Keep focus on patient charts

Friday, August 24, 2012

Stay frosty. Sounds like a slogan plucked from a beer commercial, but it’s actually military slang for staying alert and vigilant. That’s how Bruce Brothis says HME providers should act to ensure that patient charts are complete and accurate. “Don’t submit a claim unless you are as close to 100% sure as you can be that you will survive an audit,” says Brothis, who will give his advice for proper charting at Medtrade. Here’s a preview of his presentation.

HME News: What’s an example of something HME providers most often overlook on a patient chart? 

Bruce Brothis: They usually have the pieces right, but it’s what’s on the pieces that might be incomplete or incorrect. An example is delivery tickets. Nine out of 10 times, the ticket is signed by the patient. But often they don’t put the date, so the delivery tech just dates it himself. The date must be in the same handwriting and color of ink.

HME: What about errors on patient charts that originate from the physician? 

Brothis: It’s up to the provider to educate the physician about what they need. For example, for diabetic strips a physician might write “test PRN” or “test as directed.” That’s unacceptable. You have to specify the number of times per day. 

HME: What’s your advice for doing internal audits correctly?

Brothis: Most accreditors are forcing chart audits. It should be ongoing, depending on the size of your company. I suggest reviewing 10% of your patient base every month. 

HME: Are there upsides to increased scrutiny by auditors?

Brothis: The good news is that it’s getting people more compliant, but it’s a hard lesson to learn. You’re armed with enough information from Medicare to get it right.