluded the therapist, and the practice did not deviate from the standards of care and were not negligent. The six-year legal defense of this case exceeded $300,000.

Brief Case Summary

This case involved a 55-year-old who went for outpatient physical therapy one week following a total hip arthroplasty. The patient was treated while in the hospital and, according to records, achieved good progress prior to discharge from the hospital. The physical therapy outpatient orders were for phase 2 THA protocol. Reportedly the patient did well during week one of outpatient physical therapy and only complained of expected surgical pain. The patient failed to keep therapy appointments during week two and when contacted by the physical therapist the patient reported the hip had pulled loose.

The favorable verdict for the therapy practice reinforces the importance of following and documenting adherence to treatment protocols and evidence-based best practices. TheHPSO recommends clinicians document all patient discussions in the medical record while providing additional risk management strategies within the case study.

What are the Risks Implications?

In CNA HPSO’s Physical Therapy Professional Liability Exposure: 2016 Claims Report Update, allegations of improper management over the course of treatment had the highest overall percentage of closed claims at 22.2 percent. In this allegation category, improper management of a surgical patient had the highest percentage of closed claims.

Does your risk management program include routine documentation audits and observation of staff treatments? Are you monitoring to determine if staff follow post-op protocols and evidence-based best practices? What practices, policies and procedures do you need to implement to help ensure a good outcome should there be an allegation of malpractice?

These practices, policies and procedures include:

  • Patient care protocols and documentation.
  • Staff Competency Training.
  • Infection control and OSHA.
  • New Hire Compliance, HIPPA (Health Insurance Portability and Accountability Act), Fraud, Waste, Abuse, and Ethics.
  • Having a retention policy documenting the training provided.

How Can LW Consulting, Inc. Help?

  • LW Consulting, Inc. (LWCI) offers Compliance, HIPAA, and OSHA policy manuals to support your compliance program. These manuals, training modules, and more can be found at our LWCI store.
  • LWCI can also conduct external objective documentation and coding audits to support your practice’s commitment to an effective compliance plan.


LWCI can assist you with your compliance program and/or conduct a documentation and coding audit. Set up a 15-minute discussion with one of our experts, Deborah Alexander, Director, CHC, CHPC, PMP, DPT, MED, STC, CSCS.

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