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This text guides patterns of practice; improves quality of care; promotes appropriate use of health care services; and explains physical therapist practice to insurers, policymakers, and other health care professionals. This edition continues to be a resource for both daily practice and professional education.
These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS. These guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD-10-CM itself. The instructions and conventions of the classification take precedence over guidelines. These guidelines are based on the coding and sequencing instructions in the Tabular List and Alphabetic Index of ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have been adopted under HIPAA for all healthcare settings. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. These guidelines have been developed to assist both the healthcare provider and the coder in identifying those diagnoses that are to be reported. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.
Build your documentation skills—and your confidence. Step by step, this text/workbook introduces you to the importance of documentation to support quality patient care and appropriate reimbursement. It shows you how to develop and write a proper and defensible note; and prepares you to meet the technological challenges you’ll encounter in practice. You’ll learn how to provide the proper documentation to assure all forms of reimbursement (including third party) for your services. You’ll also explore issues of patient confidentiality, HIPAA requirements, and the ever-increasing demands of legal and ethical practice in a litigious society.
Documentation for Physical Therapist Practice: A Clinical Decision Making Approach provides the framework for successful documentation. It is synchronous with Medicare standards as well as the American Physical Therapy Association's recommendations for defensible documentation. It identifies documentation basics which can be readily applied to a broad spectrum of documentation formats including paper-based and electronic systems. This key resource utilizes a practical clinical decision making approach and applies this framework to all aspects of documentation. This text emphasizes how the common and standard language of the Guide to Physical Therapist Practice and the International Classification of Functioning, Disability, and Health (ICF) model can be integrated with a physical therapist's clinical reasoning process and a physical therapist assistant's skill set to produce successful documentation. Includes content on documentation formations: Initial Evaluations, Re-examination Notes, Daily Notes, Conclusion of the Episode of Care Summaries, Home Exercise Program Reviews all the important issues related to style, types of documentation, and utilization of documentation Covers documentation relevant in different settings (inpatient, home health, skilled nursing facility, outpatient) Helps students learn how to report findings and demonstrate an appropriate interpretation of results Includes up-to-date information in line with APTA Guidelines for Defensible Documentation, World Health Organization, International Classification of Functioning Disability and Health Mode, and Medicare Reviews electronic documentation, ICD-9, ICD-10, and CPT codes Includes important chapters on Interprofessional Communication, Legal Aspects, Principles of Measurement
This is a comprehensive textbook for the documentation course required in all Physical Therapy programs. The textbook incorporates current APTA terminology and covers every aspect of documentation including reimbursement and billing, coding, legal issues, PT and PTA communication, as well as utilization review and quality assurance. (Midwest).
"This text provides readers with the information and tools needed to understand what constitutes evidence, search efficiently for applicable evidence in the literature, evaluate the findings in the literature, and integrate the evidence with clinical judgment and individual patient preferences and values. Students will learn how evaluate research designs, appraise evidence, and apply research in clinical practice"--Provided by publisher.
Health Sciences & Professions
The 2010 Coding and Payment Guide for the Physical Therapist is your one-stop coding, billing, and documentation guide to submitting claims with greater precision and efficiency. This guide has the latest 2010 specialty-specific ICD-9-CM, HCPCS Level II, and CPT code sets along with Medicare payer information, CCI edits, helpful code descriptions, and clinical definitions. CPT is a registered trademark of the American Medical Association.