Compliant Rehab Documentation

Gerard Mounic, OTD, OTR/L, BCPR, C/NDT, COS-C, LSVT-C, AOTA Board Certified Physical Rehabilitation

Compliant Rehab Documentation

CE Information


Course Brochure

Contains CE information for additional professionals

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Course Highlights

  • Documenting functional progress for both part A and B Medicare services
  • Differences in payment models such as Medicare, Medicarelike, Medicaid, Bundled, Case Rate, and Value-Based
  • Prevent and prepare for general, focused and targeted audits and best practices should you be audited
  • Accurately update and document plans of care, functionaland realistic goals, treatment and discharge summaries to maximize reimbursement
  • Creating documentation that is appropriate for restorative/ compensatory interventions vs maintenance therapy
  • Avoiding major pitfalls such as medical errors, fraud, and abuse, as well as considerations for EMR
  • Ethical considerations for rehab professionals in today's landscape

Additional Info

The triple aim of our healthcare system is that we reducecosts, achieve better outcomes and improve the patient's experience (value). As a result, our healthcare reimbursement is also changing and the old rules no longer apply. In a world of value based payments, bundled payments, case rates and the like, documentation requirements and expectations have also changed. Year after year our healthcare budget gets cut, savings are achieved through stricter, and more focusedauditing and penalties. How will you navigate this new minefield? Clinicians and institutions that master how to justifytheir services have defensible (audit proof) documentation, achieve value while improving the patient experience with maximize reimbursement, strengthen their clinical & fiscal standing in the communities they serve and justify their role in an ever-changing environment.

This one-day course is designed to educate the participant on this new healthcare landscape and all of its strict clinical and documentation requirements and expectations. The course will delineate payer and clinical expectations for all rehab settings and provide the tools for clinical decision making, documentation creation, and to achieve outcomes sustained by standardized tests. Core and essential concepts pertaining to Local Coverage of Determination (LCDs) will be discussed as they apply to coredocumentation requirements and CPT billing as well as standardized tests and measures (performance based vs. patient self-rated) as they relate to G-codes (percentage ofdisability) will be discussed. Participants will be able to satisfy the clinical and documentation expectations to maximize reimbursement, achieve functional and valuable outcomes(goals) for patients, improve satisfaction, prevent premature patient discharges, and reduce re-hospitalization. Thisworkshop will focus on how to use clinical decision making optimally to determine goals, progress, and understand how interventions are used to "justify" skilled care. Most importantly is how ALL of this is documented differently depending if your treatment approach is restorative/compensatory versus maintenance, for traditionalMedicare payers vs. bundled/value based payers. Maintenance therapy will be discussed as maintenance therapy MUST be provided if the patient requires it and is increasingly being scrutinized by auditors. This workshop will address maintenance expectations and related documentation essentials.

This workshop is taught by an experienced clinician and clinical auditor with over 18 years of experience in multiple settings. This innovative workshop will provide clinicians with first hand, industry standard information to avoid the pitfalls commonly seen in audits and clinical reviews through optimized, defensible documentation. Institutions will also benefit greatly to maximize reimbursement and improve clinical outcome ratings and industry benchmarks.

  1. Describe patient deficits in terms of current disabilitymodels and document "skilled interventions" by payer source.
  2. Establish how different payment models (Medicare, Medicare like, Medicaid, Bundled, Case Rate and Value- Based) require different documentation basics.
  3. Analyze data to update plan of care, set functional and realistic goals, document treatment effectively and update progress to maximize reimbursement.
  4. Create defensible clinical documentation that demonstrates reasonable and necessary care that is skilled and valuable (patient experience).
  5. Develop the required steps for general audits, focused &targeted audits (ZPIC) probe & educate audits.
  6. Interpret what documentation is expected and appropriatefor restorative/compensatory interventions v
  7. maintenance therapy.
  8. Establish how to use task analysis to improve clinical interventions, and documentation.
  9. Evaluate how to create audit proof documentation from the start and how to avoid documentation pitfalls and how toprepare should you be audited.
  1. Healthcare TODAY and What it Means to YOU!
    1. Healthcare models: Clinical and documentation expectations
      1. Triple aim of healthcare as an underlying concept
      2. PTs, OTs, STs scope of practice and continuity ofcare
      3. New payment structures and expectations
      4. Pay for performance/value-based care
      5. Bundled payments
      6. Case rates/DISRP models
      7. Medicare and Medicare-like vs Medicaid v. Managedcare
    2. The triple aim, disablement and the ICF framework
      1. Functional outcomes and its requirement in documentation
      2. Concepts of disablement
      3. ICF-Model and classifying clinical observations and outcome measurements according to ICF
  2. Purpose and Legal Aspects of Documentation
    1. Purpose of documentation
    2. Legal expectations: Key aspects of documentation and common pitfalls
    3. Mandatory use of standardized assessments
    4. IMPACT act requirements
    5. Documenting the Plan of Care (POC) and administrative requirements (technical denials)
    6. Ethical considerations for the rehab professional
  3. Roadmap for Audit-Free Interventions: Clinical Rationalethat Depicts Skilled Services that are Reasonable, Necessary, and Valuable
    1. Reason for referral (primary diagnosis vs. comorbidities)
    2. Documenting activities
    3. Documenting impairments and limitations in body structure/function
    4. Developing and documenting effective goals
    5. Documenting goal status (progress) and functional outcomes - progress notes
    6. Justify need for ongoing services, and measuring outcomes
  4. Roadmap for Audit Free Documentation: Documenting Skilled Services that are Reasonable, Necessary, and Valuable
    1. Documentation requirements to ensure coverage for all payers: Components of Medicare documentation (11 standards and basis of audits)
    2. How to demonstrate reasonable and necessary/skilledservices
    3. Setting specific expectations and documentation requirements (for inpatient rehab, SNF, home care, outpatient)
    4. Documenting and adhering to the local coverage of determinations "LCDs" (CPT codes and what documentation is required)
    5. Restorative/compensatory therapy vs. maintenance therapy: Expectations and documentation requirements
    6. Patients have a right to maintenance therapy!
  5. Audits: How to Prevent them and/or Prepare Forthem
    1. Medicare denials, appeals (quality improvementorganizations), justification,guidelines, and requirements
    2. Therapy specific audits (ZPIC)
    3. Targeted audits; Probe and educate

Gerard Mounic is a licensed and registered Occupational Therapist and Auditor, AOTA Board Certified in Physical Rehabilitation with over 17 years of clinical experience. Dr. Mounic holds advanced certifications in Neuro Developmental Treatment (NDT), FIM, OASIS, and LSVT, he has also completed advanced training in vision/perception and vestibular rehabilitation. His experience spans multiple settings including: acute, sub-acute, hospital inpatient/outpatient, private practice and home care including hospice and palliative care. Dr. Mounic also has extensive training and experience in clinical research in the areas of upper-extremity robotics and CIMT. Dr. Mounic is an experienced program developer/consultant and neurological clinical expert presenting nationally on multiple topics including vision, cognition, postural analysis, wheelchair seating and positioning and the use of mobile apps in rehabilitation. Currently, Dr. Mounic manages the compliance department of the largest not for profit home care agency in the country and has vast auditing experience with regulation, documentation and clinical expectations. His knowledge and experience in this area is key in achieving compliant clinical documentation that supports reasonable and necessary care as well as supporting skilled services for risk free audits.


FINANCIAL: Gerard Mounic is compensated by Summit as an instructor.

NONFINANCIAL: Gerard Mounic has no nonfinancial relationships to disclose.

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Content Level: Intermediate

ASHA CE Information

ASHA Continuing Education

Summit Professional Education

Intermediate Level

ASHA CE Provider approval and use of the Brand Block does not imply endorsement of course content, specific products or clinical procedures.

SATISFACTORY COMPLETION: Participants must register, pay tuition fee, sign in with a mobile device via scanning electronic QR code at workshop location, attend the entire workshop, complete an electronic evaluation, as well as any other required state-specific supplements (if applicable) and sign out with a mobile device via scanning electronic QR code in order to receive a certificate of completion. Participants not fulfilling these requirements will not receive a certificate. Failure to sign in or out and complete a course evaluation will result in forfeiture of credit for the entire workshop. No exceptions will be made. Partial credit is not available.

Scope of Practice: Workshop content is not intended for use by participants outside of the regulatory scope of practice of their license(s). You are responsible for knowing what lies within and without your professional scope of practice.

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With that as our foundation, we are proud to now offer Online Continuing Education courses that we believe set a new standard of high quality. Leveraging our exceptional teaching faculty that delivers thousands of live workshops each year (with an average customer satisfaction rating of 4.7 out of 5.0), we have now invested in creating the same exceptional Online course experience.

We deliver Online courses that are both high quality and easy to use:

We invest in high quality video production

  • Excellent sound, multiple cameras and camera angles
  • "You are there" tight coverage of lab exercises
  • Edited video content to focus on highest learning content

Our Online platform is state of the art

  • You can see video of the instructor and slides at the same time, plus also follow the course outline and download manual
  • You can stop, start, & pick up again at your convenience (up to 30 days)
  • We are mobile friendly, and also provide live telephone technical support, Monday - Friday 6AM to 6PM CST

Finally, we are so confident that you will like our Online courses, we provide a 100% satisfaction guarantee. Watch up to the first 30 minutes, and if you are not satisfied, you will receive a full refund. Must contact Summit within initial 30-day viewing period.

On-Demand: What to Expect

We want to make sure that you are 100% comfortable with what you are purchasing, so this is a rundown of the experience you should expect.

Here's what you can expect from our media player:

  • Watch high quality video of your instructor while also viewing the power point presentation
  • Compatibility with both Mac and PC
  • Mobile compatibility so you can watch on your phone or tablet

We have also built in multiple helpful links within the media player so you can:

  • Download the manual
  • Get technical support
  • FAQs to common questions
  • Launch your post test and obtain your certification

Media Player Details

This is what the media player will look like when you first launch the video:

Note: The video will automatically start playing once you open the player. It may be beneficial to pause the video at the beginning so you can get organized and optimize your experience.

Icons at the bottom

You will notice 4 Icons on the bottom of the player, this is what these tabs do:

  • Helpful details regarding the course, anything you need before starting, and how the video player works
  • This is where you can see the course outline and download your manual
  • FAQs on the most common questions to enhance your video experience
  • Where your post course test and certification will be located after you finish the video

Links in the top right hand corner

There are also 3 links in the upper right hand corner:

  • Support - Gives you the number to the technical support team for issues with the media player
  • Account - Takes you to your online profile, and is also where you log out of the media player
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Continuing Education Credit FAQs

How do I know if the workshop is approved or registered for CE credit for my profession and state?

We do the work upfront and when you select your profession and state, we only present courses that have CE approval or registration for that profession and state. You can also view the licensing approval or registration by profession on the Product page of any course (middle of page, far right tab of "CE Credit")

If you have further questions regarding your CE approval or registration, please contact Summit Customer Service M-F from 6 a.m. to 6 p.m. CST at (800) 433-9570 or email

Why aren't all online workshops approved or registered for my profession and state?

The approval or registration of online workshops varies by state and profession, and some licensing boards have longer approval or registration turnarounds than others.

How many credits do I receive for an online course?

Typically you will receive the same number of credits that you would get at a live workshop. Currently, all of our online workshops range from 1-6 credit hours (with some exceptions based on state and profession). You can view the licensing approval or registration by profession on the Product page (middle of page, far right tab of "CE Credit") where you can see the exact number of credit hours for each profession and state.

If you have further questions regarding CE credits, please contact Summit Customer Service M-F from 6 a.m. to 6 p.m. CST at (800) 433-9570 or email

Does Summit report to CE broker? ASHA?

Yes. Once you complete your online course, post-course requirements, and the printing of your certificate, please follow the below steps.

For ASHA reporting an online course: Once you have met satisfactory completion requirements of the course, you will have access to a participant form via a "Report to ASHA" button in your account (next to the "Certificate Download" button). Simply select the "Report to ASHA" button, provide your ASHA member ID, and select "Submit". Please note, the "Report to ASHA" button will only be available in your account to submit your request for 10 days from the date you completed the online course after which Summit will be unable to report your completion to ASHA.

Online course completions are reported to ASHA following the below schedule:

  • Completions dated 1/1 - 3/31 will be reported to ASHA no later than 5/15
  • Completions dated 4/1 - 6/30 will be reported to ASHA no later than 8/14
  • Completions dated 7/1 - 9/30 will be reported to ASHA no later than 11/14
  • Completions dated 10/1 - 12/31 will be reported to ASHA no later than 2/14

Summit offers CE Broker reporting on behalf of FL PTs, OTs, SLPs and ATCs as well as for AL OTs, OH SLPs, SC PTs, OTs and SLPs. Licensees in states/professions outside of these listed should self-report at using the information provided on the certificate of completion. More information can be found here.

Online Course Content FAQs

Is an outline of the course content available before or during viewing?

You can see a course outline on the Product page under the Course Outline tab. After purchase, the course outline is also provided on the media player for watching the course.

How do I access the course manual?

Once you have purchased the course, there is a tab at the bottom of the media player where you can download the manual to save or print for your personal use.

Manual is located in the "Resources" tab

Are there labs in the course? What do I do if there are labs during the course?

Most of our courses have hands-on lab content, varying from minimal to significant. By looking at the Course Outline tab on the Product page, you can see how intensive the labs are for each course. During the lab section, we have invested heavily in providing very strong video content (i.e. very tight camera angles) so you can learn along with the live attendees. Depending on the course, you may want to simulate the activities that are presented in the course (which will be noted in the "Before You Start" section of the media player).

Where can I find who is teaching the course and his/her professional credentials?

You can see the instructor and their credentials on the product page under the Instructor Info tab

Online Video Experience

How long is the course?

Courses range in length from 1-6 hours. You can see the exact length of the course by visiting the course Product page.

Will I need any special materials to take the course?

After purchasing, the any special materials or specific advice is listed at the bottom of the "Course Info" tab.

Can I fast-forward or rewind through the online course?

Yes. For your convenience, you may fast-forward or rewind while watching the course. However, please note you will be required to certify you have watched the entire course to obtain CE credit.

Are there breaks? Can I press pause while watching the course?

There are no formal breaks in the video content. However, there is a pause feature to allow taking breaks at your own convenience.

Can I complete the course over several days? How much time do I have to finish the course?

Yes, you can always press pause or stop to take a break at your own convenience. Also, if you leave the course, please note where you left so you can pick up where you last finished. However, please remember you need to finish the course and pass your post course test within 30 days (non-subscribers) or before your subscription ends (subscribers).

Is the online course interactive? Will I be able to ask questions during the course?

The video that you will be watching is a recorded version of a live workshop. The video captures Instructor answers to participant questions, but there is no opportunity for you to ask questions with the instructor, real time. If you do have questions for the instructor, most instructors have their email address at the end of their presentations.

Am I able to re-watch the online courses even after I have completed the post course test and received my certificate?

Once you purchase the online workshop, you have 30 days to view the workshop as many times as you want as well as to review the manual (if you choose not to download while taking the course). For subscribers, your access is unlimited while your subscription is active.

Can I get a refund if I don't like the course?

We want your experience with Summit to be an enjoyable one. If you purchase an online workshop and don't like it for whatever reason, please stop within the first 30 minutes to receive a full refund. Then call us at (800) 433-9570 to talk with our customer service team to get your refund or a new online course.

Test & Certificate

Will I need to take a post course test? Why?

Yes, you are required to successfully pass the post course test to obtain CE credits and certification. This is required by our licensing boards for online courses.

What is the post course test like, what is a passing score, and how many times can I take it?

Post course tests consist of True/False and/or multiple choice questions. You will be able to retake the post course test as many time as necessary to receive a passing grade. A passing "grade" is 75% or higher for general content, 80% or higher for certain state specific workshops, like ethics, jurisprudence, and laws and rules courses. You will be able to retake the post course test as many times as necessary to receive a passing grade.

When will I receive my credits and certificate?

Once you complete your course evaluation and online test, you will be able to immediately download your certificate and request CE Broker or ASHA Reporting (if applicable).

Technical FAQs

What browsers and Operating system do I need to run for this to work properly?

The following are the supported browsers and Operating Systems for the media player to work properly:

  • Internet Explorer 11 or Microsoft Edge 44+ for Windows 10
  • Google Chrome 75.0+ for Windows, Mac OSX, or Linux
  • Mozilla Firefox 70.0+ for Windows, Mac OSX, or Linux
  • Safari 12.0+ for Mac OSX 10.13 and above

Will the media player work on both a Mac and PC?

Yes, the online courses will play on both a Mac and PC. The following are the supported browsers and Operating Systems for the media player to work properly:

  • Internet Explorer 11 or Microsoft Edge 44+ for Windows 10
  • Google Chrome 75.0+ for Windows, Mac OSX, or Linux
  • Mozilla Firefox 70.0+ for Windows, Mac OSX, or Linux
  • Safari 12.0+ for Mac OSX 10.13 and above

Can the workshops be played on my phone?

Yes! You are able to watch the workshops on your phone. Here are the technical requirements to ensure it works properly:

  • Safari on iOS 13+
  • Safari on iPadOS 13+
  • Chrome on Android 9.0+
  • Any running Android 9.0+

Are the videos downloadable or streaming?

All of the videos stream from the media player.

How does the streaming video work?

Live streaming video is content sent in compressed form over the Internet and displayed by the viewer in real time. With streaming video or streaming media, a Web user does not have to wait to download a file to play it. Instead, the media is sent in a continuous stream of data and is played as it arrives.

Will I experience any occasional buffering or freezing of the video?

Because of our streaming video approach, this rarely happens. If it does, it's typically because of customer internet access quality issues and we will provide troubleshooting tips as well as telephone support from our help desk.

Do you provide technical support?

Our help desk is available to assist you by phone Monday through Friday, 6AM to 6PM at (800) 433-9570.

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Course at a Glance

All our courses are available at a number of locations and at various dates. You can also take many of our courses online whether in video or text format. Below are all the available options for

  • Mt. Laurel, NJ - Jul 22, 2022
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  • There are no online video options available for this course.

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