Dallas (Frisco), Texas

Lucy MacedoLeave a Comment

Gawenda Seminars Event Icon

Understanding the Complex World of Therapy Services: Documentation, CPT Coding, and Billing.
This seminar will teach participants the required components of documentation from evaluation through discharge, what interventions are included within each CPT code, the 10 new speech therapy codes for 2027, and how to correctly bill to Medicare, Medicaid, and commercial insurers as it relates to outpatient therapy services.

Documentation to Submit When an Insurance Carrier Requests a Date of Service

The Centers for Medicare and Medicaid Services (CMS) and commercial insurance carriers, such as Anthem BCBS and UnitedHealthcare, have increased their requests for medical records for dates of services to ensure not only proper CPT coding and billing, but that the services provided meet the definition of medical necessity and required the unique skills of a therapist, or an assistant under the supervision of a therapist, to provide. Unfortunately, providers are not submitting all of the required information and thus, are being denied even when the daily note does support the CPT codes and units billed. In this article, I … Read More

How to Document Late Entries in the Medical Record

Occasionally, therapists and assistants may forget to document a note in the medical record. This could be a daily note, progress report, or discharge report. When this occurs, what is the correct process for documenting and dating late medical record entries? The Centers for Medicare and Medicaid Services (CMS) states the following:

Boulder/Denver, Colorado

Lucy MacedoLeave a Comment

Gawenda Seminars Event Icon

Understanding the Complex World of Therapy Services: Documentation, CPT Coding, NCCI Edits, and Billing.
This seminar will teach participants the required components of documentation from evaluation through discharge, what interventions are included within each CPT code, NCCI edits and modifier 59, and how to correctly bill to Medicare and all other insurance carriers as they relate to outpatient therapy services.

Anthem BCBS Documentation of Time Update

Anthem BCBS has implemented a revised policy that has implications for outpatient therapy services. This revised policy impacts what a therapist or assistant must document for time for therapy services provided. The following states are impacted by this change: To access the revised policy, log into your account and click

2026 Documentation for Everything after the Initial Evaluation for PT, OT, & SLP

Rick GawendaLeave a Comment

Promotional banner for the online course “2026 Documentation After the Initial Evaluation for PT, OT, and SLP” with Rick Gawenda, PT, scheduled for April 9, 2026, from 1–3:00 PM ET

This 2-hour online course will assist physical therapists, physical therapist assistants, occupational therapists, occupational therapy assistants and speech-language pathologists in understanding the required elements of documentation for a progress report, daily note, discharge report for all insurance carriers plus the Medicare Part B certification and recertification requirements.

Writing a Discharge Report on a Patient You Never Treated

A therapist (employee or traveler) has left your practice or organization. After they left, you realize this therapist had 1 or more medical records they did not write a discharge report on. A question I am often asked is can another therapist that is employed by the practice or organization who never treated this patient write the discharge report based on the existing documentation in the medical record? The answer is