At the beginning of the New Year most of us make resolutions. Whether it is for health, exercise, fiscal or general life improvements, resolutions can be good for us. Resolutions for documentation can be beneficial too. Whether you are adhering to a requirement or simply defining a best practice, the following resolutions may be good to share with your staff:
- Problem - Illegible signatures: If a reviewer/auditor cannot read the practitioner's signature on the medical record you will likely receive a denial. Solution: A signature log or signature attestation can provide clarity when there is an illegible signature.
- Problem - Illegible provider documentation: Some providers still use handwritten notes for their documentation. If a reviewer cannot read the discussion to support medical necessity of the DMEPOS item, the claim will be denied. Solution: In the event progress notes are illegible due to poor handwriting, request a transcription of the note(s).
- Problem - Inconclusive date of receipt: Although this is not a requirement for all documentation, it is a best practice to date stamp when the documentation is received by the provider. Date stamps should not obscure other information on the document and should be dark enough to be readable and show the correct date.
- Problem - Medical records do not correctly identify the patient: When submitting a multiple page progress note it is best practice to be certain the patient’s name is on each page. If not, the pages should be clearly numbered to (i.e. 1/10, 2/10, etc.) in case they get separated during the review process.
- Best Pratice - Use documentation checklists: Each of the DME MAC Jurisdictions have several documentation checklists available on their websites for supplier use. You can use these outright, or create your own checklists. These will help ensure consistency with your processes.
- Best Practice - Invest in staff training and education: A well trained staff provides for more efficiencies. Make a resolution to provide your patients with the best possible equipment, delivered timely, and with limited denials or appeals needed