Tjane Health portal

Audit-Proofing Your Practice

Module 3: Maryland COMAR Guidance for PRP Services ยท Lesson 3 of 3

An audit reads your chart without you in the room. Write for that reader.

The chart must independently show: an eligible diagnosis and functional impairment, medical necessity, an active authorized plan, interventions that match plan objectives, participant response, and progress toward measurable goals.

The most common finding is a note that describes activity but not intervention or response. 'Met with participant in community' is not billable content. 'Practiced two-step bus transfer to job site; participant completed transfer with one verbal prompt' is.

Key takeaways

  • Activity is not intervention; describe teaching and response
  • Each note should trace to a plan objective
Previous