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Additional Considerations While physician orders and proof of delivery requirements are crucial parts of any self audit, there are other pieces of required documentation that also must be considered. Medicare expects there to be and relies on documentation within the patient’s medical record to support the medical need for any item or service that you provide. This often requires you to rely on the documentation of other health-care providers, especially physicians, in order to support the medical need for your claim. Performing self audits that include a review of required documentation from sources outside of your organization is a vital part of the process. Documentation should be legible, should discuss the medical
need for the specific item or service that is being ordered, and must be signed and dated by the health-care professional who is writing the information. In cases where the signature of the referral source is not legible, you may need to obtain a signature log that identifies the signature as authentic. While it is challenging to ensure the documentation of others is written in a way that Medicare considers acceptable for supporting
Reimbursement Page
the medical need of the item you are providing, the fact remains that it is a Medicare requirement and, therefore, must be part of the self-audit process. The process of creating and administering a self-audit program is one that must be uniquely tailored to the individual needs of your O&P practice. While this issue’s Reimbursement Page only highlighted a few important components of the process, the nature of your business will dictate additional steps that you should take when creating your own self-audit process. The important thing to remember is that a thorough and effective process today may save you from serious consequences tomorrow. a Joe McTernan is AOPA’s director of coding and reimbursement services. Reach him at jmcternan@ aopanet.org.
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DECEMBER 2013 O&P Almanac
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