Medicare Documentation Errors Noted

Medicare Documentation Errors Noted

There has been an increase in the number of errors found during a Comprehensive Error Rate Testing (CERT) review involving missing or insufficient documentation. To help assure that you are properly paid for the work you have done for Medicare patients here are a few things to remember:

1.Be descriptive in your office/progress notes; if you order an x-ray or other test write down in your note that you ordered this service. Verbal orders are not sufficient. Even if the x-ray or lab is being done in your office you must still have clear written documentation that you ordered this service.
2.When documenting your order be sure that the medical necessity for having the test/lab work performed is contained in your clinical notes. When reviewing documentation the reviewer needs to be able to discern why you requested the service(s).
3.When lab work is sent to another facility, be sure the ordering provider signs the lab/imaging request you are sending to the lab.
4.Make sure you SIGN all your notes, orders, test results; all documentation that supports a claim in the patient chart should have your signature. If you are initialing this documentation you must also print your name by the initials or you may circle your typed name on an office form you are using. This lets the reviewer clearly see that the medical record was written by you.
5.If your signature is not legible please print your name along with your signature or complete an attestation. A sample attestation can be found at; http://www.cignagovernmentservices.com/partb/pubs/news/2010/0310/cope11828.html.


Dallas L Alford IV, CPA is a licensed Certified Public Accountant in the state of North Carolina and owner of Atlantic Financial Consulting, a consulting firm that provides comprehensive medical billing services, practice management consulting, coding audits, Medicare compliance, Medicare RAC support and other general medical practice consulting services.
To learn more about Atlantic Financial Consulting you may visit their website at http://atlanticfinancial.us or contact Dallas L Alford IV, CPA directly at 1 888-428-2555, Ext. 200.