Interdisciplinary Peer Review Form (Edinburg)  
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Date of Service *
MM
/
DD
/
YYYY
Therapist *
EMR # *
CPT Code *
ICD-10 code/s (separate codes with commas) *
Therapy type?  *
Required
Was medical/ electronic record for this services found? 

YES ( if there is a written note for the day of service) 
NO (if there is not written note for the day of service) 
 *
Is the medical record legible? 

YES (if you can read electronic or written note) NO (if you are unable to read note) 
 *
Does the documentation support the billing charges? 

YES (review billing charges for that DOS and decide if written note agrees with charges) 
NO (written note does not support charges) 
 *
Does the time listed on the note match with the schedule?

YES (Time in matches the schedule) 
NO ( The AM vs. PM does not match or timeframe does not match time listed on the schedule)
 *
Does the total billed time match the time in and out as noted in the previous question? 

(find total time billed this information appears on the bottom of the screen under CPT code) 

YES ( total time shows in the box and equals billed charges) 
NO ( the information under total bill does not match) 
 *
Does documentation indicate patient's response to treatment and reason to continue intervention? 

YES (if under assessment there is information on patient's response to intervention. When writing notes please make sure that there is justification to continue with treatment. Safety concerns, pain, poor endurance, level of assistance required for ADL, family support, progress towards goals are some examples) 

NO ( Assessment does not indicate response to treatment performed) 
 *
If patient was educated, is there a copy of the HEP present in the chart or documentation of instruction given for the current POC? 

YES (Copy of home program is in chart) 
NO (Note says that patient was educated on HEP and there is not copy or HEP in chart nor explanation of HEP in the note) 
N/A (patient was not educated that visit) 
 *
If auditing an initial assessment or reevaluation, does the documentation include frequency, duration and amount of time?

YES (ex. Skilled PT/OT/ST intervention 2 times per week for 3 months 30-60 minute sessions) 
NO (Plan of care lacks these measures) 
N/A (if you are reviewing a daily note)
 *
If note is completed by an Asst. SLP LPTA or COTA, does it state the name of the supervising therapist? 

YES ( name of supervising therapist is in the note) 
NO (name of supervising therapist is not in the note) 
N/A ( SLP, PT, OTR not required to list a supervisor)
 *
Are the modifiers being used correctly in the documentation? 

YES (if the written note for the day of service includes the correct modifiers) 
NO ( if there is no modifier or if a modifier is incorrect) 
 *
Does documentation indicate the place of service correctly? 

Ex. Standard Visit Place of Service= Office; Video call Visit Place of Service = Telehealth code 10 or code 2
 *
Chart reviewed by:  *
Date of review *
MM
/
DD
/
YYYY
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