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Frequenty Asked Questions

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License Holders Only

Q – So what happens when I document that something was missing but then when reviewing the chart with the treating therapist he/she shows me the information that I could not find, can the audit be amended to correct my error?
A – The audit will not be finalized or scored until it has been submitted. So it is recommended to do a self review following the completion of an audit before you “Commit & Score”. You could also review the audit with the therapist if you are unable to locate something. There will be no score at this point, but you will be able to review any concerns you may have before the audit is submitted. Once an audit has been submitted it cannot be amended at the clinic level. When an auditor is reviewing the chart and he/she cannot find the applicable documentation it usually means the therapist did not clearly document what was needed. It might have been there but it was hard to find. We want to encourage therapists to document material conditions of payment in easy to find spots. If an audit has been submitted and it is discovered that the auditor made a mistake, you can place an Audit Support call to PT Compliance Group at 888-680-7688, provide the PT Compliance Group support staff with documentation of your error (a scan or fax of the section of the chart with the applicable documentation evidence) and if there is evidence in the chart to support an amendment of an audit the PT Compliance Group staff can make the amendment.

Q – What if I score extremely low on an audit, does that mean I am committing fraud?
A – Just because you score low on an audit doesn’t mean you have committed fraud. It may simply mean you have just under-documented the treatments that were provided. We would recommend you place an Audit Support call to PT Compliance Group at 888-680-7688 to discuss the particular audit(s) in detail.

Q – How will I know if I am using the ChartSafe™ software correctly?
A – Great question! The best way to determine if you are using the ChartSafe software correctly is to place an Audit Support call to PT Compliance Group at 888-680-7688 to discuss the particular audit(s) in detail. Or you can purchase a discounted ChartSafe Audit Review package by going to www.ChartSafe.net/Catalog.

Q – Why do I get a comment on the audit report if I don’t have the Plan of Care or any updates signed by the referring provider for non-Medicare patients?
A – We think the plan of care should be signed for several reasons for all patients.

  1. Consistency: Since Medicare requires it, you don’t want there to be any chance that a staff member would forget to get the Plan of Care signed off. If he/she did it for some and not for others, over time, people sometimes forget why they are doing something. But if it is done for everyone you can develop a process that would make it very likely that he/she will not miss any certifications.
  2. It Makes Doctor’s Happy: Many of the doctors that you work expect to stay involved with the patient’s progress and want to feel included in their care. Continually having the doctor “approve” the Plan of Care helps you to make sure you are including them in the process.

    Also, if a referring provider sends a patient over and the prescription reads 2X per week for 2 weeks. And after performing the evaluation you determine the patient would benefit from 3X per week for 4 weeks. Even though you are generally not required to get the referring provider’s approval to make the Plan of Care 3X per week for 4 weeks, it is usually a good idea to communicate with the referring provider that you are changing his/her recommendation.
  3. Proof of Ongoing Involvement and Management of Care: In physician owned practices that are billing Medicare “Incident to”, there needs to be evidence in the chart that the referring provider is involved with the patient’s care. By getting the Plan of Care certified is one way to demonstrate involvement.
  4. Best Practices: During our research we found that many physical therapy offices perform this very step for all of their patients already. They find it easy to do and appreciate the consistency.

Q – Why can’t I put the patient’s name, account number, SS# or some other identifying number into the ChartSafe software for tracking what patients I have done audits on?
A – Any information that can be linked back to the patient directly or that could be used to determine who the patient is would be considered Protected Health Information (PHI). We made a decision that we would not include any PHI in any of the audit files to protect a patient’s identity.

Plus, by eliminating PHI we were able to reduce the cost of developing and hosting the software. By reducing the cost of development we are able to offer the ChartSafe software at a very low price.

All Site Users

Q – I do chart audits on paper and they seem to work just fine. Why would I want to use ChartSafe?
A – While paper audits can be effective, the ability to track your results and your progress automatically, identify areas of weakness for more coordinated trainings, keep up to date with the latest regulatory changes and have the ability to compare yourself to your peers can be challenging. By purchasing a ChartSafe software license you get all of these features and more making the auditing process far more effective.

Q – Is my data and the results secure?
A – YES. All data entered into by you the ChartSafe software is protected by a password that you establish and is backed up on a daily basis.

Q – Is the ChartSafe software HIPAA compliant?
A – YES. None of the information contained within the ChartSafe software is considered Protected Health Information (PHI) so it is HIPAA compliant. If any of the information entered could be linked back to the patient then the data would contain PHI. That is why we require you with a unique audit number for future reference of the audit that was performed. See http://edocket.access.gpo.gov/cfr_2002/octqtr/pdf/45cfr164.514.pdf for specific information relating to the de-identification of PHI.

Q – How many audits can I perform per therapist per year?
A – The ChartSafe software is designed to allow you to perform as many audits as you would like. We recommend that you sample at least 6 Medicare charts per year and make every effort to audit at least 1 chart from each of your other significant carriers (>10% of patient mix) during the year. Most practices will perform 2 to 3 audits per quarter per therapist.

Q – How does the ChartSafe software score an audit?
A – All of the questions are assigned different values based on an assessed level of risk. The questions with a higher level of risk are worth more points and those with lower assessed risk are assigned fewer points.

Q – How can I keep track of all the audits that have been performed?
A – There are several reporting options with the ChartSafe software. Go to the Reports tab and select the different types of reports we have made available to you. Reports are available by therapist, by office, and by company. There are also reports that you can review that will compare your results to those of the other users of the ChartSafe software based on the Level you have purchased. For example, if you purchased Level 1 ChartSafe then your data will be compared against all of the other Level 1 users. If you purchased Level 2, then your data will be compared against all of the other Level 2 users.

Q – Why isn’t my Level 1 audit compared against the Level 2 & 3 audits?
A – Levels 2 & 3 ChartSafe audits are certified audits and are reviewed or performed by PT Compliance Group, LLC associates.

Q – I have a therapist that is no longer with the company, can I use his/her license to access the ChartSafe software or do I need to buy a new license.
A – You do not need to buy a new license for your new therapist. You can transfer the license from the therapist that is no longer with you to the new therapist. You can purchase a Transfer License item by going to www.ChartSafe.net/Catalog. You will not lose access to the deleted therapist’s audits. You will still be able to run reports as well, you just won’t be able to create any new audits for the disabled therapist.