Conquer Common Documentation Errors Identified by CERT & RAC

Posted on 10 Aug, 2018 |comments_icon 0|By Elizabeth Debeasi

Are you on top of CMS documentation guidelines?

The following points identify CMS guidelines for correct documentation that supports and validates the claim submitted for services/procedures:

  • The record of the encounter/episode of care should be complete and legible
  • Documentation should include:
    1. Reason for the encounter
    2. Assessment, diagnosis, and clinical impression
    3. Medical plan of care
    4. Date and legible identity of observer
  • Rationale is documented for ordering diagnostic and ancillary services
  • Past and present diagnoses are documented
  • Diagnosis and treatments are supported in medical record and match the codes reported on the CMS-1500 for the patient’s services

Lack of a valid reason for an encounter is one of the most frequent pitfalls that leads to a denied claim, which could be because a patient may not present with a chief complaint (CC), or it’s difficult to determine the reason for the encounter, or when the CC does not correlate to the components of the assessment.

The Centers for Medicare & Medicaid Services (CMS) calculates the Medicare Fee-for-Service (FFS) improper payment rate through the Comprehensive Error Rate Testing (CERT) program. Each year, CERT evaluates a statistically valid random sample of claims to determine if they were paid properly under Medicare coverage, coding, and billing rules.

The fiscal year (FY) 2017 Medicare FFS program improper payment rate is 9.51 percent, representing $36.21 billion in improper payments, compared to the FY 2016 improper payment rate of 11.00 percent or $41.08 billion in improper payments.

The Medicare Fee for Service (FFS) Recovery Audit Program’s (RACs) mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of healthcare services provided to Medicare beneficiaries, and the identification of underpayments to providers so that the CMS can implement actions that will prevent future improper payments in all 50 states.

CERT and RACs shortlisted the top errors in CDI:

  • Incomplete progress notes: They are either unsigned, undated, or have insufficient details.
  • Unauthenticated medical record: The medical record bears no provider signature, initials, supervising signature, or a legible signature.
  • No documentation to support the service or procedure: Incomplete or missing signed order or progress note describing intent for service/procedure/test.

CERT Identifies Common E/M Services

Here are the top three services CERT targets:

  • E&M services for established office visits
  • Initial hospital visits
  • Subsequent hospital visits

High error rates were reported by CERT for:

  • Insufficient documentation
  • Lack of support of medical necessity
  • Inaccurate E/M codes

CERT also targets:

  1. Incomplete documentation

Including misspelled words or incomplete sentences that lack meaning led the auditor to believe the information was copied or the provider didn’t read it.

  1. Holes in the record

These appear often in records, at times with drug names missing. It is especially notable when the physician has signed off on the record, proving that he didn’t bother to read it thoroughly.

  1. Noncompliance with organizational policies

Practices should have a compliance plan in place that focuses on the CPT® codes your providers use most often for ensuring accurate and thorough documentation. The practice should train providers on compliance plan processes, require that they verify that they received and understand the training, and ensure that they follow the plan by defining disciplinary actions if they fail to do so.

Steer clear of noncompliance pitfalls:

  • Lost revenue and reimbursement. This problem can affect the physician’s bottom line in the payer audit because the documentation does not support the medical necessity or the evidence is incomplete.
  • Compromise in safe patient care. If erroneous patient information remains uncorrected and gets transmitted as is to the next provider in the circle of care, a potential harm to the patient or even a sentinel event (patient death) may result.

Tread Carefully on Medicare’s Policy on Medical Necessity

According to CMS, Medical necessity is defined as “healthcare services or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms, and that meet accepted standards of medicine.” This is the overarching criteria for payment that is a requirement of CPT® codes, in addition to ICD-10-CM codes.

Unfortunately, one of the challenges with medical necessity is the definition of medical necessity, itself. The interpretation of the definition can vary depending on who uses the term — a coder, physician, the court system, government insurers, private insurers, or consumers.

Managed care plans may use medical necessity as a rationing tool to deny access to necessary care, especially for those patients with special healthcare needs.

From the government’s viewpoint, statutes authorize payment only for medically necessary care, and the government can impose criminal and civil liability for filing claims that do not fit the criterion. Providers must walk a fine line when it comes to interpreting medical necessity.

Services must be reasonable and necessary

The provider must be clearly able to documents that the patient’s diagnosis justifies the treatment rendered to avoid the slightest indication that the treatment is for the convenience or comfort of the patient, provider, or supplier.

Drawbacks of auto-populate in an EMR

Providers should double check when the EMR auto-populates documentation. Ensure that the records do not demonstrate auto-population of the word ‘routine,’ as this might lead to diluting the provider’s case for the unique medical necessity of care for the specific medical condition.

Providers also shouldn’t quickly check off boxes in the EMR or in the record without carefully reviewing the accuracy of the documentation. Checkboxes lend themselves to quick completion of documentation that may be inaccurate.

Lesson: Physicians who get paid for an over-documented service do not necessarily get to keep the money. Auditors on the payers’ side look for evidence-based documentation to prove medical necessity, and if they don’t find it, the payers ask for their money back. Physicians must be able to substantiate their claims of medical necessity with accurate documentation.

Learn More

Master accurate and timely documentation that reflects the scope of services provided with TCI’s Clinical Documentation Sourcebook 2018.


Elizabeth Debeasi
Marketing Writer/ Editor

Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of Telehealth services.

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