How to Avoid Common Documentation Red Flags

There are many similarities between accreditors regarding the common areas of deficiencies for durable medical equipment (DME) suppliers, and many of them boil down to documentation. When you become accredited, you agree to maintain those accreditation standards for all three years of the cycle—not just the few months prior to your triennial survey. Every accredited organization should be accreditation-ready for an unannounced survey every day and not just when they “gear up” for an upcoming renewal.

Managing accreditation compliance can be difficult, however, if you’re not organized and you don’t stay prepared. You know the old saying: “If it wasn’t documented, it wasn’t done.” Ensure you are getting credit for all your hard work by making sure you are always documenting everything.

It doesn’t matter whom your accreditation organization is; it seems that suppliers all have very similar deficiencies cited on survey reports. Here are some common deficiencies that go back to making sure that you are always documenting and that your documentation is correct.

1. Incomplete Prescriber Orders & Prescriber Medical Records

You must have current, correct and complete orders for each piece of equipment you sell or rent, as well as complete medical records from the prescriber.

The written order prior to delivery (WOPD) has been a requirement in DME since mid-2013. It must be available for review at all times. You cannot provide an item without it. You can’t chase incomplete orders after the item has been provided. This would cause a delay in the delivery and use of the item. If the prescriber’s order is incomplete, clarify the information. For an oxygen order, the prescriber’s order must designate the route of delivery and the duration. If your state requires a new prescriber’s order annually, you must set up a process to ensure you obtain the new order in a timely fashion within the proper time frame. DME providers functioned on dispensing orders for many years and many prescribers think that we still can. Remind your prescribers that you must have a complete and detailed order before delivery.

The prescriber’s medical records must be provided upon audit, so most suppliers require that the documentation be in the file once the order is received. If your audit doesn’t come until years after the order, it can be impossible to get the required records when the patient may not see that provider anymore, or the provider’s office has closed, or various other reasons.

When you bill for an item with a KX modifier, such as a commode—which is the only way you can get paid—you are stating that the item is medically necessary and the justification for use is documented in the medical record, so you must be sure that you have received these records and have them on file. Getting the medical records up front ensures that you have reviewed them to be sure that they are compliant with the local coverage determination for that item. If they need to be augmented or clarified, then you are getting that done at the time of the referral and not trying to do that years later. Medicare does not accept additions to records that are made a long time after the initial order.

2. Gaps in Patient Records

When your patient records are reviewed, it is very common to see an absence of patient signatures assuring that all the proper documentation has been provided. Often there is no proof that the patient has received such things as:

• The current Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Supplier Standards or permitted statement
• Information on the organization’s complaint policy or process
• An explanation of the patient’s financial responsibility
• Educational materials about the use of the item such as a manufacturer’s booklet that educates them on the proper use of a piece of equipment and the safety risks

Use a checklist with all of the required items a patient must receive or acknowledge and get that checklist signed and into the patient’s record on every delivery to ensure that all of the necessary paperwork has been provided to the patient. Using a billing and verification software along with electronic signatures can help prevent this paperwork getting lost in the delivery van or on someone’s desk during the billing process.

3. Missing Competency Assessments

Competency is a basic tenet of accreditation and required by all accreditors. Competency assessments have become crucial to ensuring that staff—particularly those providing direct patient services—have the necessary training and skills to perform their job correctly. For DME providers, this concept of assessing and maintaining staff competence is crucial and sometimes misunderstood. Supervisors need to observe the performance of tasks to ensure that the employee can correctly perform them before they start working with customers, and then should repeat the process annually to assess whether all tasks are being performed correctly.

A typical DME delivery technician might perform dozens of different deliveries of equipment that requires setup. Ensure that observation of these tasks is completed during orientation before sending the new staff member out into the field independently, and then assess again annually to ensure that bad habits are not developed, to keep skills sharp and to maintain product and skill knowledge levels.

Document competency evaluations individually by item, or in an overall competency evaluation that includes all the items that the staff member provides to a customer as well as those they might troubleshoot, especially after hours. Use a form that can be kept in the staff member’s personnel file or keep your completed competencies in one file so that they can be performed annually on everyone.

4. Poorly Maintained Personnel Files

Whether you keep paper or electronic personnel files, you must maintain them in a secure and organized manner so they will be ready for your surveyor during your unannounced survey. A best practice is to audit your personnel files two or three times a year to ensure that the files are complete and up to date. The standards from your accreditor will list all the items your files must contain. These can include:

• A completed application or résumé
• An orientation checklist that shows all the items covered during orientation, especially those required by your accreditor
• Applicable licenses with their initial and renewal verification
• A job description for every employee within the organization (although owners may be exempt)
• A job description for the employee’s current job duties that is signed and dated
• Annual or bi-annual (every two years) evaluations—the frequency of these depends on your policy
• Completed competency assessments
• Completed continuing education or in-services

When you audit your files, use a checklist of required items to ensure that everything is complete. Auditing your personnel files on an ongoing basis will help ensure you meet all the requirements for your survey.

5. Insufficient Quality & Performance Improvement

When it comes to DME accreditation, accreditors receive multiple inquiries regarding how to monitor quality continuously and improve the performance of their organization. One of the first questions you should ask yourself is “How do I select the areas I would like to improve?” Most responses center on the Medicare Quality Standards and their guidelines. Medicare requires certain areas be reviewed, so be sure to follow those requirements, but also decide what can be the most beneficial to your operation. The concept of monitoring quality continuously is to locate, identify and correct any company weaknesses you can improve as well as their customer satisfaction.

Most providers are trying to do what is best for their customers but sometimes they don’t pay attention to make sure everything is documented. These days it seems like providers have to do more with less reimbursement—thus, administrative positions get cut and monitoring goes by the wayside. Suppliers should always pay close attention to the areas that can be problematic between their on-site triennial accreditation visits and that they are documenting when needed. Integrating the inclusion of documentation requirements a little bit at a time is much easier than trying to do everything all at once ahead of a renewal survey.