Good Documentation Resolutions for 2018

By Kay Ellen Koch, OTR/L, ATP, RESNA fellow, Rehab Clinical and Education Consultant

At the beginning of the New Year most of us make resolutions. Whether it is for health, exercise, fiscal or general life improvements, resolutions can be good for us. Resolutions for documentation can be beneficial too. No matter if it is a requirement or best practice, the following resolutions may be good to share with your staff.

  • Check to see if your documentation signatures are legible. If the auditor cannot read the signature on your documentation, a denial may result. A signature log or signature attestation can provide clarity when illegible signatures are present.
  • Date of receipt. Although this is not a requirement for all documentation, it is a best practice to date stamp documentation as it is received from the referring provider. Date stamps should not obscure other information on the document, however, they should be dark enough to be readable and show the correct date.
  • For power wheelchairs, the physician who performed the face-to-face should also be the one that creates the 7 element order. It could be a cause for denial if it appears someone other than the physician created the 7 element order
  • When submitting a multiple page evaluation, it is best practice for the patient’s name to be on each page and/or be all pages to be clearly numbered (i.e. 1/10, 2/10, etc.) in case they get separated during the review process.
  • When documenting the home evaluation for wheelchairs, although beneficiary’s address is not a Medicare requirement, documentation on where the wheelchair will be used is. It is best practice to include the beneficiary’s address on the home evaluation to provide clarification on where it will be used.
  • Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is reasonable and necessary. Be certain you have progress notes or therapist documentation that support what is being provided. Remember certain items for Medicare (wheelchair seating, certain support surfaces, and orthotics) are diagnosis driven, which must be listed in the medical documentation provided.
  • Use documentation checklists. Both the CGS and Noridian websites provide multiple checklists for all types of equipment.
  • Invest time in training or educating your staff, so everyone works efficiently. Make a resolution to provide your patient with the best possible equipment, delivered timely and the claim processed correctly.

 

Need some assistance training your staff on documentation requirements, best practices, or policy guidelines? The van Halem Group can help! Our trained consultants can provide both online and onsite training designed specifically for your needs. Contact us today for more information!