Insufficient Documentation Errors
January 29th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRSAccording 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:
- 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 that 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.
| 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 |
###
Questions, comments?
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
Latest articles: (any category)
Artificial Intelligence in Healthcare - A Medical Coder's PerspectiveDecember 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities?
Specialization: Your Advantage as a Medical Coding ContractorDecember 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike AgainDecember 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for AppendicitisNovember 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M ServicesOctober 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....
