Insufficient Documentation Errors

by  Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
January 29th, 2018

According to CMS ICN 909160, 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:

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.

Signature Requirements 
“Medicare Program Integrity Manual” (Pub. 100-08), Chapter 3, Section 3.3.2.4 “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
Functional Reporting
“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

References:

Insufficient Documentation Errors. (2018, January 29). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/insufficient-documentation-errors-32810.html

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