by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
March 2nd, 2017
When the medical documentation submitted is inadequate to support payment for the services billed, it may be determined that the claim contained insufficient documentation. If the claims reviewer is unable to conclude the services, some or all, were actually provided, they may determine the claim is unprocessable or incomplete. There are many types of documentation errors that may result in no payment, errors, or even fraud. It is vital to a practice to ensure proper documentation of services that were actually provided, were provided at the level billed, and/or were medically necessary.
Claims are also placed into this category when a specific documentation element that is required as a condition of payment is missing, such as a physician signature on an order, or a form that is required to be completed in its entirety.
Insufficient documentation errors identified by the CERT RC may include:
- Incomplete progress notes (for example, unsigned, undated, insufficient detail);
- Unauthenticated medical records (for example, no provider signature, no supervising signature,
- Illegible signatures without a signature log or attestation to identify the signer, an electronic signature without the electronic record protocol or policy that documents the process for electronic signatures); and
- No documentation of intent to order services and procedures (for example, incomplete or missing signed order or progress note describing intent for services to be provided)