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Documentation for Evaluations and Re-Evaluations

Presented by Rick Gawenda

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This course will teach participants the required elements regarding documentation for evaluations and re-evaluations. The course will focus on the importance of the subjective intake and objective examination during the initial evaluation that will establish the need for continued therapy services. The course will teach participants the four questions a goal should answer and provide examples of function-based goals. Finally, the course will discuss when a re-evaluation is appropriate to perform and bill and what must be documented to support the billing of a re-evaluation to an insurance carrier.

Meet your instructor

Rick Gawenda

Rick Gawenda is founder and president of Gawenda Seminars & Consulting, Inc. He graduated in 1991 with a Bachelor of Science in physical therapy from Wayne State University in Detroit. Rick is director of finance for a physical therapist–owned private practice with multiple offices located in Southern California. In addition,…

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Chapters & learning objectives

Introduction to Documentation

1. Introduction to Documentation

This chapter will teach participants the difference between rehabilitative therapy, habilitative therapy, and maintenance therapy as well as the difference between a medical diagnosis and a treatment/therapy diagnosis.

Subjective Intake of the Initial Evaluation

2. Subjective Intake of the Initial Evaluation

This chapter will teach participants the importance of the subjective intake and what auditors are looking for when performing a medical record review. The chapter will discuss documenting the purpose of therapy services as well as comorbidities and how they may impact the plan of care. This chapter will also explain how to document prior and current level of function. Examples will be provided to show participants how to incorporate what they learned into their actual documentation.

Objective Intake of the Initial Evaluation

3. Objective Intake of the Initial Evaluation

This chapter will teach participants the components of the objective examination and the importance of patient-reported outcomes and outcome measures that can support the need for therapy services.

Assessment and Plan of Care

4. Assessment and Plan of Care

This chapter will teach participants the required elements for a plan of care for Medicare, Aetna, Cigna, UnitedHealthcare, and several other BCBS insurance carriers.

Function-Based Goal Writing

5. Function-Based Goal Writing

This chapter will teach participants how to write function-based goals based on the information gathered during the subjective intake and objective examination of the initial evaluation. This chapter will discuss the four questions a goal should answer and provide examples of function-based goals for various conditions.

Re-Evaluations

6. Re-Evaluations

This chapter will teach participants when a reevaluation is warranted and the required documentation that must be present in order to bill a re-evaluation to the Medicare program or other insurance carrier.