Does Your Documentation Support Payment?

Abstract

When the Centers for Medicare and Medicaid Services (CMS) contractors reviewed Medicare claims for services rendered in 2009, they did so using an enhanced methodology designed to provide a more accurate assessment of unsubstantiated claims. This improved methodology aimed to reduce “waste, fraud, and abuse,” resulted in the doubling of the error rated7.8% in 2009 compared with 3.6% in 2008. Approximately 100,000 randomly sampled claims were identified for review to determine whether the medical record documentation supported the claims that were filed and paid. The focus of the review was to determine whether the claims and the underlying medical record documentation complied with Medicare coverage, coding, and billing rules. The “primary” modification to the methodology used in 2009, was CMS demand for reviewers to strictly adhere to the documentation requirements outlined in theMedicare rules andpolicy guidance, including documentation requirements contained in Local Coverage Determinations (LCDs). In the past, CMS allowed a reviewer to render a clinical judgment regarding the medical necessity for the services based on the billing history and other available information in the patient record, even when the documentation was otherwise lacking in certain respects. Under the new methodology, claims were denied when the documentation requirements were not satisfied. These denials were accompanied by comments such as “the signature is illegible,” or “there is insufficient medical record documentation to substantiate the claim.” An overpayment recovery was sought even if the reviewer noted that the records substantiated that the services were medically necessary. The absence of any medical records to support the claim (e.g., records could not be located, patient not seen on the service date noted on the claim), accounted for only 0.1% of the total 2009 dollars in error. The predominant reasons for the