QUARTERLY QUALITY ASSURANCE REVIEW



Patient Name or Record # Above Chart NumberIndicate “Y”, “N”, or “NA” for each chart.CHART 1CHART 2CHART 3CHART 4CHART 5EVALUATION & TREATMENT ORDERSSigned/Dated Physician Referral for Evaluation Signed/Dated Treatment OrdersAUTHORIZATION FOR TREATMENT (Part B only)HCFA forms (form 700/form 701)Completed 700 / 701LegibleSigned and dated by therapistSigned and dated by physicianObjective measures are utilizedSTG/LTG: Include time frame, are quantifiable and functionalPOC states procedures to be performedPOC specifies frequency and durationRehab potential is indicatedPrior level of function is adequately addressed.Patient progress measured objectivelyPatient did not meet (D)/met (M)/exceeded (E) admission goalEval Functional Limitation Reporting (Current & Goal G-Codes) applied If Dementia Dx: was a cognitive assessment (e.g.: SLUMS) completed?PQRS Measures & QDCs applied (Carrier Billing ONLY)PT/OT at Eval (CPT Codes 97001;97003) and Re-Eval (CPT Codes 97002;97004)SLP/Dysphagia with CPT codes(92507;92526;97532) appliedSigned and Dated 700 /701; Authorization Forms sent to Medical Review Dept.PROGRESS NOTESAll Progress notes up to date and completeDocumentation addresses pertinent issuesInterval Functional Limitation Reporting (Current & Goal G-Codes) applied Interval PQRS for SLP / Dysphagia (92507, 92526, 97532) appliedDISCHARGE FROM SERVICESDC summary (DC Date; reason for discharge & functional status specified)DC ordersDC Functional Limitation Reporting (Goal & Discharge G-Codes) applied BILLING LOG (Daily Treatment Record)CompletedLegibleICD-9 Code(s) match form 700/701 QUALITY ASSURANCE RECORD REVIEW Date: Facility: Audited by:QUALITY ASSURANCE RECORD REVIEW (Continued)COMMENTS: Please indicate chart number from page 1 that comment relates to.Chart #CommentQA Review Form.DocQUALITY ASSURANCE RECORD REVIEW (Continued)COMMENTS: Please indicate chart number from page 1 that comment relates to.Chart #Comment ................
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