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Compliance

Ensuring compliance with state and federal law, as well as contract regulations, is everyone’s responsibility. At Ped-I-Care, we work proactively to assist providers with compliance, from education and training materials to fact-finding, support-focused audits in which feedback and recommendations are provided. Ped-I-Care conducts both routine and for-cause audits, as described in the Compliance and Anti-Fraud Plan and Compliance Policies listed below.

Click here to review the 2016 Ped-I-Care Compliance and Anti-Fraud Plan.

Ped-I-Care’s Compliance Policies Include:

Provider Training

Photo Credit: CDC/Debora Cartagena

Photo Credit: CDC/Debora Cartagena

Providers and practices are responsible for ensuring they and their staff are adequately trained regarding the prevention of fraud, waste, and abuse. Ped-I-Care’s online training tutorial is available at http://pedicare.peds.ufl.edu/compliance/index.html. Completion of Ped-I-Care’s online training is not mandatory but is recommended and may be utilized as a resource for practices to train providers and staff.

Compliance Requirements

Ped-I-Care providers are expected to adhere to the following guidelines for medical records and claims. Note that it is not an all-inclusive list; it is a list of findings commonly identified during medical record and claims audits.

Providers/practices must:

  1. Ensure documentation is legible;
  2. Ensure documentation supports what is billed on the claim;
  3. Ensure documentation supports billed modifiers;
  4. Ensure the site/practice location of where services were rendered is documented in the note (if a practice has multiple locations, the location for each encounter must be clear in each note);
  5. Ensure the Chief Complaint is documented (the medical reason for a “follow-up” visit must be documented);
  6. Ensure each note’s documentation is unique and specific to the presenting problem(s)/reason for the encounter (be careful of copy/paste, cloning, and bringing forward information from other encounters);
  7. Ensure notes do not contain conflicting information (i.e. an assessment of Acute Respiratory Infection with no complaint of cough, runny nose, or difficulty breathing and normal respiration, lungs, ears, nose, and throat documented on the exam);
  8. Ensure the exam and service(s) rendered support the medical necessity of the reason for the encounter/presenting problem(s);
  9. Ensure all procedures are documented in medical record;
  10. Ensure subsequent pages of each note contain patient identifying information;
  11. Ensure if billing based on time, that the medical record documentation includes a statement regarding the total time spent with the patient AND a concise description of the content of the counseling that was provided;
  12. Ensure notes are signed in a timely manner (providers are expected to sign all records within a reasonable time frame, usually 48-72 hours of an encounter);
  13. Ensure electronic signatures are dated;
  14. Ensure the claim is NOT billed before the note is signed by the attending provider;
  15. Ensure each claim is submitted in the name of the provider that actually rendered services and signed (or co-signed in accordance with incident-to requirements) the note; and
  16. Ensure errors in the chart are corrected appropriately.

From the Medicare Handbook (Medicaid guidelines follow Medicare):

Signature

Requirement

Met Not Met
1 Legible full signature X
2 Legible first initial and last name X
3 Illegible signature over a typed or printed name X
4 Illegible signature where the letterhead, addressograph, or other information on the page indicates the identity of the signatory.

Example: An illegible signature appears on a prescription. The letterhead of the prescription lists (3) physicians’ names. One of the names is circled.

X
5 Illegible signature NOT over a typed/printed name and NOT on letterhead, but the submitted documentation is accompanied by: a signature log, or an attestation statement X
6 Illegible signature NOT over a typed/printed name, NOT on letterhead, and the documentation is unaccompanied by: a signature log, or an attestation statement X
7 Handwritten initials over a typed or printed name X
8 Handwritten initials NOT over a typed/printed name but accompanied by: a signature log, or an attestation statement X
9 Handwritten initials NOT over a typed/printed name UNaccompanied by: a signature log, or an attestation statement X
10 Unsigned typed note with provider’s typed name X
11 Unsigned typed note without providers typed/printed name X
12 Unsigned handwritten note, the only entry on the page X
13 Unsigned handwritten note where other entries on the same page in the same handwriting are signed. X
14 “signature on file” X

DME Compliance Reminder: Provider Type 90

The Agency is increasing statewide monitoring of DME providers and all DME providers should take measures to ensure they are fully compliant with policy. Click here to review DME Compliance Reminder – May 2014.

 

Provider Video: Staying Compliant

Ped-I-Care has produced a brief (2:42) video for providers on how to avoid common mistakes in billing and documentation. A guide to resources is also available.

 

Click here for the TRANSCRIPT – Staying Compliant.