Paper trail of physician non-complaince with proper documentation
Mark Maguire
Description
Collection
Title:
Paper trail of physician non-complaince with proper documentation
Creator:
Mark Maguire
Date:
8/28/2012
Text:
Hello List, about 4 months ago I started keeping copies of unusual finds in physician medical records. The following data will demonstrate how difficult it is for prosthetic providers to obtain Medicare compliant medical records. After just 4 months I have medical records that show:
1. (4 documents) some physicians don't know the difference between a Trans-tibial prosthesis and a Trans-femoral prosthesis, or didn't care enough to document correctly.
The physicians specified that his patient needed a new Trans-Tibial prosthesis when in fact the patient really needed a new Trans-Femoral prosthesis.
2. (3 documents) some physicians don't know the difference between an Orthosis and a prosthesis, or didn't care enough to document correctly. I have 3 physician medical records that say the prescribed device is a Brace instead of a prosthesis.
3. (2 documents) physicians just want to refer to another specialist and do nothing in the way of medical justification. Two physicians wrote orders from his EMR system that simply says: prosthesis as directed and the other physician wrote problems with prosthetic - refer for fitting. That is all that was said in the physician medical records to justify the new prosthetic device.
4. (2 documents) the Dear Physician letter is an ineffective method of training physicians in proper documentation. We sent a Dear Physician letter to two physicians prescribing a new prosthesis and in return we received a templated, hand written, illegible physician note that didn't mention one thing required by Medicare.
None of the above physician records would pass a Medicare audit and garner a prosthetist payment for a prosthesis. Policing physicians and correcting these errors should not be the responsibility of a prosthetic provider who (by Medicare guidelines) is responsible for following physician orders. This may or may not seem like a lot of problematic medical records but when prosthetists payments hinge on the validity of a physicians medical records I shouldn't have anything to report to you in this email. The eleven instances above is eleven prosthetics devices I may not be paid for by Medicare.
I just thought I would share these interesting facts with everyone and stir up some more experiences by others.
Mark
1. (4 documents) some physicians don't know the difference between a Trans-tibial prosthesis and a Trans-femoral prosthesis, or didn't care enough to document correctly.
The physicians specified that his patient needed a new Trans-Tibial prosthesis when in fact the patient really needed a new Trans-Femoral prosthesis.
2. (3 documents) some physicians don't know the difference between an Orthosis and a prosthesis, or didn't care enough to document correctly. I have 3 physician medical records that say the prescribed device is a Brace instead of a prosthesis.
3. (2 documents) physicians just want to refer to another specialist and do nothing in the way of medical justification. Two physicians wrote orders from his EMR system that simply says: prosthesis as directed and the other physician wrote problems with prosthetic - refer for fitting. That is all that was said in the physician medical records to justify the new prosthetic device.
4. (2 documents) the Dear Physician letter is an ineffective method of training physicians in proper documentation. We sent a Dear Physician letter to two physicians prescribing a new prosthesis and in return we received a templated, hand written, illegible physician note that didn't mention one thing required by Medicare.
None of the above physician records would pass a Medicare audit and garner a prosthetist payment for a prosthesis. Policing physicians and correcting these errors should not be the responsibility of a prosthetic provider who (by Medicare guidelines) is responsible for following physician orders. This may or may not seem like a lot of problematic medical records but when prosthetists payments hinge on the validity of a physicians medical records I shouldn't have anything to report to you in this email. The eleven instances above is eleven prosthetics devices I may not be paid for by Medicare.
I just thought I would share these interesting facts with everyone and stir up some more experiences by others.
Mark
Citation
Mark Maguire, “Paper trail of physician non-complaince with proper documentation,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/234287.
