by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
May 3rd, 2022
According to the 2021 Comprehensive Error Rate Testing (CERT) report, the improper payment rate was noted to be only 6.26%, with a proper payment rate of 93.74%. While this is looking better than many other years, it still warrants researching to identify how the numbers can be improved. Of the 6.26% of improper payments, the majority were caused by insufficient documentation (64.1%), medical necessity (13.6%), incorrect coding (10.6%), Other miscellaneous causes (6.9%), and finally no documentation at all (4.8%). At the top of the list of services ranking highest for improper payments are laboratory services with an improper payment rate of 24.8% and minor procedures (other than musculoskeletal) at 15.0%. The report identifies insufficient documentation as the main culprit for classifying these services as improperly paid.
How Do CERT Reviewers Define Insufficient Documentation?
Reviewers may deem a claim improperly paid based on insufficient documentation when:
- The documentation fails to meet the requirements of the code description
- An element, required as a condition of payment, is actually missing from the record such as
- An incomplete encounter note
- Contains insufficient details
- Unauthenticated records
- Missing provider or supervising physician signature
- Illegible signature without a signature log or attestation to identify the signer
- Electronic signature without the electronic record protocol or policy that documents the electronic signature process
- Incomplete or missing order for services or procedures including,
- A missing physician’s order
- An encounter note that does not describe the physician’s intent to order the service
- An incomplete encounter note
- Failure to include ancillary information stored in the medical record but not the specific encounter note. This may include, but is not limited to, such things as:
- Patient questionnaires referred to in the encounter note but not included with the medical record delivery to the payer/auditor
- Test results
Insufficient documentation is not the same as no documentation. It is not uncommon to review provider records requested by a payer as part of an audit only to find the provider has not included all of the records requested by the payer. When no records are submitted for review, the finding is no documentation and another check mark in the improperly paid column.
Use Templates with Formatting to Capture Documentation Details
With the advent of the EHR and the never ending demands for increased detail within the encounter note, provider organizations have come to rely on properly organized templates with section headers that identify the segmented portions of the service. For example, an Evaluation and Management (E/M) template may include the following section headers:
History of Present Illness:
Review of Systems:
Past Medical History:
The provider simply fills in the specific patient information under the appropriate section header, signs, and dates it and hopefully, the note is completed with all the required details.
Documenting Minor Procedures
Regardless of where a minor procedure is performed, they are usually documented as part of a greater service, such as an E/M encounter. These encounters can occur in the provider’s office, the emergency department (ED) of a hospital, or elsewhere. Formatting patient notes to include an area to document any procedures performed during the evaluation is a critical step in capturing and reporting services. For example, if a patient had an E/M encounter that includes the above template details and also had a minor procedure performed, the optimal way to support the service is to have a separate location within the encounter note for the procedure details. Here's an example of how procedure details might be notated within the encounter note.
Procedure: List the name of the procedure under this section header. If multiple procedures are performed list each procedure on its own line.
Details of the Procedure: A description of the procedure should include all required supporting details. Always refer to the CPT code description to ensure what details must be included in the procedure note to support billing the service.
Note: Failure to properly sign and authenticate an encounter note can ensure audit failures. According to Medicare, signature requirements include legibility of the provider’s name or if illegible, then there must be a printed name and title on the report or a signature log that identifies the signature with a printed name as well. For a best practices guide to provider signatures, click HERE
It can be very surprising to find how many procedures are not reported simply because the encounter note is not formatted in a way that the procedure itself stands out from the rest of the documentation or the details needed to support the procedure performed are missing from the note itself.
For additional information on how to improve documentation for minor procedures, join us for our next webinar, "Webinar Title" scheduled for Thursday, Add Date @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 PM ET. Click HERE to register for this FREE webinar.
Disclaimer: The above article is the opinion of the author(s) and should not be interpreted by providers/payers as official guidance. For any questions about the content of this article, please contact the author(s).
About the Author: Aimee L. Wilcox is a medical coding, billing, and auditing consultant, author, and educator with more than 30 years of clinical and administrative experience in healthcare, coding, billing, and auditing. Medicine, including coding and billing, is a constantly changing field full of challenges and learning and she loves both. Aimee believes there are talented medical professionals who, with proper training and excellent information, can continue to practice the art of healing while feeling secure in their billing and reimbursement for such care.