by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
February 15th, 2017
Claims are determined to have insufficient documentation errors when the medical documentation submitted is inadequate to support payment for the services billed - meaning the reviewer could not conclude that some of the allowed services 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 signature); 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). Some of the more common procedures have resulted in insufficient documentation errors, description of errors, and links to the requirements are summarized below.
Listed below are important resources from CMS' PUB-100. This can be found in a PDF format or online at FindACode.com under the information tab.
“Medicare Program Integrity Manual” (Pub. 100-08), Chapter 3, Section 18.104.22.168 “Complying With Medicare Signature Requirements”
|Medicare Coverage Database (MCD) for Local Coverage Determinations (LCDs) from your local MAC|
|Outpatient Therapy Must Be Under the Care of a Physician/Non-physician Practitioner (NPP)
(Orders/Referrals and Need for Care)“Medicare Benefit Policy Manual” (Pub. 100-02), Chapter 15, Section 220.1.1
|Certification and Recertification of Need for Treatment and Therapy Plans of Care
“Medicare Benefit Policy Manual” (Pub. 100-02), Chapter 15, Section 220.1.3
“Medicare Benefit Policy Manual” (Pub. 100-02), Chapter 15, Section 220.4
|Evaluation and Management Service Codes - General (Codes 99201–99499)
“Medicare Claims Processing Manual” (Pub. 100-04), Chapter 12, Section 30.6
|Evaluation and Management Services 1995 and 1997 Documentation Guidelines|
|DME - MLN Matters® Article MM8304, “Detailed Written Orders for Face-to-Face Encounters|
|Requirements for Ordering and Following Orders for Diagnostic Tests
“Medicare Benefit Policy Manual” (Pub. 100-02), Chapter 15, Section 80.6
|Provider Compliance : https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html|