Documentation Compliance Audit (LTACHs)

Objectives

  • Help resolve discrepancies between care rendered and care recorded using careful documentation review

  • Ensure that documentation proves medical necessity

  • Ensure documentation supports the CARE data set

  • Identify opportunities to improve documentation and coding to support an LTACH admission, medical necessity, and compliance with CMS quality reporting

  • Educate your staff and physicians

  • Develop procedures that support these goals over time

Process

  • Analyze LTRAX reports and historical data related to CARE data set completion, timeliness, and pressure ulcer data

  • Review the assessment, documentation, and data entry process for the CARE data set

  • Assess documentation to determine strengths and identify missed opportunities related to medical necessity, coding, and CARE data set items

Deliverables

  • Data analysis with industry comparisons and trends

  • Documentation, billing, and CARE data set assessment with a detailed report including recommendations for improvement

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