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  • Self Audit DOS 10/12/2017

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    Prajan J
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    The document summarizes various issues found during a self-audit of medical documentation and billing practices. It provides suggestions to standardize documentation of advanced care planning discussions, lab test results, injections, and smoking cessation counseling. It also notes issues with replacing inactive insurance information, missing documentation of patient encounters, and discrepancies between medication administration documentation and inventory records. Standardizing documentation in key areas would help streamline billing and ensure accurate claims are submitted.

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    The document summarizes various issues found during a self-audit of medical documentation and billing practices. It provides suggestions to standardize documentation of advanced care planning discussions, lab test results, injections, and smoking cessation counseling. It also notes issues with replacing inactive insurance information, missing documentation of patient encounters, and discrepancies between medication administration documentation and inventory records. Standardizing documentation in key areas would help streamline billing and ensure accurate claims are submitted.

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    18 views2 pages

    Self Audit DOS 10/12/2017

    Uploaded by

    Prajan J
    The document summarizes various issues found during a self-audit of medical documentation and billing practices. It provides suggestions to standardize documentation of advanced care planning discussions, lab test results, injections, and smoking cessation counseling. It also notes issues with replacing inactive insurance information, missing documentation of patient encounters, and discrepancies between medication administration documentation and inventory records. Standardizing documentation in key areas would help streamline billing and ensure accurate claims are submitted.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 2

    Self Audit DOS 10/12/2017

    **Sun, Richard – Summary says “ACP discussed on 1/17, will discuss on next visit” ACP(Advanced Care
    Planning 99497 can be billed once in 6 months). Providers mention in summary as “ACP discussed”. I
    need to check all previous visits and go back 6 months to find if ACP is required for the visit which makes
    billing complicated.

    SUGGESTION: All providers can create a sub-header like injection description for ACP and mention next
    due date and when it was done previously.

    Example

    ACP:

    Discussed on 10/12/2017, Next due date on 4/13/2018

    ***Few providers do not mention CBC description in summary but when checked in medcom I find CBC
    was done. I do not have an example for this but this happens once in a while.

    SUGGESTION: All providers can create a sub header for CBC and mention whether it was seen today or if
    they are mentioning a previous CBC

    Example:

    CBC:

    CBC done today 10/12/2017

    ***Injections by MA - MA’s at satellite office can mention if the injection was PDP or outside RX as well
    as we provide in injection description as earlier which was helpful. At times they are missing to enter in
    in house reports(Inventory)

    Example: 2 injections were given on 12/27/2017 at satellite office but couldn’t find details in inventory-
    in house reports.

    DOS 12/27/2017 patient name Rice Shirley, ZAHL Merton injections were not pulled in inhouse reports.

    ****Smoking cessations- In summary providers can create a sub header for smoking cessation as well.

    Example:

    Smoking cessation discussed-duration 10 minutes- This will be helpful for me to bill 99406
    ***Insurance Eligibility:

    Eligibility team replaces inactive insurance in the demographics tab. For example patient has cal optima
    until 12/31/2017 and active with medicare from 1/1/2018. When I post dos 12/22/2017 I see Genius
    picks up active insurance which is Medicare. This is incorrect as claim should go to Cal optima for dos
    billed. So eligibility team should mention effective and termination date in genius doc and should not
    replace old insurance with new one which I see around 3-4 cases a month. I come to know about this
    when inventory has old insurance pulled since it has old data. I then go to eligibility excel and add old
    insurance id # which is really time consuming and can be simplified.

    ***DOS 10/12/2017- Groom, Catherine patient not found in inventory. I had to check with Johnny to
    post the account since this was SCOA patient.

    ***DOS 10/12/2017-Duarte Trujillo Eliaser – GD shows VIDAZA WAS GIVEN ONLY 200 UNITS BUT IN GD
    WE HAVE 100 WASTAGE AND 200 WAS GIVEN, INVENTORY SHOWS ONLY 200 with no Wastage. I have
    posted as per inventory

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