Communicating Clinical Decision-Making Through Documentation: Coding, Payment, and Patient Categorization

Eric Shamus, DPT, PhD, CSCS has taught national and international continuing education courses on Orthopeadics, Sports Medicine, and Manual Therapy, with a focus on documentation and reimbursement. He is presently a professor at Florida Gulf Coast University and works at an outpatient orthopedic facility in Fort Lauderdale. Debra F. Stern, PT, MSM, DBA is an Associate Professor at Nova Southeastern University in Fort Lauderdale, FL. She serves as a clinical instructor with a focus on geriatrics, neuromuscular disorders, and also coordinates service learning experiences for the school's PT department. She received her BS in Physical Therapy from SUNY Buffalo, her MSM from Rollins College, and her DBAS at Nova Southeastern.

Contents
Contributors
Preface
Acknowledgements

SECTION 1 How to Write Patient Care Notes
1. Introduction, Background, Purpose, and General Rules for Health Information Management
2. Record Organization and General Principles
3. Application of Models for Organization and Guidelines for Content
4. The Electronic Medical Record
5. Content Standardization and Component Requirements
6. Documentation for Pediatrics
7. Documentation for Home Health
8. Documentation for Certified Nursing Homes

SECTION 2 How to Document Clinical Decision-Making
9. Evidence-Based Practice
10. Clinical Decision-Making
11. Legal Issues in the Medical Record
12. Utilization Review and Utilization Management

SECTION 3 Payment and Coding
13. Coding
14. Documentation Content Principles
15. Alternative Payment Models

SECTION 4 Steps and Framework for Coding and Documentation
16. Documentation Writing Examples and Worksheets

Appendix A Abbreviations
Appendix B OASIS D
Appendix C CMS Form 1500 with Instructions
Appendix D ICD-10 Guidelines
Appendix E APTA Guidelines for Physical Therapy Documentation
Appendix F APTA Documentation Review Checklist

Index