Docstoc

ComplianceInfractionChecklist

Document Sample
ComplianceInfractionChecklist Powered By Docstoc
					                   COMPLIANCE INFRACTION NOTIFICATION
                       AND FOLLOW-UP CHECKLIST

DATE : __________________

CHART : ______________ Requires The Following To Be Completed By : ____________________


 Fee Ticket: (office, surgery, correct date, correct Dr. #, signed by Dr., etc.)
        provider on Fee Ticket corresponds to Dr. providing service.

 Referral Memo: (new patient / consult)
 Exam Sheet:
      ___ Heading      ___ Purpose of visit    ___ CC      ___ HPI    ___ Past med/fam/social      ___ LVA
      ___ Mental status      ___ Visual acuity___ AG       ___ VF     ___ EOM        ___ Lids/external
      ___ Pupils      ___ Tonometry      ___ Dilation ___ Time       ___ Initials ___ Video      ___ Conj
      ___ Slit lamp      ___ Cornea      ___ AC      ___ Lens ___ Anterior vitreous
      ___ Fundus Exam: ___ Post. Vitreous ___ Disk ___ Macula ___ Vessels ___ periph ___ RD
                   ___ lattice ___ Retinal tear
      ___ Impressions ___ Comments
      ___ Discussion with pt.: ___ Booklets ___ Observe ___ Tests ___ Laser ___ Surgery
      ___ Pt.’s progress and response to treatment or change in treatment or any revised diagnosis and
                    follow-up plan noted
      ___ Signature      ___ Return visit      ___ Letter dictated    ___ Extended exam
 Surgery / Laser:       ___ Pre-auth       ___ Consent present, signed and dates correspond     ___ Tests
                         ___ Surgery scheduling sheet      ___ OP report    ___ Progress report
 Benefits, Risks, and Alternatives of Surgery Documented
 Inaccurate or Incorrect Charges During Post-Op Period
 CPT Codes or Procedures Missing for Services Provided
 Medical History:
      ___ PCP      ___ CC ___ ROS ___ Explanation of all yes answers ___ Allergies documented
      ___ Meds        ___ Gen surgery       ___ Eye surgery      ___ Family hx      ___ Social
      ___ Other       ___ Dated         ___ Signature of Tech/COA/Dr.       ___ Reviewed/updated/signed

 Medical Record Notations Legible and Complete


                                                                                     Implemented February 2001
Compliance Infraction Notification and Follow-Up Checklist



 Chart Papers in Correct location and Chronological Order and Secured
 Pt. Encounter for Purpose of Clinical Research Clearly Noted in Chart
 All Pages Have:                 ___ Patient identified ___ Person providing care identified

 Correct Modifiers Used for CPT (Surgery)
 All Entries Signed: with name, title, and position
 Transcription Reviewed, Dated, and Signed by the Doctor
 Diagnostic Tests Billed Correspond with Diagnostic Test in Medical Record
 Diagnostic Report / Order Form Properly Completed (eye, interpretation)
 Lab Orders Documented with Size, Eye, and Location
 Clinical Conformance of Documentation Supporting Level of Service or Diagnosis in the
       Medical Record Lacking _________________________
 Clinical Staff Involved in CPT Code Selection of Hospital Services without Proper
       Documentation for CPT Code
 Billing Selection of Initial (New) Service Visit for Established Patient/ Established Patient
       Service for New Patient
 Clinical Staff Providing Medical Records without going through Medical Records Personnel or
       Procedures
 Corrections to Medical Record Notations Made on other than Original DOS Need to be done in
       Addendum Form
 Upcoding, Undercoding, or Unbundling Corrections
 Physician Daily Review of Staff Documentation in Medical Record of Advise Given to Patient,
       Reviewed / Dated / Signed Daily or Noted How many Days Behind? __________
 Other ___________________________________________________________________________
       _______________________________________________________________________________
 Telephone Notes: (all contact with patient documented by all involved)




                                                             2                         Implemented February 2001

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:0
posted:6/3/2012
language:
pages:2