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Documentation: Everything After the Evaluation Until Discharge

presented by Rick Gawenda, PT

Accrediting Body:

Target Audience:

Disclosure Statement:

Financial: Rick Gawenda receives compensation from MedBridge for this course. There is no financial interest beyond the production of this course.

Non-Financial: Rick Gawenda has no competing non-financial interests or relationships with regard to the content presented in this course.

Satisfactory completion requirements: All disciplines must complete learning assessments to be awarded credit, no minimum score required unless otherwise specified within the course.

MedBridge is committed to accessibility for all of our subscribers. If you are in need of a disability-related accommodation, please contact [email protected]. We will process requests for reasonable accommodation and will provide reasonable accommodations where appropriate, in a prompt and efficient manner.

Accreditation Check:

This course will teach participants the required elements for a progress report, daily note, discharge report, and Medicare Part B certifications and recertifications. While completing this course, participants will learn how a progress report should support the therapy already provided and why continued therapy is necessary. The course will teach participants how to document in the daily note to support the services required the skills of a therapist to provide and the CPT codes that were billed that date of service. The course will discuss the importance of a discharge report and what insurance carriers require a discharge report. Finally, the course will discuss the Medicare Part B certification and recertification requirements.

Meet Your Instructor

Rick Gawenda, PT

Rick Gawenda, PT, is founder and President of Gawenda Seminars & Consulting, Inc. He graduated in 1991 with a Bachelor of Science in Physical Therapy from Wayne State University, Detroit, Michigan. Rick is Director of Finance for a physical-therapist-owned private practice with multiple offices located in Southern California. In addition, he was Director of Physical…

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Chapters & Learning Objectives

1. Progress Reports

This chapter will teach participants how often a progress is report is required under the Medicare program and other insurance carriers. The chapter will teach participants what the required elements are for a progress report, discuss delayed reports, and show participants how a progress report may also serve as a reevaluation, a physician order, and/or a Medicare recertification.

2. Daily Notes: Documentation of Time and Required Elements

This chapter will teach participants what the required elements are for a daily note for the Medicare Part B program and several commercial insurance carriers.

3. Daily Notes: How to Write a Defensible Note

This chapter will teach participants how to write a daily note that demonstrates why the patient required skilled therapy services on that date of service. This chapter will also teach participants how to avoid the most common mistakes made when documenting services billed under the modality CPT codes, therapeutic exercise, neuromuscular reeducation, gait training, manual therapy, therapeutic activities, and self-care/home management.

4. Discharge Reports

This chapter will teach participants the required elements for a discharge report and how their discharge report is the same as an attorney’s closing argument to a jury.

5. Medicare Part B: Certifications and Recertifications

This chapter will teach participants the required elements of a Medicare Part B plan of care and who can certify and recertify for outpatient therapy services, as well as when a certification or recertification is considered timely or delayed. This chapter will provide examples of documentation that may be requested by a Medicare contractor to support delayed certification and/or recertification.

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