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ADVANCE Perspective: Physical Therapy & Rehab Medicine

CSM 2012 Preview: Get Your (Audit) House in Order

Published January 23, 2012 10:00 AM by Lisa Lombardo

ADVANCE consistently covers issues on proper documentation and how physical therapists can improve their record-keeping strategies, through adopting electronic record systems, using the latest technology and software and streamlining their staffing duties to make sure employees are operating with best practices on billing, patient privacy and other tasks.

But what about conducting your own audit? Have any PTs or PTA practice owners or managers considered a "pre-emptive strike" on their own documentation practices, before the knock on the door comes for a real-life medical review?

The best defense when faced with medical review, denials and payment recovery is clean billing and comprehensive and supportive documentation. Internal audit is a critical part of the therapy department's compliance plan related to medical review and denial prevention. During pre- and post-payment review, therapy documentation is reviewed to determine if services delivered were covered, coded correctly and reasonable and necessary to treat the patient's condition.

"Preparing for Medical Review: Auditing Your Documentation," presented on Friday, February 10 at APTA's Combined Sections Meeting in Chicago, reviews the ways physical therapists practicing in multiple venues can be proactive and successful under heightened medical review. Speaker Holly Hester, PT, MPT, will focus on physical therapy documentation and billing and provide participants with practical tips and strategies for auditing records for accuracy and compliance with Medicare regulations as well as for preparing for a RAC audit or medical review. All topics and points discussed are consistent with those used by fiscal intermediaries (FIs), MACs and comprehensive error rate testing (CERT) contractors when reviewing submitted claims, and they are supported by Medicare Coverage Manuals as published by the Centers for Medicare and Medicaid Services (CMS).

PTs in managerial positions should be able to identify Medicare requirements for physical therapy documentation and billing, and recognize common errors and key elements of an audit program to prevent denials/recovery.  

Have you ever conducted a "trial" audit or a documentation review? Do you think there is benefit to conducting a preemptive audit to be more fully prepared should an actual audit occur?


Great idea! A very good technique for self audit is to develop a tool to assess the documentation, and then have all staff audit someone else's records in the department. It winds up being very educational as good and bad examples both are found and discussed.


Dean Metz January 23, 2012 1:22 PM

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