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:

Untapped Potential: The Art of Discovering and Selling Your PT Value - Regular BannerUntapped Potential: The Art of Discovering and Selling Your PT Value - 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!

  • The How and Why of an Effective Rehab Therapy Compliance Program Image

    articleAug 9, 2018 | 7 min. read

    The How and Why of an Effective Rehab Therapy Compliance Program

    It’s no secret that the US healthcare industry is heavily regulated—and those regulations are strictly enforced. Take this recent press release from the Department of Justice (DOJ), for example. It explains how the DOJ charged 601 individuals with fraud—the largest healthcare fraud takedown in history. Among them: 71 physicians charged with falsely billing Medicare, Medicaid, and TRICARE in cases involving the prescription and distribution of narcotics. And in New York, 13 individuals were charged with conspiracy for …

  • Common Questions from Our Medicare Open Forum Webinar Image

    articleOct 25, 2018 | 43 min. read

    Common Questions from Our Medicare Open Forum Webinar

    Earlier this week, WebPT President Dr. Heidi Jannenga, PT, DPT, ATC, teamed up with Rick Gawenda, PT—President and CEO of Gawenda Seminars & Consulting—to host a Medicare Open Forum . As expected, we received more questions than our Medicare experts could answer during the live session, so we've provided the answers to the most frequently asked ones below. Don't see the answer you're looking for? Post your question in the comment section at the end of this …

  • Signature Move: Medicare's Certification Requirements for Therapy Plans of Care Image

    articleNov 28, 2016 | 5 min. read

    Signature Move: Medicare's Certification Requirements for Therapy Plans of Care

    Oh, CMS. If only you made your wishes clear, there’d be a lot less confusion—and fewer claim denials—in the world of health care. Unfortunately, that’s just not the case, which is why WebPT devotes a solid quarter every year to educating rehab therapists on the nuances of compliance. And we haven’t come close to running out of relevant topics yet. Today, we’re clarifying some important aspects of Medicare certification requirements for physical therapy care plans. Have questions …

  • What is Defensible Documentation? Image

    articleNov 20, 2018 | 7 min. read

    What is Defensible Documentation?

    We get it: no one actually enjoys documentation. It can be cumbersome and time-consuming—not to mention frustrating. Unfortunately, though, for a PT, OT, or SLP, defensible documentation is a necessary evil. It’s a good thing, then, that technology can help make the entire process smoother—and that there are resources available to help you ensure your documentation meets all defensibility standards. But, what are those standards? What, exactly, is defensible documentation? In short, it’s documentation that not only …

  • Goodbye, Grace: CMS Ends ICD-10 Flexibility Period Image

    articleOct 5, 2016 | 4 min. read

    Goodbye, Grace: CMS Ends ICD-10 Flexibility Period

    As healthcare providers say “goodbye” to the month of September, they’ll have to say “ hello ” to more than just cooler temps and the beginning of a new season. That’s because, as of October 1, 2016, Medicare’s ICD-10 grace period is officially over. That means if providers continue to submit unspecified codes when other, more specific codes exist, Medicare will start saying “no” to paying for those claims. Feeling a bit underprepared for this change? Here’s …

  • The Devil is in the Details: How to Document Defensibly Image

    articleNov 18, 2016 | 8 min. read

    The Devil is in the Details: How to Document Defensibly

    If we polled our readers—rehab professionals like you, that is—and asked them what they love most about their jobs, we could safely bet our bank accounts that not one of our lovely PTs, OTs, or SLPs would say, “documenting defensibly.” We know; documentation is no one’s favorite. Just ask WebPTers Brian Kunich, PT, OCS, COMT, and Bradley LaFave, who surveyed their audience with that very same question during a presentation they gave at Ascend 2016 . Some …

  • articleNov 5, 2013 | 3 min. read

    Founder Letter: PQRS 2014

    Well, it’s November already, and that means two things: Thanksgiving and Physician Quality Reporting System (PQRS). Sure, PQRS doesn’t involve mouthwatering roasted turkey, savory stuffing, or creamy mashed potatoes, but it has become quite the November tradition for us here at WebPT. You see, this is the time of year that the Centers for Medicare & Medicaid Services (CMS) typically confirms the details of next year’s reporting requirements, thus allowing us to update our PQRS solution (claims- …

  • The Rehab Therapist’s Quick Guide to the 2016 Final Rule Image

    articleNov 4, 2015 | 6 min. read

    The Rehab Therapist’s Quick Guide to the 2016 Final Rule

    November is finally here, which means we here at WebPT can’t stop thinking about a juicy, flavorful, hot-out-of-the oven—Medicare Final Rule. While your tastebuds probably aren’t jumping with joy over the thought of chewing over a bunch of regulatory gobbledygook, the good news is that this year’s final rule shouldn’t be too tough to swallow (and if it is, you can always add more gravy). We’ve already picked out the most important pieces and served ’em up …

  • The Medicare Maintenance Care Myth Image

    articleNov 8, 2016 | 4 min. read

    The Medicare Maintenance Care Myth

    There’s been quite a bit of confusion over the years about maintenance care in the rehab therapy space. In fact, some providers still believe that maintenance care doesn’t meet Medicare’s definition of medical necessity. However, Medicare’s coverage of outpatient physical, occupational, and speech therapy services doesn’t depend on a patient’s potential for improvement from therapy, but rather on the beneficiary’s need for skilled care. Read on to learn the myth-busting truth about Medicare maintenance care: The Definition …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.