Bookeditors, Eric Shamus, Debra Stern, William F. McGehee, Kara Gainer.
Summary: In a changing healthcare environment, physical therapists and physical therapist assistants need to be paid for services rendered. Therapists cannot afford third-party payer denial for services they provide. This textbook will help lay the foundation on what, how, and why to document. Clinical decision-making, evidence-based practice, legal issues, coding, and utilization review are just a few of the content areas covered.
Contents:
How to write patient care notes
How to document clinical decision-making
Payment and coding
Steps and framework for coding and documentation
Appendix A. Abbreviations
Appendix B. OASIS D
Appendix C. CMS Form 1500 with instructions
Appendix D. ICD-10 guidelines
Appendix E. APTA guidelines: physical therapy documentation of patient/client management
Appendix F. APTA documentation review checklist.