Course Description:

Documentation is an incredibly important part of being a medical professional. With the transition in healthcare to value-based care, it is vitally important to accurately document your findings, treatments, patient education efforts, and outcomes. Thorough documentation can affect reimbursement from insurance companies and is essential to establish the need for continued skilled care. This course will highlight the important statements that always need to be a part of your SOAP notes, including on the initial evaluation, re-evaluations, progress notes, and discharge summaries. Proper ICD-10 diagnostic coding and CPT activity coding and billing will also be addressed. Maintenance therapy will be discussed, focusing on how to properly document and bill for therapy when a patient continues to require skilled care in order to avoid decline of function. This course will be immediately useful in clinical practice to all outpatient PT and OT professionals.