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Exploring the Essential Features of “Effective Documentation Strategies: Master the Ins & Outs of Getting Paid Correctly! – Trent Brown – PESI”
Is your return of money to Medicare, Medicaid and other insurance companies due to your lack of understanding of documentation requirements? Are you over documenting unnecessary areas and under documenting the essential areas? Some clinicians claim narrative documentation takes more time than “checking boxes” or “menus”. However, if done correctly, it can save you time and focus a reviewer to the skill and progress you provide ensuring reimbursement and avoiding further review.
Watch this recording and learn essential strategies to master documentation. You will learn how following specific principles when documenting will fulfill the requirements of CMS and payer sources while demonstrating skills, medical necessity, and objective progress regardless of software used. You will learn the purpose of RAC system, appeals process and red flags to ensure you are documenting only what is essential. Simple narrative emphasis can reduce reviews or negate them altogether. Specific examples will be shared of how to take standard exercises, activities, and treatment strategies and apply the principles learned in this course.
Speaker
Trent Brown, MOT, OTR/L, BCG, ATP, CFPS
Advanced Healthcare
Trent Brown, MOT, OTR/L, BCG, ATP, CFPS, is a practicing therapist in Utah and is one of 36 credential holders of a board certification in gerontology (BCG) from the AOTA. Mr. Brown also holds a certification as an assistive technology professional (ATP) from RESNA. He completed his undergraduate and graduate work at the University of Utah where he is also an adjunct professor. He is employed by the Utah Department of Health (UDOH) to develop, implement, and operate healthcare quality improvement programs and has authored multiple laws to legislate improved patient care. Mr. Brown also reviews clinical documentation for UDOH as an expert witness in reviewing cases. Mr. Brown has over 15 years of clinical experience in skilled nursing, transitional care, acute, and home health. Recently, he served as the VP for the UOTA where he co-authored SB 131, advancing OT practice in the state of Utah, and has received multiple awards for his clinical, academic, and legislative work. Through his expertise in advocating for therapy services authoring law and rule, he has evolved into an expert presenter on ethical and legal issues facing therapy. Mr. Brown has provided courses for thousands of clinicians throughout the country in conferences, private settings, and specialty conferences. Mr. Brown is a master clinician and lecturer on a myriad of topics including joint arthroplasty, core strengthening, documentation, aging, functional mobility, ethics, and fall reduction. He has also been a keynote speaker at multiple events throughout the country.
Speaker Disclosures:
Financial: Trent Brown has employment relationships with the University of Utah, the Utah Department of Health, Well Being Services, Northern Utah Rehab Hospital, and Aspenridge Home Health. He receives compensation as an instructor. Trent Brown receives a speaking honorarium and recording royalties from PESI, Inc. He has no relevant financial relationships with ineligible organizations.
Non-financial: Trent Brown has no relevant non-financial relationships.
Objectives
- Identify how payers review documentation, who reviews documentation, and the general process of review.
- Identify the platforms required for documentation, how to avoid review, and what to do if a review is requested.
- Implement the necessary components of documentation to support skilled therapy services for accurate payment.
Outline
Introduction
Purpose of RAC and documentation review
- Why reviews happen
- Who reviews
General process of a documentation review
Identify red flags
- Billing
- Trends (OP-Medicare B, In-patient –Medicare A, HH)
Identify the 3 areas reviewed
- Qualified clinician
- Skilled level of care
- Medical Necessity
- Actual Good/Bad Examples
Appeals process: what to do if a review is requested
Requirements of a “maintenance program”
5 platforms of successful documentation
Underutilized terminology
- Avoiding “trap phrases”
Platforms of successful documentation with case examples
- Joint mob
- Gait ther-ex
- Transfer training
- Spontaneous class example
Questions
Target Audience
- Physical Therapists
- Physical Therapist Assistants
- Occupational Therapists
- Occupational Therapy Assistants
- Athletic Trainers
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