Documentation and Coding for the Outpatient Therapist
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.
Physicourses is an AOTA Approved Provider of professional development. Course approval ID# 6295. This distance learning-independent course is offered at 0.6 CEUs Intermediate Level, OT Service Delivery, Foundational Knowledge. AOTA does not endorse specific course content, products, or clinical procedures.
Available Course Credits
| Alaska State PT & OT Board | 6.00 | ||
 |
AOTA | 6.00 | |
| Arizona State Board of Physical Therapy | 6.00 | ||
| California Physical Therapy Board | 6.00 | ||
| Colorado Division of Professions and Occupations | 6.00 | ||
| Connecticut Department of Public Health | 6.00 | ||
| Delaware Examining Board of Physical Therapists and Athletic Trainers | 6.00 | ||
| District Of Columbia Department of Health | 6.00 | ||
| Georgia State Board of Physical Therapy | 6.00 | ||
| Hawaii Board of Physical Therapy | 6.00 | ||
| Idaho Physical Therapy Licensure Board | 6.00 | ||
| Indiana Physical Therapy Board | 6.00 | ||
| Iowa Board of Physical Therapy and Occupational Therapy | 6.00 | ||
| Kansas State Board of Healing Arts | 6.00 | ||
| Kentucky Board of Physical Therapy | 6.00 | ||
| Louisiana Physical Therapy Board | 6.00 | ||
| Maine Board of Physical Therapy | 6.00 | ||
| Maryland Board of Physical Therapy | 0.60 | ||
| Massachusetts Board of Allied Health Professionals | 6.00 | ||
| Michigan Board of Physical Therapy | 6.00 | ||
| Minnesota Board of Physical Therapy | 6.00 | ||
| Mississippi State Board of Physical Therapy | 6.00 | ||
| Missouri Advisory Commission for Physical Therapists | 6.00 | ||
| Montana Board of Physical Therapy Examiners | 6.00 | ||
| Nebraska Department of Health and Human Services | 6.00 | ||
| New York State Education Department | 6.00 | ||
| North Carolina Board of Physical Therapy Examiners | 6.00 | ||
| North Dakota Board of Physical Therapy | 6.00 | ||
| Oklahoma Physical Therapy Board | 6.00 | ||
| Oregon Board of Physical Therapy | 6.00 | ||
| Pennsylvania State Board of Physical Therapy | 6.00 | ||
| Physical Therapy Governing Board New Hampshire | 6.00 | ||
| South Carolina Board of Physical Therapy | 6.00 | ||
| South Dakota Physical Therapy License Board | 6.00 | ||
| State of Alabama Board of Physical Therapy | 6.00 | ||
| State of Rhode Island Department of Health | 6.00 | ||
| Tennessee Board of Physical Therapy | 6.00 | ||
| Texas Physical Therapy Association | 6.00 | ||
| Utah Physical Therapy Licensing Board | 6.00 | ||
| Virginia Board of Physical Therapy | 6.00 | ||
| Washington State Board of Physical Therapy | 6.00 | ||
| West Virginia Board of Physical Therapy | 6.00 | ||
| Wisconsin Physical Therapy License Board | 6.00 | ||
| Wyoming Board of Physical Therapy | 6.00 |
Course Content
| 811 Documentation and Coding for the Outpatient Therapist | Module | ||
| Course Evaluation | Module |
Amy Elder, PT, DPT
Dr. Amy Elder received her BS in Kinesiology from James Madison University and her DPT degree from Arcadia University. She specialized in outpatient orthopedics, became very interested in spinal mechanics, and became McKenzie Certified. Dr. Elder is a stroke survivor who experienced a massive cerebellar stroke in 2011. From 2014 to 2021, she worked as a Clinical Documentation Specialist for Phoenix Rehabilitation. Dr. Elder is currently a freelance health content writer and educator.
811 Documentation and Coding for the Outpatient
Therapist—Course Objectives
After taking this course, the learner should be able to:
Recall elements of documentation that should always be on an initial evaluation, regardless of diagnosis.
Identify each part of a SOAP note and the requirement and best practices of each.
Recall specific, unchanging Medicare rules/parts of documentation that a reviewer will always look for.
Interpret specific elements of ICD-10 diagnostic coding and be able to easily choose the correct code.
Differentiate coding specificity for prescribed activities/exercises and be able to choose proper CPT billing codes for the different activities prescribed during a session.
Choose situations in which Group Therapy must be billed.
811 Documentation and Coding for the Outpatient Therapist
Table of Contents
Hour 1 Page
Course Instructions 2
About the Author/Course Objectives 3
Course Description 4
Table of Contents 5
Chapter 1: Introduction 7
Chapter 2: The Transition of Healthcare to Value-Based Care 8
Chapter 3: Initial Evaluation 11
Tiered Evaluation Codes 14
Chapter 4: Daily Notes 17
Subjective
Objective 18
Documentation for Manual Techniques and Modalities 19
Documentation for HEP 20
Hour 2:
Assessment 21
Medical Necessity 22
Plan 23
Chapter 5: Progress Notes 24
Chapter 6: Re-Evaluations 27
Chapter 7: Maintenance Therapy Programs 31
Hour 3:
Chapter 8: Discharge Summary Requirement 36
Chapter 9: Medicare Rules 38
KX Modifier
Targeted Medical Review 40
When to Issue an Advance Beneficiary Notice 43
GA Modifier 44
Rules Regarding Signed POCs 45
Timely Certification of a POC 47
Amendments to a Signed POC 48
Signature Requirements 51
Hour 4:
Chapter 10: ICD-10 Diagnostic Coding 53
Tabular List
Using a 7th Character 55
Using Aftercare Codes 57
Using External Cause Codes (V00-Y99) 59
Specificity of Diagnosis Coding 61
More on Coding Specificity 62
Chapter 11: Current Procedural Terminology (CPT) Coding 63
Activity Coding Specificity
97110 Ther Ex/ 97112 NMR/ 97535 Ther Act/ 97129 Cognitive Function Intervention 64
Hour 5:
Billing for Manual Therapy 66
Durable Medical Equipment (DME) 69
Dry Needling (PT Only) 71
Billing for Patient Education 72
Billing for Physical Performance Tests 74
When to Bill Group Therapy 75
Hour 6:
Chapter 12: Conclusion 79
References 81
Examination 86
Evaluation
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Educational Level: Intermediate
Target Audience: PT, PTA, OT, OTA
Course Completion Requirements: Passing an online exam with 70% or greater will be required to earn continuing education credit
This course is approved for 0.9 CEUS. 9 contact hours
Physicourses is committed to ensuring accessibility to the most extensive audience possible. If you have any questions or special needs requests, please contact us at info@physicourses.com.