Administrative Review, PT Solutions

• There are specific Administrative Review inspection for the following : WebPT, EPIC, Cerner/ReDoc. If this location is using one of those EMR, please close this inspection and use the correct inspection.

• What EMR system does this location use?

• Site conducted

  Select

• Conducted on

  Date

• Reviewed by

• Quarter

  1

  2

  3

  4

• ALERT - this system is not HIPAA-Compliant. As you complete your review, be sure to avoid inclusion of PHI (Protected Health Information). Anything that could potentially identify a patient should be omitted. If you have any questions, contact compliance@ptsolutions.com prior to proceeding. Please sign your name below indicating that you have read this statement and fully understand before proceeding.

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• Administrative Chart Review will be perform the throughout the year.
  
  Chart Selection will consist of 3-10 charts. The charts selected shall include Medicare (or other Federal payers) and Commercial payers. Sample selection shall be primarily Active charts with a minimum of at least 1 Discharged chart within the assigned review period. If Medicare charts are not available any other Federal payer may be used. If no Federal payer charts are available Commercial charts may be used.

Administrative Review

• What is the EMR ID?

• What is the status of this Account?

  Active

  Discharged

• What date was this account discharged?

  Date

• What is the Primary Insurance ?

  Select

• Is there a Secondary Insurance?

  Yes

  No

• What is the Secondary Insurance?

EMR REVIEW

• Is there a Photo ID present in chart?

  Yes

  No

• Is the Primary Insurance Card present in the chart for the current year?

  Yes

  No

• Is the Secondary Insurance Card present in the chart for the current year?

  Yes

  No

  N/A

• Is the Referring Therapy Order with ICD10 Code(s) listed present in the chart?

  Yes

  No

• Is this patient being treated under Direct Access?

  Yes

  No

• Is there a signed Direct Access Disclosure form present in the chart?

  Yes

  No

• Are State Direct Access guidelines and visit limitations being tracked under EMR Authorization guidelines?

  Yes

  No

• Does the chart reflect the referring physician's name or Direct Access if treating under Direct Access?

  Yes

  No

• Is this patient Self Pay?

  Yes

  No

• Is there a signed Self-Pay Opt-Out form present in the chart?

  Yes

  No

• Does the chart reflect a physician, PCP or EMR Self-Pay guidelines?

  Yes

  No

• Is the Insurance Verification forms present in the chart?

  Yes

  No

• Does this patient have Medicaid?

  Yes

  No

• Are the Monthly Medicaid benefits check present in the chart?

  Yes

  No

• Is there a Signed Explanation of Benefits/Financial Responsibility/Estimation Letter present in the chart?

  Yes

  No

• Are the New Patient Paperwork/Encounter Forms completed, signed and dated present in the chart?

  Yes

  No

• Does this patient have Medicare or Managed Medicare?

  Yes

  No

• Is the MSPQ present in the chart? *Required for all Medicare & Managed Medicare

  Yes

  No

• Has the patient met or exceeded the Medicare Threshold amount?

  Yes

  No

  N/A

• Is there a signed Letter of Medical Necessity present in the chart?

  Yes

  No

• Is there an ABN present in the chart?

  Yes

  No

• If over the $3,500 threshold, has authorization been obtained through the KX review process?

  Yes

  No

  N/A

• Are the approved visits being tracked under the ERM authorization guidelines?

  Yes

  No

• Is the Intake Functional Outcome Index or FOTO present in chart?

  Yes

  No

• Is the Status Functional Outcome Index or FOTO present in chart?

  Yes

  No

  N/A

• Is there a Signed IE POC present in the chart?

  Yes

  No

• Are there chart notes present in the chart on attempts to obtain the signed IE POC?

  Yes

  No

• Are the Follow-Up POC Signed and present in the chart?

  Yes

  No

  N/A

• Are there chart notes present in the chart on the attempts to obtain the signed Follow-Up POC?

  Yes

  No

• Are the documents properly named per EMR guidelines?

  Yes

  No

PATIENT DEMOGRAPHICS / CHART COMPLETION

• Has this patient been registered with their legal name and entered per EMR guidelines?

  Yes

  No

• Does this patient's chart reflect the correct date of birth?

  Yes

  No

• Has this patient been registered with their complete address?

  Yes

  No

• Have all contact numbers that have been provided been correctly entered into the EMR?

  Yes

  No

• Have the patient's emergency contact(s) been correctly entered into the EMR?

  Yes

  No

• If the patient provided an email address, has it been correctly entered into the EMR?

  Yes

  No

• Is the patient receiving appointment reminders per approved system guidelines?

  Yes

  No

• Has the patient's Occupational and/or Retirement date been correctly entered into the EMR?

  Yes

  No

• Has the Primary Insurance been correctly selected based on claim billing address?

  Yes

  No

• Has the Primary Insurance Policy Number / ID Number been correctly entered into the EMR?

  Yes

  No

• Has the Primary Insurance Group Number been correctly entered into the EMR? (if applicable)

  Yes

  No

  N/A

• Does the Primary Insurance have the correctly effective and termination dates listed in the EMR?

  Yes

  No

• Has the primary insurance benefits been entered under the correct EMR fields? *Copay, deductibles, visit limitations, approved codes

  Yes

  No

• Is the Primary Insurance Subscriber and subscriber DOB correctly listed within the EMR?

  Yes

  No

• If this patient is a minor, does the Primary Insurance Plan list the correct Guarantor information?

  Yes

  No

  N/A

• Has the Secondary Insurance been correctly selected based on claim billing address?

  Yes

  No

  N/A

• Has the Secondary Insurance Policy Number / ID Number been correctly entered into the EMR?

  Yes

  No

• Has the Secondary Insurance Group Number been correctly entered into the EMR? (if applicable)

  Yes

  No

  N/A

• Does the Secondary Insurance have the correctly effective and termination dates listed in the EMR?

  Yes

  No

• Has the Secondary insurance benefits been entered under the correct EMR fields? *Copay, deductibles, visit limitations, approved codes

  Yes

  No

• Is the Secondary Insurance Subscriber and subscriber DOB correctly listed within the EMR?

  Yes

  No

• If this patient is a minor, does the Secondary Insurance Plan list the correct Guarantor information?

  Yes

  No

  N/A

• Is the Referring Diagnosis code listed on the chart?

  Yes

  No

AUTHORIZATION

• Is this a Worker's Compensation case?

  Yes

  No

• Are the Worker's Employer details correctly entered within the chart?

  Yes

  No

• Has the Claim Number and Date of Injury (DOI) been correctly entered within the chart?

  Yes

  No

• Is there a valid, written Authorization for present, past and future visit in the chart?

  Yes

  No

• Is this a Motor Vehicle Accident (MVA) case?

  Yes

  No

• Has the MedPay / Funds verified, available and tracked in the chart per EMR guidelines?

  Yes

  No

• Is the patient's Commercial Insurance or Self-Pay listed as secondary in the chart?

  Yes

  No

  N/A

• Does this patient's insurance plan require Authorization?

  Yes

  No

• Is there a valid, written Authorization for present, past and future visit in the chart?

  Yes

  No

• Has the authorization been logged in the chart per the EMR per guidelines?

  Yes

  No

• Was a verbal Authorization obtained?

  Yes

  No

• Has the authorization been logged in the chart per the EMR per guidelines?

  Yes

  No

PATIENT PAYMENTS / OTC COLLECTIONS

• Is the estimation for services present in the chart per EMR guidelines?

  Yes

  No

• Is the clinic collecting patient responsibility at time the time of service?

  Yes

  No

  N/A

• Compliance Team will perform the Clinic Chart Review throughout the year. If the clinic scores 80% or better during the Chart Review no additional Chart Reviews from Compliance will be performed for the remainder of the year. **The Target goal is to achieve 90% or greater compliance.**

• Is a meeting required with the local team?

  Yes

  No

• Additional Reviewer Notes: