Re: Physician Documentation
Schwelke, Eric
Description
Collection
Title:
Re: Physician Documentation
Creator:
Schwelke, Eric
Date:
5/13/2013
Text:
Due to some responses I received that suggested that Medicare or recoupment subcontractors would not look kindly on forms that we provide the physician to complete. I would like to clarify my original post:
Hi all:
referring to the current pervasive problem of procuring the correct physician documentation, our facility developed an evaluation form and it is supposed to be completed by the physician while in a clinic setting with the patient/family, prosthetist, PT/OT, and other stakeholders. The form is then included into the medical chart and we retain a signed copy for our files.
In order to speed up the evaluation, I have been asked by some of our team physicians whether some of the questions on the form that asks about past/present functional status (and other info the patient can answer) could be put into a questionnaire that the patient completes prior to the clinic visit.
I am looking for comments on whether this patient questionnaire would be considered part of the medical record when completed and signed by the patient.
This form is still a draft document and would not be on our stationery; it will be printed on the Hospital's stationery to be used by the physicians as an additional item during evaluation by the clinical team to include in the patients' chart along with the regular medical eval. We are collaborating with the physicians and administrative staff to include the pertinent questions and statements on the form.
During a clinic session, we, as the specialists/experts, must provide our knowledge to develop a treatment plan that is suitable for the patient. This information has to be included somewhere; if it is specific information that Medicare and other insurers are looking for, why shouldn't we be able to provide assistance in the creation of a medical record document intended to capture that information?
I'm still wondering about whether a questionnaire provided to the patient prior to a prosthetic clinical evaluation and completed/signed by the patient would be considered part of the medical record. Does anyone care to comment on this?
Best regards,
Eric
Eric Schwelke CPO LPO, Director
Kessler O & P Services
11 Microlab Road
Livingston, NJ 07039
973 992 9700 Ext 201
Direct Fax: 717 635 3920
Success in Motion
________________________________
From: Anthony Gutierrez [mailto:<Email Address Redacted>]
Sent: Monday, May 13, 2013 9:48 AM
To: Schwelke, Eric
Subject: Re: [OANDP-L] Physician Documentation
From experience in these audits, if you provide the physician with an evaluation form to fill out that you created, it will not be considered part of their evaluation. You may suggest that they answer certain questions as to the patient's functional ability, but supplier provided evaluation forms are not allowed. See medicare Program integrity Manual section 5.1.3 I believe.
Take care and good luck,
Tony Gutierrez CP
On Fri, May 10, 2013 at 6:40 PM, Schwelke, Eric < <Email Address Redacted> <mailto:<Email Address Redacted>>> wrote:
Hi all:
referring to the current pervasive problem of procuring the correct physician documentation, our facility developed an evaluation form and it is supposed to be completed by the physician while in a clinic setting with the patient/family, prosthetist, PT/OT, and other stakeholders. The form is then included into the medical chart and we retain a signed copy for our files.
In order to speed up the evaluation, I have been asked by some of our team physicians whether some of the questions on the form that asks about past/present functional status (and other info the patient can answer) could be put into a questionnaire that the patient completes prior to the clinic visit.
I am looking for comments on whether this patient questionnaire would be considered part of the medical record when completed and signed by the patient.
Eric Schwelke CPO LPO Director
Kessler Prosthetic & Orthotic Services
11 Microlab Road
Livingston, NJ 07039
973 992 9700 Ext 201<tel:973%20992%209700%20Ext%20201>
Success in Motion
Note: The information contained in this message may be
privileged and confidential and protected from
disclosure. If the reader of this message is not the
intended recipient, or an employee or agent responsible
for delivering this message to the intended recipient, you
are hereby notified that any dissemination, distribution
or copying of this communication is strictly prohibited.
If you have received this communication in error, please
notify us immediately by replying to the message and
deleting it from your computer. Thank you.
Hi all:
referring to the current pervasive problem of procuring the correct physician documentation, our facility developed an evaluation form and it is supposed to be completed by the physician while in a clinic setting with the patient/family, prosthetist, PT/OT, and other stakeholders. The form is then included into the medical chart and we retain a signed copy for our files.
In order to speed up the evaluation, I have been asked by some of our team physicians whether some of the questions on the form that asks about past/present functional status (and other info the patient can answer) could be put into a questionnaire that the patient completes prior to the clinic visit.
I am looking for comments on whether this patient questionnaire would be considered part of the medical record when completed and signed by the patient.
This form is still a draft document and would not be on our stationery; it will be printed on the Hospital's stationery to be used by the physicians as an additional item during evaluation by the clinical team to include in the patients' chart along with the regular medical eval. We are collaborating with the physicians and administrative staff to include the pertinent questions and statements on the form.
During a clinic session, we, as the specialists/experts, must provide our knowledge to develop a treatment plan that is suitable for the patient. This information has to be included somewhere; if it is specific information that Medicare and other insurers are looking for, why shouldn't we be able to provide assistance in the creation of a medical record document intended to capture that information?
I'm still wondering about whether a questionnaire provided to the patient prior to a prosthetic clinical evaluation and completed/signed by the patient would be considered part of the medical record. Does anyone care to comment on this?
Best regards,
Eric
Eric Schwelke CPO LPO, Director
Kessler O & P Services
11 Microlab Road
Livingston, NJ 07039
973 992 9700 Ext 201
Direct Fax: 717 635 3920
Success in Motion
________________________________
From: Anthony Gutierrez [mailto:<Email Address Redacted>]
Sent: Monday, May 13, 2013 9:48 AM
To: Schwelke, Eric
Subject: Re: [OANDP-L] Physician Documentation
From experience in these audits, if you provide the physician with an evaluation form to fill out that you created, it will not be considered part of their evaluation. You may suggest that they answer certain questions as to the patient's functional ability, but supplier provided evaluation forms are not allowed. See medicare Program integrity Manual section 5.1.3 I believe.
Take care and good luck,
Tony Gutierrez CP
On Fri, May 10, 2013 at 6:40 PM, Schwelke, Eric < <Email Address Redacted> <mailto:<Email Address Redacted>>> wrote:
Hi all:
referring to the current pervasive problem of procuring the correct physician documentation, our facility developed an evaluation form and it is supposed to be completed by the physician while in a clinic setting with the patient/family, prosthetist, PT/OT, and other stakeholders. The form is then included into the medical chart and we retain a signed copy for our files.
In order to speed up the evaluation, I have been asked by some of our team physicians whether some of the questions on the form that asks about past/present functional status (and other info the patient can answer) could be put into a questionnaire that the patient completes prior to the clinic visit.
I am looking for comments on whether this patient questionnaire would be considered part of the medical record when completed and signed by the patient.
Eric Schwelke CPO LPO Director
Kessler Prosthetic & Orthotic Services
11 Microlab Road
Livingston, NJ 07039
973 992 9700 Ext 201<tel:973%20992%209700%20Ext%20201>
Success in Motion
Note: The information contained in this message may be
privileged and confidential and protected from
disclosure. If the reader of this message is not the
intended recipient, or an employee or agent responsible
for delivering this message to the intended recipient, you
are hereby notified that any dissemination, distribution
or copying of this communication is strictly prohibited.
If you have received this communication in error, please
notify us immediately by replying to the message and
deleting it from your computer. Thank you.
Citation
Schwelke, Eric, “Re: Physician Documentation,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/235165.
