Documentation: Everything After the Evaluation Until Discharge
Presented by Rick Gawenda
Non-Financial: Rick Gawenda has no competing non-financial interests or relationships with regard to the content presented in this course.
Meet your instructor
Rick Gawenda
Rick Gawenda 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 in Detroit. Rick is director of finance for a physical therapist–owned private practice with multiple offices located in Southern California. In addition,…
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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