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This course will focus on compliant documentation utilizing the Medicare’ Documentation Requirements as published in the Medicare Benefit Policy Manual and the APTA Defensible Documentation. It will not only address specific content requirements but also the consequences of not complying with these regulations. Special attention will be afforded to effective drafting of Plans of Care, differentiating the evaluation from a progress report, the purpose of the treatment encounter note and ultimately how to document in a way that tells the ‘whole’ story without writing a book.
Learning Objectives:
1. Explain the difference between the "evaluation in the initial examination with that" in the progress report
2.Articulate when and how to use the "Delayed Plan of Care" provision
3. Execute a compliant Treatment Encounter Note
4. Capture relevant evaluative findings and document to justify skilled intervention
5. Identify documentation deficiencies that lead to denials, refunds, and/or sanctions
You can purchase Part 2 here.
Mary Daulong
PT, CHC, CHP
Mary Daulong, PT, CHC, CHP, is owner of Business & Clinical Management Services Inc, providing consultation for small- to medium-sized private practices and billing companies. For 2 decades she has guided private practitioners, rehab agencies, and therapy-specific billing companies through the maze of health care regulatory change. Daulong earned a bachelor’s degree from the University of Texas Medical Branch, SAHS, has master’s-level business management education, and has over 1,500 hours of postgraduate education in health care-related matters. She is certified in health care compliance and is credentialed by the HIPAA Academy as a HIPAA privacy professional. Her past career includes self-employment as a private practitioner, and senior and mid-management employment in diverse settings, and she has specific expertise in health care regulation including OIG guidance; Medicare payment, documentation, and coverage regulations; OSHA; ADA; Department of Labor; HIPAA/HITECH; professional practice regulatory compliance; and operational integration
Daulong has been recognized by her profession and community, regularly speaking in both national and state venues. She has been honored by academic institutions, state agencies, and professional, community, and civic associations as well as by her peers, and she continues to be an active volunteer in her professional associations.
Course Instructions
- Click on the Contents tab to watch the course recording.
- Click the Take Quiz button to complete the assessment. Learners will have 3 attempts to pass and must answer at least 70% of questions correctly.
- Click Fill Out Survey under the Evaluation listing to provide valuable course feedback. Scroll down on all questions as there may be answer options that expand past the size of the window.
- Click the View/Print Your Certificate button under the Certificate listing. You can view/print your certificate at any time by visiting the APTA Learning Center and clicking the CEU Certificate/Transcript link on the left-hand side of the page.
Need Assistance?
For assistance logging in, accessing activities, claiming credit, or for other questions or concerns, please e-mail learningcenter@apta.org.
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