Audit Triggers in PM&R

Tags: compliance audit risk

High Risk Indicators

1. High Unit Counts: Consistently billing max units (e.g., 8 units of 97110 daily).
2. Lack of Progress: Notes show no improvement over 30+ days.
3. Cloned Documentation: Identical notes for different patients or dates.
4. Weekend Services: Billing therapy on weekends without justification.
5. Modifier Overuse: Using Modifier 59 on >10% of claims.

Documentation Red Flags

• Missing signature/date.
• Therapy notes written by MD instead of Therapist (for therapy codes).
• Plan of Care not signed within required timeframe (30 days).
• Vague goals (“Patient will improve strength”).

Defense Strategy

• Ensure Functional Goals are measurable.
• Document Medical Necessity for every visit.
• Keep time logs for timed codes.

Self-Audit

Perform a quarterly self-audit on 5 random charts per provider. Check for signature, time logs, and goal progression.

00 PM&R Coding MOC Documentation Requirements