Complying with Medical Record Documentation Requirements

CMS published a valuable and (surprisingly) easy to read fact sheet relevant to anyone in the mid-revenue cycle. 

Link to “Complying with Medical Record Documentation Requirements” below, along with a handy ACDIS recap.

The fact sheet lays out four common sources of denial related to insufficient documentation. CDI, coding, and compliance professionals, take note.

The fact sheet summarizes findings from the Comprehensive Error Rate Testing (CERT) program. Each year, the CERT program reviews a statistically valid stratified random sample of Medicare FFS claims to determine if they were paid properly under Medicare coverage, coding, and payment rules. 

When CERT requests a review, the billing provider must send supporting documentation (for example, physician’s order or notes to support medical necessity) from a referring physician’s office or from the hospital. 

That documentation is used to support the justification for the claim, and if it doesn’t, recoupments occur.

Last year, Medicare FFS claims had an estimated 7.66% error rate per CERT, accounting for $31.7 billion (B, billion) in improper payments. 

What were the four most common sources of error?

1. Evaluation & Management (E/M) Services: CERT identified office visits (established), hospital (initial), and hospital (subsequent) as the top three errors in E/M service categories. High errors included insufficient documentation, medical necessity, and incorrect coding of E/M services to support medical necessity and accurate billing of those services.
2. Diagnostic Tests: CERT identified there was insufficient documentation to support medical necessity in the plan, or intent to order diagnostic tests. If the handwritten signature is illegible, include a signature log, CMS advises.
3. Physical Therapy Services: CERT identified the documentation submitted by the physician or NPP didn’t support certification of the plan of care (POC). CERT requires the physician’s or NPP’s signature and date of certification of the POC, or progress note.
4. Durable Medical Equipment (DME): Hospital beds, glucose monitors, and manual wheelchairs require a written order or prescription from the treating practitioner as a condition for payment, which must meet standard written order requirements. Many apparently did not.

Other common sources of error noted in the fact sheet include: 

• Incomplete progress notes (for example, insufficient detail to support providing the service according to coverage requirements)
• Medical records that fail to demonstrate authenticity or otherwise meet a signature requirement for payment (examples: no provider signature, no supervising signature, illegible signatures without a signature log or attestation to identify the signer)
• No documentation of order or intent to order services and procedures if required by Medicare policy

The ACDIS article below includes some great strategies for beefing up supporting documentation. Check it out. And share the fact sheet with your CDI, coding, and compliance teams.

And don’t forget your John Hancock. I’m surprised signatures are still a problem … but there you have it.

References

MLN Fact Sheet: Complying with Medicare Documentation Requirements: https://www.cms.gov/files/mln909160-complying-with-medical-record-documentation-requirements.pdf 

Note from the CDI Education Director: Ensuring Compliance with Medicare Documentation Requirements: https://acdis.org/articles/note-cdi-education-director-ensuring-compliance-medicare-documentation-requirements

Comprehensive Error Rate Testing (CERT) program: https://www.cms.gov/data-research/monitoring-programs/improper-payment-measurement-programs/comprehensive-error-rate-testing-cert