Instructions for Claims Review Tool

The claims to be reviewed have been randomly chosen. 60 claims have been selected although only the first 50 will be reviewed. If a record is not available or cannot be found score that as a failed claim with no errors noted.

The tool is built to be able to count types of errors and total errors automatically. A zero generally means that the item being reviewed is there and complete. A 1 denotes an error or an incomplete document. There is no alternative or partial score for a partially complete document. Complete each worksheet for 10 claims each and the totals will automatically be calculated on the Totals worksheet.

All questions should be answered for every claim. A column to the left of the question denotes whether or not the error is a “fatal” error. Fatal errors are errors that fail the claim regardless of compliance with other questions. If there are one or more fatal errors determined through the review of the claim, the claim must be reversed. This must be manually entered into the audit tool in the last row. This will not be done automatically.

The following describes each question and how to score: 1. Is there a treatment plan that is current?

Enter If… 1. For Individuals within 180 days of initial assessment:

a. There is a treatment plan with start and stop times that cover the date of the claim.

2. For individuals in treatment for > 180 days from date of initial assessment: 0 a. There is a treatment plan review within 180 days of claim and the current treatment plan dates cover the date of the claim, OR

b. There is an updated treatment plan with start and stop times that cover the date of the claim. This may need to be revised if the final policy states a different requirement.

There is no treatment plan with dates listed for start and stop that cover the date of the 1 claim or there is no review (on a treatment plan review form) or update of the plan within 180 calendar days of the date of the claim.

2. Is the treatment plan signed with credentials and date by the clinician completing the plan?

Enter If… There is a treatment plan with the signature, credentials and date of signature of the 0 clinician completing the plan. 1 There is no treatment plan with the signature, credentials and date of signature of the 1 clinician completing the plan.

3. Is the treatment plan signed by an appropriately licensed practitioner of the healing arts?

Enter If… The plan is signed and dated by the appropriately licensed health care practitioner using 0 the table below. The date of the signature must be on or before they begin date of the treatment plan. The plan is not signed and dated by the appropriately licensed health care practitioner using the table below. The date of the signature must be on or before they begin date of 1 the treatment plan. Medicaid ONLY: The following chart is intended to help medical record reviewers determine which credential is required on a treatment plan.

NOTE: Please read down each numbered columns 1 – 3 to determine the signature requirements based on services ordered in the plan

Treatment Plan Types 1 2 3

A. Medication and/or nursing services are ordered? Yes Yes No

B. Psychotherapy and other rehabilitative Services are ordered? Yes No Yes

Who Must Sign the Plan? 1 2 3 C. Is a physician or nurse practitioner required to sign the treatment Yes Yes No plan?

D. Is any other LPHA Signature required on the ISP? No No Yes

Medicare/Medicaid Dually Eligible: all plans must be signed by a physician.

4. Is the treatment plan signed by the Medicaid beneficiary or is there a progress note detailing why the plan is not signed?

Enter If… The plan is signed by the Medicaid beneficiary or the parent/guardian with responsibility for health care decisions for the beneficiary. 0 OR The plan is not signed by the beneficiary but there is a progress note detailing why the plan is not signed. The plan is not signed by the beneficiary or the parent/guardian with responsibility for health care decisions for the beneficiary. 1 OR The plan is not signed and there is NOT a progress note detailing why the plan is not signed. 2 5. Is there a progress note?

Enter If… 0 There is a progress note for the date of the service/claim being reviewed. There is no progress note for the date of the service/claim being reviewed. *If a “1” is 1 entered here, a “1” must be entered on items 6-14 below.

6. Is the service type documented and does it match the service listed in the claim?

Enter If… The type of service provided – either name of service or code for service – is listed in 0 the progress note and matches the service listed on the claim. The type of service provided – either name of service or code for service – is NOT 1 listed in the progress note or does not match the service listed on the claim.

7. Is the time the service started and the duration listed in the progress note?

Enter If… The start and stop time OR start and duration time of the service is listed in the progress 0 note. The start and stop time OR the start and duration of the service is NOT listed in the 1 progress note.

8. The units of service listed in the progress note match the units of service billed?

Enter If… The units of service listed in the progress note match the units of service billed, OR 0 The total time of the service when converted to units, matches the units of service billed. The units of service listed in the progress note does not match the units of service billed, 1 OR The total time of the service when converted to units, does not match the units of service billed.

3 9. The date of signature, signature, title or credentials of person providing the service is listed in progress note? The auditor can look for either credentials or, in the case of paraprofessionals, a title is sufficient.

Enter If… The date of signature, signature, title, or credentials of person providing the service is listed in the progress note, OR There is a signed attestation from the provider stating that they provided the service on 0 the date listed and the progress note is a true and correct depiction of the service. This attestation must be signed and dated by the provider, OR If the service is provided by an intern, there is a co-signature by licensed supervisor, with date and credentials listed. The date of signature, signature, title or credentials of person providing the service is NOT listed in the progress note, OR There is NO signed attestation from the provider stating that they provided the service 1 on the date listed and the progress note is a true and correct depiction of the service. This attestation must be signed and dated by the provider, OR If the service is provided by an intern, there is NO co-signature by licensed supervisor, with date and credentials listed.

10. The setting in which the service was provided is listed in the progress note and is allowed by regulation for the service provided?

Enter If… Both the location where the service was provided is listed in the progress note AND 0 that location is allowed by regulation for the service provided. The location of the service is NOT listed or the location is NOT allowed by regulation 1 for the service provided.

11. Is the service provided authorized (i.e. ordered) on a current and appropriately signed treatment plan?

Enter If… The service listed in the progress note is ordered in a current and appropriately signed 0 treatment plan. The service listed in the progress note is not ordered in a current and appropriately 1 signed treatment plan.

4 12. Does the progress note describe a service that is linked to a goal or objective listed on the treatment plan?

Enter If… The service described in the progress note is linked to a goal or objective on the treatment plan (Note: both conditions must be met for A to receive a 0): A. The goal or objective from the treatment plan being addressed in the service is described in the documentation is listed in the progress note. 0 AND, If listed, does the service appear to be appropriate or relevant to the goal or objective listed in the progress note? OR B. No goal or objective listed, but the body of the note describes how the service is linked to a goal or objective on the treatment plan. The service described in the progress note is NOT linked to a goal or objective on the treatment plan: A. The goal or objective relevant to the service provided is listed BUT 1 The service described is not appropriate or relevant to the goal or objective listed in the progress note. OR B. A goal or objective is not listed and the body of the note does not describe how the service and the treatment plan are linked.

13. The service described in the content of the progress note matches the service billed in the claim?

Enter If… There is a progress note that describes the service listed on the claim. For example, if 0 Case Management is billed, it is evident from the interventions provided that a case management service was provided. 1 There is a progress note that does NOT describe the service listed on the claim.

14. The diagnosis that was the primary focus of the service billed is listed?

Enter If… 0 There is a diagnosis listed and it corresponds to the service provided. 1 There is no diagnosis listed or if listed does not correspond to the service provided.

5 Item Audit Item 2 3 4 5 6 Fatal Staff 30 40 50 Error 20 Claims Totals Name Claims Claims Claims ? # Claims 0 Is there a treatment plan 1 F that is current? 0 0 0 0 0 Is the treatment plan signed with credentials and date 2 F by the clinician completing 0 0 0 0 0 the plan? Is the treatment plan signed with credentials and date 3 F by the appropriately 0 0 0 0 0 licensed practitioner of the healing arts? Is the treatment plan signed by the Medicaid beneficiary or is there a 4 F 0 0 0 0 0 progress note detailing the reasons why the plan is not signed? Is there a progress note for 4 F the date of the claim 0 0 0 0 0 reviewed? Service Type is 5 F Documented and matches 0 0 0 0 0 claim? Service Date is 6 F 0 0 0 0 0 Documented? Duration and Actual Time During Which the Service 7 F Was Rendered is 0 0 0 0 0 Documented. Number of Units Billed 8 F Matches Actual Units 0 0 0 0 0 Billed Name, Title and Credentials and date of 9 signature of the Person 0 0 0 0 0 Providing Service is Documented. The Setting in Which the 10 F Service Was Rendered is 0 0 0 0 0 Documented.

6 The Service Delivered is Contained in the 11 F 0 0 0 0 0 Consumer's ISP or Treatment Plan. The Progress Note describes a service that is 12 F linked to a goal in the 0 0 0 0 0 treatment plan? There is a Progress Note 13 F that corresponds to the 0 0 0 0 0 Service Billed. Diagnosis that was the 14 focus of treatment is listed? 0 0 0 0 0 Total 0 0 0 0 0 Errors Reversed 0 0 0 0 0 Claim

0= Medical Record Document ation is correct 1= Medical Record Document ation is not correct F= Fatal error and claim fails regardless of compliance in other questions.