hi i'm angela at the Centers for
Medicare and Medicaid Services as a
health care professional your goal is to
provide the best patient care possible
you document on a daily basis but do you
think about how your documentation fits
into patient care and claims payment
proper documentation of items or
services is the primary communication
tool for promoting quality patient care
documentation is the vehicle that
communicates who what when why and how
to other patient caregivers proper
documentation is important for a number
of reasons first it ensures that
patients get items or services that are
reasonable and necessary next proper
documentation supports proper claim
payment when you completely and
accurately document the items you
furnished or the services that you
provided Medicare can process your
claims for those items or services
correctly the first time proper
documentation also helps support
favorable medical review decisions and
in turn it reduces the administrative
costs that are associated with Appeals
even though we know that proper
documentation is important the
comprehensive error rate testing or cert
program continually finds that the
leading cause of claims errors is
insufficient documentation so what is
insufficient documentation to understand
what insufficient documentation is let's
start with what it isn't insufficient
documentation doesn't mean documentation
doesn't exist it means that something
was incomplete or missing from the
documentation submitted with the claim
now that we've discussed the benefits of
proper documentation and we understand
what insufficient documentation is let's
take a look at what happens when you
don't provide proper documentation when
your claims are denied your practice or
facility loses revenue take a moment to
consider the cost to your practice or
facility because of claim denials
appealing claim denials can be costly
the time and costs associated with
resubmitting a claim from completing
forms submitting documentation and
sometimes sending a letter about why you
believe the claim should be paid all
cost time and money proper documentation
is a sound way to protect the financial
health and sustainability of your
facility or practice
and your medical peers ensuring that
your documentation reflects the medical
necessity of the items you furnish or
the services you provide and correctly
coding your claims will help reduce
denials and reduce overpayments even
more importantly proper documentation is
critical to proper and comprehensive
patient care think of it this way if an
order is illegible a patient could get
the wrong medication test item or
service patient care errors and
financial consequences can significantly
impact your facility or practice and
that's why it's important to respond to
documentation request from the cert
program clinics facilities laboratories
durable medical equipment suppliers and
other physicians your documentation may
support a related claim review here are
some tips to help you if you need to
respond to a request for records from
the cert program first make sure you
send all associated documentation
supporting the item or service you build
keep in mind some of that information
may come from a prior encounter or a
test performed earlier than the date of
service for the claim under review if
you're not sure if you should include
the document it's a good idea to include
it anyway it might be the key document
or information that supports the item
you furnished or the service you
provided next make sure you send the
documentation by the deadline in the
request and then the last step is to
review your documentation a good way to
double check is to make sure that it
answers the questions who what when why
and how even the most comprehensive
documentation must not only verify that
each item or service billed was
performed but it also must verify the
medical necessity for each and every
item or service build your Medicare
administrative contractor or your Mac
can help you understand the
documentation requirements such as the
signature requirements to get more
information you can visit your Mac's
website to review more information on
Medicare's documentation requirements
you can review the Medicare Learning
Network or mln factsheet that's called
complying with medical record
documentation requirements and for more
information on medicare signature
requirements review the mln factsheet
that's called complying with medicare
signature requirements
finally the CERT A/B MAC outreach and
education page on CMS gov has more
information to help you