Premier Physician Testimonial: Bill Tucker, MD
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Government Payors are Stepping Up Their Audits: Help Minimize the Impact by Being Compliant
June 15, 2010
Premier has seen a dramatic increase in the number of charts being audited by Medicare. This coincides with what other practices are experiencing nationwide. Between the Prepayment, CERT, RAC, and MIC audits, practices are seeing many claims being downcoded or flat out denied as a result of these audits. Don’t worry, many of these decisions can be overturned in the Appeal process. However, the best approach is to prevent many of these negative decisions from occurring in the first place.
What You Can Do to Help
As a clinician, you can do several things to help prevent claims from being downcoded or denied. Most of these suggestions are what you already know, so they won’t be burdensome.
All Chart Entries Must be Legible
If an auditor is not able to read a clinician’s handwriting, the entire service can be denied due to illegibility. All handwritten entries should be legible – make sure your entries can be read by others.
All Signatures Must be Valid and Legible
(Includes the Order’s sheet.) Either a handwritten or an electronic signature is an acceptable valid signature. For handwritten signatures, a full name or your first initial and last name are acceptable. Stamped signatures are not acceptable and should never be used.
Clear Documentation of Medical Necessity for Diagnostic Testing
If you order diagnostic tests, your reason for the orders should be clearly stated.
Example:
CT abdominal scan did not show any evidence of an AAA.
Document the Conditions You are Ruling Out
The number and type of conditions you are ruling out can ultimately affect the level of service of that encounter. Don’t forget to document the differential diagnoses, as well as the risks.
Example:
Medical Decisionmaking: To rule out an AAA, obstructive pyleonephritis or visceral etiology, a CT scan was ordered.
Templated Charts
Be careful when completing templates.
T sheets:
- Follow the T sheets instructions for documenting (i.e., circle or check affirmatives, backslash negatives). Ensure your markings are over the appropriate response(s).
- ROS section – When performing a comprehensive ROS, don’t forget to check the “all systems negative box.”
Following these guidelines ensures your chart is compliant, and all your hard work will be recognized.
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