Outpatient Documentation – Standards and Best Practices

NOTE: This webinar will no longer be available after 6/29/2024. You will only have until 6/29/2024 to complete all components and review materials. 


Description: Healthcare reform is rapidly changing the landscape of reimbursement moving towards a value-based payment system. Clear and concise documentation is critical to payment. This course is designed for clinicians to rethink how they document patient care to show value and progress. Additionally, this educational opportunity will provide clinicians with practical tools proven for defensible documentation in the outpatient level of care. Lastly therapists will be educated on the appeal process for therapy denials which includes examples of appeal/denial letters, key takeaways and lessons learned.

Objectives: Upon completion of this course, participants will be able to: 

  • Upon completion of this course, participants will be able to:
  • Implement defensible clinical documentation that demonstrates skill, medical necessity and value.
  • Differentiate between functional and impairments level deficits and the role each play in establishing medical necessity and skilled services.
  • Analyze documentation examples to set realistic functional goals, establish treatment effectiveness, and correctly modify selected interventions.
  • Identify and utilize appropriate CPT codes and modifiers when billing.
  • Describe the difference between a rehabilitation and maintenance plan of care under Medicare Guidelines.
  • Describe the different levels of appeal and what occurs at each level.
  • Provide appropriate detail in documentation to support the denial/appeal process.

Instructor:  Kari Maurelia, PT, MBA, AMITA Health Alexian Brothers Rehabilitation Hospital/AMITA Health Adventist La Grange Medical Center

Blake Stahl, PT, MBA, Director, Rehabilitation Services, Alexian Rehabilitation Hospital

Audience:  Occupational Therapists, Occupational Therapy Assistants, Physical Therapists, Physical Therapist Assistants, Speech-Language Pathologists

Continuing Education Credits

Physical Therapy 

The Illinois Physical Therapy Board has approved this course for 1.5 Contact Hours.  Approval #216-000069

The Shirley Ryan AbilityLab is recognized by the New York State Education Department’s State Board of Physical Therapy as an approved provider of physical therapy and physical therapist assistant continuing education.  This course has been approved by the New York Physical Therapy Board for 1.5 Contact Hours

Occupational Therapy

The Shirley Ryan AbilityLab is an AOTA Approved Provider of professional development. Course approval ID# 00576. This distance learning – independent and interactive webinar is offered at .15 CEUs [intermediate, Professional Issues]. AOTA does not endorse specific course content, products, or clinical procedures.

Speech-Language Pathology

This course is offered for 0.15 ASHA CEUs (Intermediate level, Professional area).


Kari Maurelia, PT, MBA
Financial: Receives an honorarium for teaching this course from the Shirley Ryan AbilityLab; receives a salary from AMITA Alexian Brothers Rehabilitation Hospital
Non-financial: No relevant non-financial relationships to disclose.

Blake Stahl, PT, MBA
Financial: Receives an honorarium for teaching this course from the Shirley Ryan AbilityLab
Non-financial: Member of APTA and Gawenda Seminars

Basic Computer Requirements: You will need access to a computer with an Internet connection. High speed broadband access (LAN, Cable or DSL) is highly recommended. 

  • PC: Compatible Operating System: Windows XP, Vista, 7, 8, 8.1 Web Browser: Mozilla Firefox & Google Chrome
  • MAC: Compatible Operating System: OS X Web Browser: Firefox, Chrome, Safari
  • Do NOT use Internet Explorer or Microsoft Edge as they are not supported.

Cancellation Policy: To request a cancellation of an on-demand program, please provide written notice by letter, email, or fax or contact us by phone within 24 hours of placing your order and we will refund you the full course fee. If you cannot give notice within 24 hours, a credit towards a future course of equal value would apply.


Online Learning Occupational Therapists Occupational Therapy Assistants OTA and PTA Physical Therapist Assistants Physical Therapists Speech Language Pathologists