We all know there will come a day when the audit request comes in…the question is, will you be ready?
Recoupments can occur for missing parent signatures to inadequate session notes. Are you clear on what each of your payors require in your clinical documentation? In general, the below recommendations are a good starting point (but only a starting point) that you may build upon to ensure you are meeting the documentation standards for various payers:
- Client name/DOB
- Payer/Insurance ID
- Time In and out of Session
- Units
- Place of Service Code
- Specific Location
- Other Persons Present
- Responsible Provider’s Name + Date
- Responsible Provider’s Signature
- Challenging Behavior Observed
- Programs/Goals Targeted
- Was Client Participatory?