How Often Should We Audit? A documentation audit should be completed once a year. It should include five charts per provider. If your initial audit findings show a high error rate, then you will want to follow the suggested follow-up audit schedule listed below. NOTE: In addition to a full documentation audit, we highly recommend…
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Enforcing Standards The OIG General Compliance Program Guidance states, “Small entities should be prepared to designate someone, whether it is the compliance contact, an entity leader, or another designated employee, to determine whether a violation exists and the steps necessary to correct any problems. As appropriate, such steps could include: a corrective action plan; the…
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Meet the Minimum on Each Encounter Most states have a minimum documentation requirement for licensed physicians and guidance from the licensing board. Some states’ regulations include chiropractic-specific details. Often, providers forget the Routine Office Visit (ROV) within “episodic care” must have a minimum set of targeted “updated” (comparative) subjective data components from the previous visit,…
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The purpose of formal re-evaluation during an episode of care is to document changes to that point and to determine whether more active treatment is necessary. The frequency of these re-evaluations is at the doctor’s discretion and can vary based on the patient’s condition. The audit process will help you take a closer look at…
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Do Not Skip the Re-evaluation! We hear it all the time… “My doctor does not do re-evaluations because the insurance company doesn’t cover it!” Despite that statement’s error, whether something was paid for by a payer is not a good reason to avoid a necessary element of documentation. There are several types of re-evaluations. During…
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The audit process is not something that you can multi-task. It requires your undivided attention. Be sure to carve out time without interruption when auditing. The same applies to the training in this course. We do not recommend playing the videos in the background while working on another task. Be sure to download the tools…
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