OT_Documentation_Reimbursement in pediatric.pptx

Medicine

1. Considerations for Documentation and Reimbursement Across Settings Occupational Therapy Practice for Children and Youth

2. Importance of Documentation • Represents profession and service value • Facilitates participation and engagement • Must align with legal, ethical, and reimbursement standards • Requires timely, accurate, and complete records • Ensures confidentiality and security of client data

3. Legislation and Privacy • HIPAA: Protects client PHI use, sharing, storage • FERPA: Protects student records; grants parental and eligible student access • Documentation must remain objective and non-offensive • Avoid harsh or judgmental language

4. Documentation for Billing • AOTA Code of Ethics: Honest, accurate documentation • Fabrication or falsification is unethical and illegal • Billing codes are legal verification of services • Improper billing = fraud with legal implications • Practitioners must safeguard PHI in billing

5. Privacy & Confidentiality Practices • Secure verbal communications • Avoid discussing outside team • Secure files/screens when unattended • Use secured wireless networks • Log off systems after use • Do not share passwords or post client data on social media

6. Electronic Medical Records (EMRs) • EMRs include: demographics, insurance, evaluations, progress notes, billing • Benefits: efficiency, scheduling, invoicing • Billing: CMS Form 1500 or superbill • Limitations: cross-system sharing • EHR required for multi-provider data sharing • Safeguards: unique login credentials only

7. Professional Writing & Audience • Documentation reflects professional reasoning and skills • Must be clear, concise, accurate, objective, grammatically correct • Tailored to audience: schools, medical professionals, insurers, caregivers • School docs: less jargon, focus on functional engagement • Medical docs: clinical terminology expected • Administrators ensure payer-specific billing compliance