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Documentation under the Magnifying Glass
Documentation under the Magnifying Glass

Facts & findings from recent Medicare audits reveal 3 main areas where payment errors were identified.  The  results?  Charges denied as “Insufficient Documentation” ….leading to recoupment.

The 3 most common deficiencies were:

  • Illegible or missing signatures on documentation or orders

Signature requirements are nothing new–but CMS and its audit contractors are now strictly enforcing them.

Learn more about these requirements: http://www.cignagovernmentservices.com/partb/claims/cert/SignatureRequirements.html

  • Documentation errors or insufficient documentaton

Missing date of ocurrence

 Nature of onset

Incomplete plan of care and initial assessment

“Cloned” plans of care

Improperly documented time or undocumented time for time-based codes

CPT/HCPCS codes and modifiers chosen that are not supported by documentation

  • Choosing inappropriate level of E/M code



Both are considered errors!  Learn more about E/M guidelines at:


Virginia College Healthcare Reimbursement Services offers assistance with coding, billing, and  documentation guidelines.  Call us today, we’d love to hear from you!