Insufficient documentation is a common claims error, a Centers for Medicare & Medicaid Services (CMS) review of claims showed.
In a retrospective review of three codes – and recoupment of claims paid in error – CMS found that medical documentation inadequate to support payment for the services billed and missing documentation elements required as a condition of payment occurred frequently.
That's why for any service billed to Medicare, it's important to review relevant national and local coverage determinations for coding and documentation specifics. The mere lack of a signature on specific portions of otherwise complete documentation can
be enough to warrant a recoupment.
The Medicare Comprehensive Error Rate Testing review looked at claims for retinal photocoagulation (HCPCS code 67228), facet joint inspection (HCPCS code 64635), and radiation therapy (HCPCS code 77330). Examples of common documentation errors from all three studies are:
- Inadequately describes the service as defined by the HCPCS code;
- No documentation to support the medical need for the procedure;
- No procedure note;
- No signature log or attestation submitted; and
- No physician’s signature on a procedure note, diagnostic report, or progress note.
Among other errors highlighted in the CMS report:
- For retinal photocoagulation: no intent to order diagnostic or lab test; no diagnostic test result.
- For facet joint injection: no valid physician order (includes physician signature or date); no preoperative surgeon’s office notes; though a valid ICD-10 code(s) was submitted, the ICD-10 code(s) alone was insufficient information (the CERT study covered dates of service in 2015). Note that Texas Medicare payer Novitas Solutions has a local coverage determination policy for Facet Joint Interventions for Pain Management L34892.
- For radiation therapy: no radiation therapy plan was submitted.
Have a coding or documentation question? Email your question to TMA’s reimbursement specialists at reimbursementservices[at]texmed[dot]org, or call (800) 880-7955. Or contact TMA Practice Consulting to have a certified professional coder conduct a coding and documentation check-up or in-depth review for your practice, or train you and your staff on site.
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Last Updated On
March 30, 2021
Originally Published On
February 07, 2017