Documentation

Laboratory services are one of the top service types with high improper payment rates due to insufficient documentation. We are seeing documentation of the risk level but the risk assessment to support the risk level is not included. Urine drug testing (UDT) provides timely, objective, and actionable information to clinicians by identifying the presence or absence of drugs of potential abuse in the body to assist the clinician in making treatment decisions.

Medicare covers annual screening for adults for depression in the primary care setting that has staff-assisted depression care supports in place to assure accurate diagnosis, effective treatment and follow-up.

This module will cover an overview of New Patient Office Visits with the goal of preventing costly denials and achieve effective results during the review process.

This CMS video will help providers and physicians understand the need and importance of medical record documentation to support the services billed.

This updated article includes information and instructions on how to respond to a Comprehensive Error Rate Testing (CERT) Documentation Request.

CMS guidelines mandate the presence of signatures for medical review purposes. However, records pertaining to any procedures billed to Medicare are potentially subject to review by not only Palmetto GBA, but other CMS contractors. Because of this, we are alerting you to the importance of these signature requirements and if changes are needed, we suggest you take immediate action.

This CMS Medicare Learning Network fact sheet addresses updated medical record maintenance and access requirements, documentation and best practices.

Medicare providers must comply with documentation requirements, including the timeliness of documentation in connection with the provider signature.

​​​​​​​Palmetto GBA frequently encounters errors assessed by the Comprehensive Error Rate Testing (CERT) Review contractor due to signature problems on submitted medical records, X-ray reports and laboratory/radiology orders. As Medicare providers, you may be asking what significance this has for you. The discovery of CERT errors may lead to increased scrutiny of future  services that you bill to Medicare. Your understanding of this important issue is essential to ensuring the accuracy of your Medicare claims.

All health care providers to enter information into the patient’s medical record at the time the service is provided to the patient; that is, contemporaneously.

When services are denied or down-coded by the CERT Review Contractor and an overpayment is identified, providers are entitled to file a redetermination request with Palmetto GBA.

When a provider receives a Comprehensive Error Rate Testing (CERT) error for insufficient documentation, it means that elements of the medical record that are imperative for Medicare payment are missing from the medical record sent in to the CERT contractor for review. Some tips to prevent this error are included in this updated article.

Here are some guidelines for documenting medical records. All information about services performed must be documented. If it isn’t documented, then no one knows what was performed.

When laboratory services are provided, the order - or intent to order - is vital and must be included in the medical record. If you bill laboratory services to Medicare, you must obtain the treating physician's signed order or signed progress note to support intent to order, and documentation to support medical necessity for the ordered services. Verifying the ordering or treating provider's intent and involvement with requesting the patient's tests is a crucial aspect of establishing medical necessity. Documentation in the patient's medical record must support the medical necessity for ordering the services per Medicare regulations and applicable Local Coverage Determinations (LCDs).

The CERT contractor should not be referred to a third party to obtain medical records.

A scribe can be a nonphysician practitioner (NPP), nurse or other appropriate personnel designated by the physician or NPP to document or dictate on their behalf.