Course Detail

Course #1178
Documentation Essentials

Registration Fee:  This course is included in your $99 annual Professional Subscription.

CEUs/PDUs Offered: AOTA/0.1 Introductory, Category 3: Professional Issues - Legal & Legislative,Regulatory & Reimbursement Issues; NBCOT/1.25 Beginner


Course Abstract

This presentation was designed to provide a general documentation review and training for creating a therapy medical record that reflects best practice and meets the CMS guidelines for services provided in a skilled nursing facility and outpatient settings for rehabilitation. This course will provide the participant with both general information and specific skilled verbiage which can be incorporated into the therapy record to justify the services provided.

Course Learning Outcomes Preview Exam

  • After this course, participants will be able to list basic Medicare coverage guidelines for skilled therapy services including required documentation.
  • After this course, participants will be able to select documentation and billing practices that meet CMS guidelines
  • After this course, participants will be able to identify skilled terminology to document the justification of therapy services
  • After this course, participants will be able to select strategies for improving efficiency in creating a therapy record including point of service documentation.

Time-ordered Agenda

0-15 Minutes Medicare coverage guidelines for skilled therapy
15-30 Minutes CMS guidelines for documentation and billing
30-40 Minutes Documenting justification for therapy
40-50 Minutes Proper medical error corrections, approved abbreviations and point of service documentation
50-60 Minutes Conclusions and Questions and Answer

Average Rating +++++ (5 Reviews)

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Review by: Member on Mon Mar 19 2012
Descriptive and helpful relevant
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Review by: Member on Tue Feb 21 2012
Very relevant subject.
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Review by: Member on Tue Mar 20 2012
the infromation was very up to date with current medicare guidlines . because i work in a SNF setting , i am able to use this info right away .
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Review by: Member on Thu Mar 8 2012
Concise, with examples
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Review by: Member on Sun Mar 18 2012
helped me to understand the basic of documentation guidelines

Course Information

This is an audio recording of a live session.

Review technical requirements >>

Email us questions or Call 866-782-9924 >>


Course Presenter

mylinda barisas matula

Mylinda Barisas-Matula, MBA, OT

Mylinda Barisas-Matula, OT, CLT. MBA has worked with the geriatric population for over 20 years in a number of health care venues including outpatient clinics and SNFs in both operational and clinical roles. Mylinda most recently worked as a Rehabilitation Consultant and provided education and resources nationally on CMS regulation specific to rehabilitation services.  Mylinda has provided MDS 3.0 and documentation educational in-services at both the facility level and at professional conferences.  Currently, Mylinda also serves on the Occupational Therapy Affiliated Credentialing Board for the State of Wisconsin. 


Continuing Education Information

CEUs/PDUs Offered: AOTA/0.1 Introductory, Category 3: Professional Issues - Legal & Legislative,Regulatory & Reimbursement Issues; NBCOT/1.25 Beginner
Passing an online exam will be required to earn continuing education credit.
Please note: CEU tests must be passed within 30 days of the event.
To participate in the course, complete the CEU exam and earn continuing education credit, you must be a Professional Subscriber.
American Occupational Therapy Association




OccupationalTherapy.com is an approved CE provider by the American Occupational Therapy Association (AOTA). This course is offered for 0.1 CEUs. Courses approved by AOTA are accepted by the National Board for Certification in Occupational Therapy (NBCOT) Certificate Renewal program. The assignment of AOTA CEUs does not imply endorsement of specific course content, products, or clinical procedures by AOTA.
National Board for Certification in Occupational TherapyOccupationalTherapy.com is a NBCOT Professional Development Provider. This course is offered for 1.25 NBCOT PDUs.

If you have any technical questions or problems related to this course,
please contact OccupationalTherapy.com toll free at 866-782-9924