Getting Started: Billing, Documentation and Compliance

This introductory course provides foundational guidance for occupational therapy practitioners exploring private practice and solo-preneurship. Participants will be introduced to essential considerations in billing, documentation, and compliance, with practical insights to support sustainable and ethical business development. The session offers key factors to evaluate when selecting an electronic medical record (EMR) system, outlines recommended intake paperwork components, and reviews documentation expectations for concussion and neurological evaluations in alignment with reimbursable guidelines. Attendees will define what constitutes “skilled” therapy services, examine common billing structures and review frequently utilized CPT codes relevant to outpatient neuro and concussion care. The course also introduces Medicare compliance principles and highlights areas that require careful attention to reduce audit risk.

While not a comprehensive billing or legal course, this module provides emerging entrepreneurs with practical tools, reflective prompts, and strategic considerations as they begin building a private practice. Participants will leave with greater clarity on documentation standards, revenue streams, and supplemental income opportunities to thoughtfully support their transition into independent practice. This course consists of approximately one hour of lecture.