Report hospice backdating documents

Although quality-reporting programs such as meaningful use provide incentives to help providers implement and use electronic health records (EHRs) to collect and report on clinical data, practices often need help deciding what data to collect, which measures to report ...A solicitor has been struck off for backdating a letter to the court to cover a mistake while employed in the Treasury Solicitor’s Department.He told the tribunal his mother had died in January 2013 and his arranged marriage had been on the point of collapse.

To assess the impact of these two documents, providers should conduct their own review of order signatures to see if they meet these new requirements.

At the same time, the documentation supporting the services provided should be reviewed to determine if it provides all the information necessary to support medical necessity.

Now, CERT requires evidence of the treating physician's intent to order tests, including signed orders and/or progress notes.

Again, in the past, CERT would review available documentation, including physician orders, supplier documentation, and patient billing history, then apply clinical review judgment.

In healthcare, every interaction with the patient matters.

Especially in today’s environment of continuous improvement, efforts have been concentrated on coordination among providers, the patient care experience and quality outcomes – all laudable goals.

Two recent publications issued by CMS clearly indicate that the organization is tightening its requirements for the documentation required to support medical necessity and mandated signatures on prescriptions and orders for services.

The first publication is the "Improper Medicare Fee for Service Payments Report of November 2009." This report details the type and percentage of errors found in claims as determined by reviews performed under the CERT (Comprehensive Error Rate Testing) program.

In the past, CERT would apply clinical review judgment in considering medical record entries with missing or illegible signatures.

Now, CERT disallows entries if a signature is missing or illegible.

Page 9 of this document describes changes in what is acceptable and not acceptable for documentation to support the medical necessity of services provided.

Tags: , ,