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    Documentation for Physical Therapy Assistants

    I am new to PT/OT billing. I work in a Private Practice setting. Our state allows for the PTA's to provide services with general supervision and still bill under the Treating Therapist. CMS requires direct supervision and for services to be billed under the Therapist providing the direct...
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    Medical Record Guidelines

    Hi Everyone! We are looking for documentation guidelines regarding how documents should be handled. For example, if the Dr amends a record after the original chart note was created, does a new record need to be sent to the PCP? Does the record sent to the PCP or referring need to include hx's...
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    PFSH - Reviewed No Changes

    I was wondering if the documentation states Reviewed no changes, last detailed document date: mm/dd/yyyy. Do I need to worry about/or Should I be going back to that document to make sure it is documented and how much is documented in order to give the MD the appropriate credit? Would an...
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    Management Options

    I work for Orthopedic Specialists and I have a Dr that always discusses surgery as an option along with conservative treatment. I am confused as to when I should give him points in the MDM for surgery. Does he get points just for discussing surgery or does it need to be the treatment plan that...