Course Description

This is Part 1 of the Medicare Documentation series. You can purchase Part 2 here. 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.

Related courses:

Defensible Documentation: A Framework for PT Documentation

Defensible Documentation - The Medicare Perspective - Part 2

Defensible Documentation - The Payer Perspective

Home Health Regulation and Documentation

Meet our Speaker

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 Code:


Completion Instructions

Review the content, complete assessment with at least 70% score, claim certificate.

Course level


Delivery method



Mary Daulong, PT, CHC, CHP

Learning objectives

  1. Explain the difference between the ‘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


Veterans Administration (VA)

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2Assessment - Defensible Documentation Part 1
Type:E-Learning Course
Credit Categories
Domains:Mary Daulong, Documentation, medicare, defensible documentation

The following credits are available upon completion of these activities.

Total credits:  0.2
Key Dates
Enrollment:Prior to  12/31/2022
Available discounts:
  • Non Member
    (until 12/31/2030)
  • Member
    (until 12/31/2030)
* Prices in US Dollars