Documentation

I posted this on another forum, not getting much traffic. Anyone?

Can anyone direct me to a regulation or policy that states medical records must stand alone? I recall reading recently that CERT, RAC, etc. reviewers will only consider records on a stand-alone basis to support a billed service. I don't see this in transmittal 327 where I thought it might have been addressed. Thanks,

Jenny Berkshire, CPC, CEMC, CGIC

records

http://www.cignagovernmentservices.com/partb/pubs/news/2009/0609/cope9992.htmlhttp://www.codingnetwork.com/blog/post/recovery-audit-contractors-are-rac-audits-a-permanent-feature-of-the-helath/
http://www.cbhc.org/news/wp-content/uploads/2010/07/Session-2002-2.pdf

CMS has instructed CERT contractors to follow the letter of the law in determining whether a claim has been billed properly and if there is sufficient documentation present to support the need for services. Thus, each claim must stand alone and be supported by documentation clearly showing the intent of the ordering physician and the reasons for ordering the service(s) for that episode of care, with orders that are complete and signed.

Further details related to signatures were published in Transmittal 327 of the Medicare Program Integrity Manual (100-08), released on March 16, 2010. The signature guidelines apply to reviews conducted by Medicare Administrative Contractors (MACs), CERT Contractors and Recovery Audit Contractors (RACs)