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!