Audit Documentation During Sign Off

As part of the sign off process for documentation, the clinical services documented by the clinician are audited by the system. The documentation is audited based upon the total time of the clinical services provided compared against the length of the visit.

During the sign off process, the clinician will be warned when one of the following occurs:

  • The total documented minutes of service exceed the documented length of the visit
  • The total documented minutes of service are significantly less than the documented length of the visit
  • If it may be appropriate to add a modifier to a procedure code
  • The patient is approaching the annual Medicare Therapy Threshold and adding the KX modifier may be appropriate
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