Defensible Documentation Part 2: If You were the Auditor
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You can purchase Part 1 here.
This course will continue the discussion on compliant documentation utilizing Medicare’ Documentation Requirements as published in the Medicare Benefit Policy Manual. 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 goals of an evaluation and progress report’s assessment, 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
Mary Daulong
PT, CHC, CHP
Mary Daulong is a nationally recognized healthcare compliance expert with more than five decades of experience spanning private practice ownership, corporate-managed services, and hospital-based physical therapy. As the founder of her consulting firm in
1985, she has spent the past twenty-five years exclusively guiding healthcare providers through the complexities of regulatory compliance. As BCMS continues to evolve,Mary’s role has shifted from direct operational oversight to BCMS stewardship. Her
primary focus is guiding the company’s vision, ensuring its long-term financial viability, and conducting in-depth research and regulatory analysis affecting outpatient therapy providers and practices.
Mary is known for translating highly technical regulatory requirements into practical, real-world strategies that providers can implement immediately. Her areas of expertise include, but are not limited to, HIPAA, OSHA, federal payment, coverage, and fraud
regulations, state licensure laws, commercial payer policies, billing, coding, documentation integrity, and compliance program development, specifically tailored to outpatient therapy practices.
A long-standing leader in the profession, Mary has been a member of the American Physical Therapy Association for over fifty years and served nine years on the Payment Policy Committee of the APTA Private Practice Section. She has also held multiple
leadership roles as chairwoman of Payment Policy and Governmental Affairs within the Texas Physical Therapy Association and was appointed to the Texas Board of Physical Therapy Examiners, where she served on its Executive Council and Investigations
Committee. She has volunteered at the local, state, and national levels of the APTA for all but five years as a physical therapist.
In 2002, Mary became the first physical therapist to be certified in healthcare compliance and has been a member of the Health Care Compliance Association, as well as a certified HIPAA Professional through the HIPAA Academy.
Mary is married to her middle school sweetheart, Paul. She is the proud mother of her son, Stephen, and her daughter, Alicia, and she cherishes her relationship with both of their spouses, her three loving and talented grandchildren, and her three wonderful
stepdaughters. Paul and Mary are currently petless for the first time in over fifty years...but that may soon change.
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.
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