The ABCs of Compliance

NEW ORLEANS — Documentation is the key to validation, according to a presenter at the American Academy of Orthotists & Prosthetists Annual Meeting and Scientific Symposium, here.

Jim Lawson, outreach development manager for the American Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC), offered tips for both first-time and renewal site surveys for O&P practices applying for accreditation.

Jim Lawson

Jim Lawson

Lawson said as far as the basics, O&P practitioners should not apply for first-time accreditation until they are ready, as a surveyor may come at any time after receiving an application. Practices will receive notification from ABC that their accreditation will expire 8 months in advance, and will need to apply for renewal about 6 months before expiration.

He also said applicants should notify ABC of dates they cannot be in the office for a survey, as ABC will respect those dates. ABC also will block off a requested date that comes up after the application is sent, if notified 30 days in advance.

Survey basics

ABC employs 30 surveyors, all of whom are extensively trained in Medicare and ABC’s standards. The surveyors also have extensive experience working in the O&P profession.

“Consistency is extremely important to us,” Lawson said, adding that the results of a survey should be the same for a practice no matter which surveyor visits.

ABC also employs a consultative approach for its surveys.

“Our surveyors will come in and they will work with you on what you are going through,” he said, explaining that they will use their experience to make recommendations based on successes they have seen in other practices. “They will make suggestions. You do not have to take those suggestions, but it may be something worth looking into.”

Under requirements from CMS, surveys are unscheduled and unannounced; therefore, ABC requires each applicant to provide a primary contact and a backup contact.

Each survey will begin with a meet and greet between surveyors and employees, and a tour of the facility. Lawson advised practitioners to let their staff know a surveyor may be coming.

Complete documentation an imperative

“Please do not apply until you have your patient charts… and your practice is ready,” Lawson said.

For a successful survey, Lawson said, practices should have documentation ready for review and should be able to offer a workspace for the surveyor[s] to review items.

ABC surveyors will require the practice to provide a minimum of 10 patient charts per practitioner and may request additional charts. They also are required by CMS to call five patients per practice to ask for feedback on the care they have received.

Lawson emphasized the importance of complete documentation, as incomplete patient charts are one of the top issues surveyors identified among accreditation visits.

“This is what hits facility owners in the pocketbook sometimes. Have everything as well written and well documented as possible so that you will not lose the dollars that you have earned,” Lawson said, adding that RAC auditors look for incomplete patient charts.

Common missing items from patient charts include the practitioner’s evaluation, diagnosis, patient history, assessment, goals, referrals, prescriptions, encounters, delivery receipts, dates and signatures.

If a document is missing, Lawson said the facility owner will need to write an explanation and state the steps they will take to keep that from happening in the future.

From surveys to fire drills

Lawson said satisfaction surveys should be offered to every patient, and CMS would like to see a 33% return rate. ABC requires accredited practices to create a report and action plan on its surveys once a year.

Lawson also suggested using survey results as a marketing tool by creating a one-pager with numbers and positive feedback and sending it to referral sources.


Fire/emergency drills also must happen once a year and all staff must be present. Lawson said if a staff person is absent during the drill, the practice should hold a second drill.

Each practice must have an emergency plan and renew it once a year. Policy and procedure manuals should be updated annually and be accessible to all staff. Safety inspections must occur once a year, and Lawson emphasized the importance of checking fire extinguishers.

The business owner should also make sure billings and claims are in order.

“The surveyors are looking to make sure your clinical narratives are matching your billing. They are not assessing your business’ financial viability. That is not part of accreditation standards,” Lawson said. “They do not care if you are just getting by [financially]. That does not matter to them. But they are looking for red flags. They need to know [your processes].”

For instance, if the company submitted 30 claims to CMS in one month and 14 were returned, the surveyor needs to know the company’s process to correct and resubmit those claims.

Exit interview and follow-up

Last is the exit interview, an opportunity to meet with the surveyor in person or over the phone to review and share information. The surveyor will review noncompliance or partial compliance issues and go over positive findings. The surveyor will also share best practices and make suggestions.

“Pick their brains. Take advantage of that,” Lawson said.

After the exit interview is complete, the practice may subsequently receive a request for a Corrective Action Plan (CAP).

“That does not mean you did not pass,” Lawson said.

The request for a CAP will list the required standards and each standard will be marked with a letter: C for compliant, N for noncompliant and P for partially compliant. The practice will have 45 days to bring the noncompliant standards into compliance.

Facilities that earn accreditation will receive their certificate which must be displayed where the public can see that they have met the profession’s standards.

Lawson said ABC-accredited facilities can access an accreditation compliance calendar and accreditation guide as well as templates for a patient chart audit, patient satisfaction survey, facility review checklist and more through the ABC website, – by Amanda Alexander


Lawson J. American Board for Certification in Orthotics, Prosthetics & Pedorthics: Improving your business while increasing your compliance. Presented at: American Academy of Orthotists and Prosthetists Annual Meeting and Scientific Symposium; Feb. 18-21, 2015; New Orleans.

Disclosure: Lawson reports no relevant financial disclosures.

Leave a Reply

Your email address will not be published.