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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