October is finally upon us, which means it’s time for spooky memes, pictures of Corgis in costumes, trick-or-treating, and a scary story or two. If you’re a physical therapist, occupational therapist, or speech-language pathologist, though, there are few tricks more bone-chilling than the prospect of a Medicare audit. But, here’s a treat: being audited by Medicare doesn’t have to be a fright fest. Just make sure you follow these tips:

The State of Rehab Therapy in 2019 - Regular BannerThe State of Rehab Therapy in 2019 - Small Banner

1. Have a procedure in place.

You may not think you need one—until you do. But if—or more likely, when—Medicare asks to take a peek at your patient records, having a written procedure in place will help you keep things organized and make the process as painless as possible. If you’re not sure what that policy should look like, make sure it denotes:

  • who is in charge of the audit internally;
  • who is responsible for organizing the documents; and
  • how to transmit the documents.

2. Review the letter carefully.

This may seem like a no-brainer, but it’s impossible to overstate the importance of reading the records request letter carefully. Some Medicare auditors may request specific documents, while others may ask to see an entire medical record. So, make sure you carefully review the request for:

  • specific dates of service,
  • document types, and
  • any other special instructions.

3. Attach a cover letter.

While it isn’t required, attaching a cover letter to the requested documents is a very smart move. Going the extra mile will not only make everyone’s lives a little easier, but it’ll also save you a serious headache should you decide to appeal any demands resulting from your audit. Your cover letter is particularly useful when it comes to explaining any gaps in treatment episodes and providing a brief summary of the patient’s status. That said, it shouldn’t replace your documentation. Rather, it’ll minimize confusion and help the auditor if he or she isn’t super experienced with PT, OT, or SLP documentation.

4. Provide legible documentation.

Let’s be real: medical documentation isn’t known for being easy to read—particularly if it’s handwritten. While you’re most likely not writing your notes by hand, some of the non-SOAP notes within the medical record may be handwritten (or poorly photocopied). If that’s the case, you may need to transcribe the information. Here are a few other things to consider when it comes to readability:

  • If you’re unsure whether a particular piece of documentation is legible, have someone on your team take a look.
  • List any transcribed documentation on your cover letter.
  • Make sure your copies or print-outs are in color (if you use different colors of ink or text in your documentation).
  • Include a legend of any non-standard abbreviations you use.
  • Verify that all of your documentation is within the page margins and hasn’t been cut off.
  • Consider upgrading to an EMR if you’re still writing your documentation by hand.

5. Don’t leave anything out.

According to this article from the American Chiropractic Association, an OIG report from June 2005 found “94% of the documentation reviewed was missing one or more required elements.” So, make sure you include everything in the patient record for requested dates of service, not just the SOAP notes. This includes exam notes, medical history, plans of care, and diagnostic findings.

That said, if a document is missing from the original record, do not fabricate it. Instead, indicate the missing document in your cover letter. And if you received a physician’s signature on a plan of care outside of the 30-day timeframe, be sure to include documentation that shows you made reasonable attempts to obtain the signature in a timely manner.

6. Track what you send.

And finally, keep copies and/or make a list of every document you send and number the pages before you ship them off. That way, should you need to appeal your audit, you’ll know what you sent—and it’ll be much easier on you and anyone helping you through your audit.

7. Get receipts.

If you’re sending your documents by mail, don’t just ship them off and hope for the best. Instead, be sure to request a return receipt so you can have a record of delivery. If you submit the record electronically, keep a physical print-out of the submission on file.

Also, make sure you keep track of any phone conversations you have with the Medicare auditor. In fact, this article from PPS Impact advises you to follow up with a letter of confirmation after any telephone conference you have with a Medicare auditor.


’Tis the season of ghouls and ghosts, but if you find tales of things that go bump in the night less hair-raising as the threat of a Medicare audit, then hopefully these quick tips will help put your mind at ease. Got any Medicare audit tips of your own? Leave them in the comment section below!

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