Medical Record Documentation Compliance Audit Paper

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Outpatient Therapy Services
Medical Record Documentation Compliance Audit

I. Purpose
• To ensure compliance with Medicare Benefit Policy Manual Chapter 15 – Covered Medical and Other Health Services part 220 - Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance (Rev. 194, Issued: 09-03-14) and other third party payer documentation requirements for outpatient rehabilitation services.
• To proactively identify patterns of potential billing errors concerning third party payer coverage and coding made by providers through data analysis and evaluation of other information.
• Review Recovery Audit Contractor (RAC) vulnerabilities.
• Take …show more content…
Nurse Practitioner (NP), Clinical Nurse Specialist are not able to provide a valid referral for physical therapy, occupational therapy, or speech language pathology services, per Michigan State Practice Act.

2. Patient Intake Care Summary Form
a. The form will be completed in its entirety.
b. Non-applicable questions will be answered N/A or a slash to indicate this.
c. All additions or entries made by the practitioner will be initialed by the practitioner.
d. Patient provided lists (eg., past medical/surgical history, medications and/or allergies) should be referenced on the Patient Intake Summary Care Form. Referenced medical documentation should be signed by the therapist indicating it was reviewed, labeled with patient identifiers and placed in the medical record.
e. The form must be initialed on the first page by the practitioner and signed, dated, and timed by both patient and practitioner on the second page.

3. Initial Evaluation
a. Will include medical diagnosis, treating impairment or dysfunction, subjective observation, objective observation (e.g., identified impairments and severity or complexity) and assessment.
b. Will be dictated by close of the next business …show more content…
Progress Notes
a. A progress note with updated plan of care must be completed once every 10 visits (Evaluation being visit 1).
b. The progress note shall be written by the therapist/clinician with focus on progress toward current goals; professional judgment about continued care; modification of goals and/or treatment; or terminating services.

8. Discharge Summary
a. The clinician should consider the discharge note/summary, the last opportunity to justify medical necessity of the entire treatment episode.
b. Discharge Summaries must be dictated and completed within 30 days of acknowledgement of termination of care.
c. If a discharge is anticipated within 3 treatment days of the progress report, the clinician may provide objective goals which, when met, will authorize the assistant to discharge the patient.
IV. Compliance Metrics Utilized
1. EMR Form 0176
a. Metric #1: Patient Intake Care Summary completed
i. Condition: present in record ii. Condition: signed by therapist

b. Metric #2: Referral Signed
i. Condition: physician/non-physician practitioner prescription, electronic order, fax, ii. Condition: physician/non-physician practitioner signature,
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