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Quandaries in Medical Documentation and Early Intervention Therapies

presented by Jeanine Colburn, PT, DPT, MS, PCS

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Target Audience:

Disclosure Statement:

Financial: Jeanine Colburn receives royalties from Three Leaf Press for the book “The Small Patient Practice: A Beginner’s Guide to Starting a Pediatric PT, OT or SLP Solo Practice, Including Medical Documentation, Billing and Coding” and receives compensation from MedBridge for this course. There is no financial interest beyond the production of this course.

Non-Financial: Jeanine Colburn 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.

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The purpose of this course is to help pediatric physical therapists, occupational therapists and speech therapists providing outpatient therapy and/or working in an early intervention setting, to learn the principles of medical documentation required for successful billing and reimbursement from healthcare payers. These principals of medical documentation are compared to early intervention documentation requirements. Useful guidelines for vocabulary will be provided.

Meet Your Instructor

Jeanine Colburn, PT, DPT, MS, PCS

Jeanine has been a practicing physical therapist since 1975. A pediatric clinical specialist since 1994, she had extensive experience with the adult rehabilitation population earlier in her career. She first began billing for services as a solo provider in 1992 when she moved to an area that did not have pediatric physical therapy. Since that…

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Chapters & Learning Objectives

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1. Early Intervention Documentation and Elements of Medical Documentation Required for Billing Health Insurance

This chapter reviews early intervention documentation requirements and compares them to documentation required for reimbursement from health insurance. It introduces the basic elements of documentation required for the medically oriented evaluation. The requirements for the medically oriented re-evaluation are also discussed.

2. Pediatric Therapist Jargon, Documentation and Denials

This chapter highlights how using popular pediatric therapy terms can sabotage medical reimbursement. It will introduce known ‘red flag’ terms and why these terms may not be appropriate for medical documentation. This chapter helps the participant determine more relevant and appropriate terms for documentation of patient disorders.

3. Treatment Notes and Progress Reports

This chapter will help the participant will demonstrate an understanding of the elements of a treatment note versus a progress report. It will review the basic elements required in the treatment note, and the expected elements of a progress report. This chapter will also give examples of information that should not be included in a treatment note or progress report.

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